Diabetes: Acute Complications

Question 1

most common diabetic emergency

Answer 1

hypoglycaemia

Question 2

def. of severe hypoglycaemia

Answer 2

need for external assistance

Question 3

common causes of hypos

Answer 3

too much insulin
too little carbohydrate
missed/late meal
exercise
alcohol
sulfonyureas

Question 4

sulfonylureas and problem in diabetes

Answer 4

they encourage beta cells to produce more insulin
but could cause too much insulin and cause a hypo

Question 5

MoA of sulfonylureas

Answer 5

blocks ATP sensitive calcium channels (same action as ATP)
the cell depolarises
Ca2+ channels open
Ca2+ influx triggers insulin release

Question 6

other causes of hypoglycaemia

Answer 6

decreased insulin requirements (e.g. weight loss)
liver disease
conditions associated with T1DM
- addision’s
- hypothyroidism
- coeliac
complications of DM
- autonomic neuropathy
- renal failure
- counterregulatory failure
- injection sites/lipohypertrophy

Question 7

why can addison’s cause hypos

Answer 7

cortisol is important in counterregulation
but cortisol low in addisons

Question 8

counterregulation mechanisms to insulin

Answer 8

pituitary secretes GH and ACTH
ACTH stimulates cortisol and adrenaline/epinephrine from adrenal gland
pancreas secretes glucagon

Question 9

rise in what hormone causes the symptoms of hypos

Answer 9

adrenaline
released in response to low blood sugars to try to correct problem

Question 10

below what blood glucose level is a patient likely to have reduced consciousness/coma

Answer 10

1.5mmol/l

Question 11

symptoms of hypoglycaemia

Answer 11

shaky
fast heart beat
sweating
dizziness
hungry
headache
nausea
difficulty speaking
confusion
incoordination
irritable
blurry vision
odd behaviour (esp. children)
weakness
fatigue

Question 12

elderly presentation of hypo

Answer 12

can have stroke like symptoms (e.g. hemiparesis)

Question 13

what happens to counterregulatory mechanisms over time with diabetes

Answer 13

deficiencies in counterregulatory hormones increase over time

Question 14

describe cycle of hypoglycaemia un/awareness

Answer 14

hypoglycaemia episode → impaired physiological responses to hypoglycaemia → reduced awareness of hypoglycaemia → increased vulnerability to further episodes → less likely to detect as early → more severe hypo

Question 15

diagnosis of hypoglycaemia

Answer 15

2 of 3 of whipple’s triad
- typical symptoms
- biochemical confirmation (<4mmol/l)
- symptoms resolve with carbohydrate

but don’t delay treatment to wait for confirmation

Question 16

management of hypos

Answer 16

if safe swallow - sweet drink or dextrose tablet
if not - IV 20% dextrose
if can’t get IV - intramuscular glucagon and sweet drink

follow up with slow release carbohydrates

Question 17

what should be done if recovery is not rapid after management of hypo

Answer 17

consider other causes

Question 18

driving consideration after hypo

Answer 18

full cognitive recovery can take 45 minutes so can’t drive

Question 19

risk factors for attending hospital with hypo

Answer 19

elderly
live alone
comorbidity
sulfonylurea therapy

Question 20

after care of hypo

Answer 20

inform diabetes team
discharge unless caused by sulfonylureas
tell them to monitor glucose closely for 72h
treat cause if possible
reduce insulin/sulfonylurea dose

Question 21

what do you need to take when you’re driving as a diabetic

Answer 21

GLC meter
or
real time glucose monitoring
or
flash glucose monitoring

rescue carbohydrate (snack)

ID saying you have diabetes in case of accident

Question 22

what do you need do before driving

Answer 22

check glc before any journey

Question 23

long journey rules in diabetes

Answer 23

test every 2h and take regular snacks

Question 24

what glc require action before driving

Answer 24

if <5mmol/l - take a snack
if 4mmol/l - do not drive, treat hypo and wait 45m

Question 25

what should you do if you have a hypo while driving

Answer 25

stop vehicle as soon as safe switch off engine remove keys from ignition get out of driver seat what 45m after normal glc before driving

Question 26

who has extra rules for driving in diabtes

Answer 26

group 2 licenses and taxi drivers depending on local authority

Question 27

what must you inform the DVLA of

Answer 27

more than 1 severe hypo in last year whilst awake if you or your carer think you are at high risk of developing a hypo if you develop impaired awareness of hypos suffer hypo while driving

Question 28

hyperglycaemia in type 1 leads to

Answer 28

diabetic ketoacidosis

Question 29

hyperglycaemia in type 2 leads to

Answer 29

hyperosmolar hyperglycaemic state

Question 30

dka management

Answer 30

fluids - fast then slow IV insulin monitor K+ determine cause give 10% glucose when blood glucose reaches 14 or less

Question 31

what is common cause of DKA

Answer 31

infection errors/omissions initial presentation of T1DM

Question 32

presentation of DKA

Answer 32

polyuria polydipsia hypovolaemia abdo pain nausea and vomiting kussmaul breathing ketotic breath muscle cramps evidence of cause (e.g. sepsis)

Question 33

DKA managment after the event

Answer 33

swap to subcutaneous insulin once patient eating and drinking ensure basal inulin is given an hour or more before IV insulin stops

Question 34

biochem findings in HHS

Answer 34

marked hyperglycaemia raised osmolality mild/no ketoacidosis

Question 35

biochem findings in HHS

Answer 35

marked hyperglycaemia (>30) raised osmolality mild/no ketoacidosis severe dehydration and pre-renal failure

Question 36

presentation of HHS

Answer 36

hypercoagubiliy profound dehydration confusion comas fits gastroparesis nausea vomiting haematemesis

Question 37

HHS management

Answer 37

slower prolonged rehydration (slow reduction in Na+) gentler glucose reduction (than DKA) anticoagulation (prophylactic sc heparin) seek cause

Question 38

how is metformin secreted

Answer 38

through kidney

Question 39

does metformin cause lactic acidosis

Answer 39

no

Question 40

when does metformin accumulate

Answer 40

late renal disease

Question 41

when should you stop metformin

Answer 41

if eGFR<30 or worsening quickly during tissue hypoxia - shock - MI - sepsis - dehydration - acute renal failure for 3 days after iodine containing contrast check U&Es before reinstating 2 days before general anaesthetic reinstate once stable renal function