5. diabetic emergencies Flashcards
(35 cards)
what is diabetic ketoacidosis (DKA) characterised by?
hyperglycaemia
metabolic acidosis
hyperketonaemia
(mainly in T1DM)
what is the specific diagnostic criteria (values) for DKA
blood glucose > 11mmol/L (aka diabetes)
blood ketones > 3mmol/L
bicarbonate < 15mmol/L or venous pH < 7.3
what are some main causes of DKA
- infection (e.g. UTI, surgery..)
- poor compliance
- first presentation of type 1 diabetes
- dehydration
- fasting
what is the relevance of potassium in DKA
insulin causes potassium to move INTO cells
-insulin deficiency = move out = high extracellular K = renal K loss = whole body K depletion
what other processes happen with DKA
increased lipolysis with release of NEFA
-NEFA is partially oxidised to ketone bodies = ketonaemia
symptoms of DKA
- polyuria, polydipsia, thirst
- blurred vision
- vomiting
- abdominal pain
- weakness
- leg cramping
- gradual drowsiness and dehydration in T1DM (rarely T2)
signs of DKA
- Kussmal respiration
- ketonic fetor (acetone smell)
- dehydration
- tachycardia
- hypotension
- mild hypothermia
- confusion, drowsiness, coma
how should DKA be confirmed
clinical feature with a blood glucose measurement and blood gas sample (metabolic acidosis with respiratory compensation)
what are the ESSENTIAL early investigations DKA
- capillary blood glucose (>11.1mmol/L)
- Blood (or urinary) ketones (>3mmol/L)
- Urea and eletrolytes
- venous blood gas analysis
- Urinary glucose and ketones
- Blood cultures (if evidence of infection)
- Cardiac monitoring/ECG (any ischaemic changes or changes secondary to hypokalaemia)
what are some other investigations DKA
- glucose, renal profile, FBC, CRP
- ECG
- CXR
- blood culture
- MSU
what is the initial management (i.e. within first hour) of a patient in DKA
- start 0.9% NaCl IV infusion (large bore annular)
- start fixed rate of IV insulin infusion at 0.1 unit/kg/hour. 50 units human soluble insulin made up to 50ml with 0.9% NaCl solution
- assess patient (GCS, RR..)
- further investigations
examples of human soluble insulin (brands)
Actrapid
Humulin S
complications of DKA
*cerebral oedema Adult respiratory distress syndrome (ARDS) /Acute lung injury Pulmonary embolus Arrhythmias Multi-organ failure Co-morbid states
what prophylaxis needs to be considered for DKA
venous thromboembolism
what is Hyperosmolar hyperglycemic state (HHS)
state of severe uncontrolled diabetes
T2DM
-high blood sugar results in high osmolarity without significant ketoacidosis
[[more severe than DKA]]
what is HHS characterised by
– severe hyperglycaemia ≥30mmol/l
– Hyperosmolarity (serum osmolality ≥ 320mosmol/kg
– Hypovolaemia
what is the key difference between HHS and DKA
No significant ketonaemia (serum ketones<3mmol/l) or acidosis (pH>7.3, bicarbonate>15mmol/l)
causing factors of HHS
infection
new onset diabetes
acute illness
non compliance
complications of HHS
– Cerebral oedema
– Osmotic demyelination syndrome (pontine myelinolysis) – Seizures
– Arterial thrombosis MI, CVA, peripheral arterial
– Venous thrombosis (pulmonary embolism)
– Multiorgan failure
– Foot ulceration
– Co-morbid condition
symptoms of HHS
▪Thirst, Polyuria,
▪Blurred vision
▪Weakness
signs of HHS
▪Dehydration ▪Tachycardia ▪Hypotension ▪Confusion & drowsiness ▪Coma
bedside investigations for HHS
– Capillary blood glucose
– Blood ketones (portable ketone meters)
– Urine ketones
– Venous blood gases
what are the values expected of HHS
- Blood glucose ≥30mmol/l
* Blood ketones<3mmol/l or urine ketones 0/trace •Osmolality ≥ 320mosmol/kg
other investigations for HHS
- Glucose/renal profile/FBC
* ECG, CXR, Blood culture, MSU
