28: Diabetic Emergencies - Dodge Flashcards Preview

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Flashcards in 28: Diabetic Emergencies - Dodge Deck (32):
1

DKA type 1 ___ type 2

>>>

2

describe pathophysiology of DKA

- due to relative or absolute insulin deficiency
- elevated glucagon, cortisol, growth hormones

3

increased glucagon:insulin ration

DKA

this causes increased gluconeogenesis, glycogenolysis and ketone body formation

4

decreased GLUT4 -->

decrease glucose into cell

- decreased glucose metabolism in skeltal muscle and fat
-increased reliance on alt fuel sources

5

increased glucagon, decreased insulin -->

pyruvate --> gluconeogenesis

increased glycogenolysis

6

describe ketoacidosis

-increased lipolyiss
-release of FFA
- liver: elevated glucagon leads to increased ketone body formation
- VLDL and triglyceride formation also increased (usual pathway for FFA) but less than ketone bodies

7

___ beta-hydroxybutyrate: acetoacetate

3:1 ketone body formation

both can be detected by available assays

urine acetoacetate preferentially

8

key presentations of DKA

abdominal tenderness

kussmaul/tachypnea respirations

tachycardia

decreased urine output

altered mental status

9

diagnostic criteria for DKA (4)

- serum glucose > 250 mg/dL
- serum bicarb less than 18 mEq/L
- presence of serum ketones (more accurate representation of body ketone levels than urine)
- serum pH less than 7.3

10

anion gap will be _______ with DKA

normal is 10-12

increased

due to increased ketoacids which neutralized bicarb; potentially from lactic acidosis as well

11

the work up of DKA is incomplete without...

attempting to determine inciting event, the WHY

ask about: recent sick contact, illnesses, medication compliance, sexual activity (infection, preggers), cough, fever, sweats, diarrhea, chest pain, drug use

12

the "I"s of DKA

infection
infarction/Ischemia
Intoxication
Impregnation
Idiocy - no meds

13

what will you order when you suspect DKA?

- serum glucose, electrolytes, ketones, ABG
- urinalysis, dipstick for ketones
- EKG (especially if older)
- CBC with diff
- renal function, ELECTROLYTES, liver enzymes
- culture blood urine sputum
- chest xray

14

3 key DKA treatments

1. fluid resuscitation
2. insulin treatment
3. electrolytes

15

DKA: replace fluids initially with __

0.9% NaCl solution

initial bolus of 2-3 liters of fluid over the first 1-3 hrs and reassess as you go

will need to change to 5% dextrose in 0.9% of 0.45% NaCl once serum glucose is less than 200 mg/dL

16

_____ REQUIRED to reverse/treat DKA

insulin

2 options:
- bolus 0.1 unit/kg, then 0.1 units/kg/hr continuous insulin infusion
- 0.14 untis/kg/hr continuous infusion with no bolus

follow serum or fingerstick glucose every hr; once DKA resolved transition to subcutaneous insulin

17

DKA: potassium levels are _____; sodium levels are _

depleted; low

- replace K before starting insulin if less than 3.3 mEq/L
- sodium levels are falsely diluted from hyperlgycemia [psuedohyponatremia], decreases about 1.6 mEq/L for every 100 mg/dL over 100 blood sugar levels

follow electrolytes and renal function every 3-4 hrs during treatment

18

DKA considered resolved when (4)

- serum glucose less than 200
- serum bicarb greater than 15
- serum pH greater than 7.3
- anion gap less than 12


can start subcutaneous insulin at this time; restart home or calculate new dose

19

HHS =

hyperglycemic hyperosmolar syndrome

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type 2 _____ type 1 with HHS

>>>

higher mortality than DKA

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what is the pathophysiology of HHS/

- due to relative insulin deficiency or inadequate fluid intake
- deficient insulin = increased hepatic glucose production
- hyperglycemia leads to somotic diuresis = dehyrdatation

22

HHS: believed that _____ _______ deficiency leads to less counter regulator hormones and therefor no ketoacid production

relative insulin

23

symptoms of HHS

less severe, slower onset

- polyuria, weight loss, decreased oral intake
- altered mental status
- dehyrdation with hypotension, tachycardia

NO nausea, vomiting , kussmaul breathing, and abdominal pain

24

diagnostic criteria HHS

- serum glucose > 600
- hyperosmolarity: osmolality > 350
- elevated BUN and creatinine often
- no/mild acidosis and ketoacidosis

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potential cases of HHS ...

stroke
MI
infection/sepsis
decreased fluid intake

26

treatment for HHS (3)

#1 fluid resuscitation
- insulin
- electrolytes

27

what fluid would you give to an HHS pt?

- bolus with 0.9% NaCl to stabilize hemodynamics
- monitor electrolytes with volume replacement

28

what is the insulin treatment for HHS?

- bolus 0.1 units/kg, then 0.1 units/kg/hr infusion

continue until glucose improved and eating, then subcutaneous

29

what do the electrolytes look like with HHS?

- monitor K and replace with tx of hyperglycemia
- Na may be elevated to to dehydration

30

define hypoglycemia

serum glucose less than 70 mg/dL

usually has increased catecholamines and glucagon

31

symptoms of hypoglycemia

tremor, palpitations, anxiety

tachycardia, sweating, parasthesias

seizure and coma are possible when severe

32

severe tx for hypoglycemia

admission with infusion of dextrose containing fluids until insulin effect has worn off

glucagon injection can be considered