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Endocrine > diabetes emergencies > Flashcards

diabetes emergencies Flashcards

1
Q

definition of a hypo

A

<4

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2
Q

definition of a severe hypo

A

a hypo that requires assistance

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3
Q

how many severe hypo’s before driving licence revoked in a year

A

2

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4
Q

causes of hypoglycaemia

A
  • excess insulin administration
  • overdose of other antidiabetic medication eg SU’s
  • not eating enough carbs
  • alcohol excess
  • physiological stressors
  • rarely (insulinomas, addison’s disease)
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5
Q

symptoms of hypoglycaemia

A
  • adrenergic symptoms due to adrenaline release
  • sweating
  • trembling
  • tachycardia
  • anxiety
  • hunger
  • pallor
  • nausea
  • vomiting
  • neuroglycopaenic symptoms
  • confusion
  • tiredness
  • irritable
  • visual disturb
  • arrhythmias
  • seizure
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6
Q

hypo management if mild

A

abcde

  • if mild/conscious then give 15g glucose surgary drink wait 10 mins and reassess, repeat 3x then call dr
  • give long acting carb after
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7
Q

hypo management if severe and unconscious

A
  • establish IV access 10% dextrose 150ml or 80ml

- glucagon 1mg IM

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8
Q

why dont you get ketones in 2dm

A

as some insulin prevents uncontrolled lipolysis as only need a very small mount

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9
Q

causes of DKA AND HHS 4I’s

A

insufficient insulin
infection
infarction
intercurrent illness

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10
Q

inx of hyperglycaemia

A
  • capillary prick
  • ketones
  • urinalysis
  • urea and electrolytes
  • arterial blood gases
  • fbc
  • bp and hr
  • ecg for potassium signs
  • cxr for cause and blood cultures
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11
Q

ecg signs of hyperkalaemia

A

flattened p wave and prolonged QRS segment, tall peaked t weaves and sign wave, shortened qt interval

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12
Q

3 parameters for dka

A

hyperglycaemia >11
ketones >3
acidosis ph <7.3 or bicarb <15

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13
Q

how can dka cause mortality

A
  • children by cerebral oedema

- adults by hypokalaemia, ards, comorbid

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14
Q

who gets dka 1 or 2

A

usually 1

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15
Q

precipitation of dka

A
  • intercurrent illness as need to increase insulin
  • eating disorder
  • non-compliance
  • infection
  • infarction
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16
Q

what causes ketosis

A
  • insulin deficiency exacerbated by elevated catecholamines and other stress hormones that cause unrestratined lipolysis
  • lots of FFA for hepatic ketogenesis
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17
Q

2 types of ketones

A

3-hydroxybutyrate and acetoacetate

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18
Q

symptoms of dka

A
  • dehydration (osmotic diuresis)
  • electrolyte loss (na and k)
  • polyuria
  • weight loss
  • weakness
  • N&V
  • leg cramps
  • blurred vision
  • abdo pain : amylase raise
  • kussmaul breathing and smell of acetone
  • hypotension
  • hypothermia
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19
Q

why do infected patients with dka get pyrexia

A

vasodilation secondary to acidosis

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20
Q

inx dka

A
  • venous blood
  • urinalysis or blood for ketones
  • ecg for hyperk
  • blood cultures and cxr
  • blood pressure hypovolaemia
  • anion gap
21
Q

dka is potassium raised or not raised

A
  • in the blood potassium are raised as pH causes efflux from cells
  • but potassium is intracellular cation so actually is low
22
Q

what needs to be given with insulin

A

potassium as insulin also drives potassium out of cells

23
Q

definition of severe dka

A 
blood ketones>6
bicarb <5
pH <7
hypok already 
gcs <12 
o2 <92%
hr >100 or <60
24
Q

what is the anion gap formula and usual range

A

(Na+K)-(Bic+Cl)

8-16

25
Q

causes of a raised anion gap

A 
KUSMAEL
ketoacidosis
uraemia
salicyltaes
methanol
alcohol
ethylene glycol
lactate
26
Q

management of DKA

A

think VIP

  1. volume- iv initially fast than slower to rehydrate 0.9% saline per hr, more rapid in shock
  2. insulin: 6 units actrapid, give dextrose if blood glucose drops
  3. potassium: when give insulin get potassium shift into.
  4. low molecular weight heparin due to hypercoaguable state
  5. avoid hypos so add glucose after an hr 10%
  6. ECG risk of arrthymias
27
Q

what potassium level means insulin shouldn’t be started

A

<3.5

28
Q

dka protocol 0-60 minutes

A
  • confirm dx
  • iv fluid sodium chloride
  • insulin treatment soluble
  • monitoring
29
Q

dka protocol 60-6 hours

A
  • give sodium chloride iv with potassium after checking K+
  • as hyperkalaemia can occur if given too early
  • add 10% glucose when <14
  • continue insulin
  • seek fluid balance chart
  • prescribe low molecular weight heparin prophylactically due to risk of dvt
30
Q

dka protocol 12-24 hours

A

if patient is not eating and drinking still due to ketoacidosis then lower insulin

31
Q

additional management dka

A

-urinary catheterisation if anuric after 3 hours or incontinent
-insert nasogastric tube if persistent vomiting or gastroparesis
-insert central venous line if cardio system if compromised
measure arterial bg
-ecg monitor
-thrombophylaxis

32
Q

definition of a severe dka

A

pH <7

bicarb <5

33
Q

management if severe dka progressed to cerebral oedema and who is at risk

A

younger patients are at risk of cerebral oedema if too much fluid
-dexamethasone and mannitol

34
Q

management after DKA

A
  • continue with long acting throughout treatment
  • give short acting insulin once eaten
  • can stop IV insulin when eating normal
35
Q

parameters of HHS

A

Hyperglycaemia >30
Hyperosmolar >320
Hypovolaemia secondary to osmotic diuresis
blood ketones <3
marked hyperglycaemia without any hyperketonaemia

36
Q

cause of HHS

A

seen in 2dm due to relative deficiency of insulin rather than absolute 4I’s

37
Q

speed of onset of HHS

A

slower than DKA over several days so metabolic disturbance more extreme

38
Q

mortality HHS

A

HHS has a higher mortality rate than DKA due to prevalence of co-morbidities in 2dm

39
Q

management of hhs

A
  1. fluids 0.9% sodium chloride given at a slower rate (1l over first hr), slower if cardiac failure
  2. Insulin 0.05 units/kg/ hr IV
  3. monitor potassium
  4. antibiotics
  5. prophylactic heparin
40
Q

aim for reduction of osmolality of HHS at and fluid balance of

A

3-8 mmol kg per hr

2-3L positive fluid balance by 6 hours

41
Q

why does iv fluid for HHS need to be given slower

A

HHS develops slower so sudden reversal of fluid status can cause seizures, cerebral oedema and cerebral pontine myelinolysis

42
Q

symptoms of HHS

A

-insidious onset
-profound dehydration (9-10L deficit)
-hypercoaguability
-confusion,coma and fits
-gastroparesis, N&V
-polyuria, polydipsia
-weakness,cramps
-neuro symptoms: acute stroke/ focal weakness
-seizures
-n&v
-coma 10%
high mortality

43
Q

signs of HHS

A
  • dehydration: tachycardia, hypotension, decreased skin turgor
  • general exam look for cause pneumonia, MI
  • focal/ global neurological dysfunction
  • acute abdo pain-paralytic ileus, gastroparesis
44
Q

inx hhs

A

o Finger prick glucose
o Bloods-glucose, bicarb, u&e
o Culture
o ABG often acidosis
o Serum osmolality
o Urine: ketones, glucose dipstick, +/- MSU
o ECG if hyperk- flattened p waver, prolonged QRS segment, tall peaked T waves, and sign waves
o CXR
o May need CT/ MRI head if concern of cerebral oedema

45
Q

complications of hhs

A
  • embolic: ischaemia, infarction
  • hypoKa, cardiac failure
  • cerebral oedema
  • foot ulcers
  • multi-organ fail, ards
46
Q

what can metformin cause

A

lactic acidosis

47
Q

how is metformin excreted

A

kidney

48
Q

when should metformin not be given

A

if eGFR <30 cr 130-150

  • tissue hypoxia present
  • iodine containing contrast mediuum

Endocrine (14 decks)

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