Diabetic Emergencies

Question 1

What is the triad of DKA

Answer 1

hyperglycaemia
high anion gap metabolic acidosis
ketonaemia

Question 2

What are some precipitating factors in known diabetes for DKA

Answer 2

inadequate insulin treatment 
non-compliance 
infection 
new-onset diabetes 
MI 
stroke 
acute pancreatitis 
trauma 
drugs

Question 3

How does DKA present

Answer 3

Insulin deficiency causes impaired glucose utilisation as well as increased gluconeogenesis and glycogenolysis resulting in hyperglycaemia
Elevated plasma glucose increases the filtered load of glucose in the renal tubules
As the maximal renal tubular reabsorptive capacity is exceeded glucose is excreted in the urine
The osmotic force exerted by unreabsorbed glucose holds water in the tubules, thereby preventing its reabsorption and increased urine output (osmotic diruresis)
This leads to dehydration and loss of electrolytes

Question 4

What are the 3 ketone bodies produced in DKA

Answer 4

2 ketoacids and one neutral ketone (acetone)

Question 5

What might a patient in DKA present with

Answer 5

polyuria and polydipsia resulting in dehydration
abdominal pain and vomiting
fatigue, weakness and weight loss
confusion, coma

Question 6

What is the term given to deep sighing respiration secondary to acidosis

Answer 6

Kussmaul’s respiration

Question 7

What does the diagnosis of DKA require

Answer 7

plasma glucose >11mmol/L
Positive urinary ketones or plasma ketones >3mmol/L
acidosis (pH

Question 8

What type of acidosis in DKA

Answer 8

metabolic acidosis (associated with low bicarbonate levels and a reduction of partial pressure of carbon dioxide due to compensatory hyperventilation with a high anion gap

Question 9

What should be performed in any patient presenting with DAK

Answer 9

ECG and septic screen

Question 10

What are some other causes of a high anion gap metabolic acidosis

Answer 10

lactic acidosis (due to tissue hypo perfusion caused by hypovolaemia, cardiac failure or sepsis) 
renal failure and drugs such as aspirin, methanol and ethylene glycol

Question 11

What does the treatment of DKA include

Answer 11

Resuscitation (ABCDE) 
insulin 
fluids 
potassium 
Broad spectrum AB if infection is suspected

Question 12

Why should patients remain nil by mouth for at least 6 hours

Answer 12

gastroparesis is common

Question 13

What is the only indication for delaying insulin in DKA

Answer 13

a serum potassium less than 3.3.mmol/L as insulin will worsen the hypokalaemia by driving potassium into the cells

Question 14

How much insulin is given in DKA

Answer 14

50U of soluble insulin to 50ml 0.9% saline

Question 15

If the patient is not eating and drinking, what should be used in DKA

Answer 15

Sliding scale

Question 16

When is dextrose given

Answer 16

when the blood glucose reaches 15mmol/L

Question 17

What does insulin deficiency lead to in terms of potassium

Answer 17

potassium movement out of the cells and into the extracellular fluid

Question 18

Why must potassium be given in DKA

Answer 18

treatment with insulin lowers the potassium concentration and may cause severe hypokalaemia as potassium shifts into the cells under the action of insulin

Question 19

What is monitored hourly for the first 15 hours

Answer 19

blood glucose
capillary ketones
urine output

Question 20

What is monitored 4 hourly

Answer 20

urea and electrolytes

Question 21

How often are capillary ketones monitored

Answer 21

2 hourly

Question 22

What is a serious complication in children with DKA

Answer 22

cerebral oedema

Question 23

What are some signs of cerebral oedema

Answer 23

Headache
recurrent vomiting 
age-inappropriate incontinence 
irritability 
lethargy 
altered levels of consciousness

Question 24

How can we treat cerebral oedema

Answer 24

reducing the rate of fluid administration

administer IV mannitol

Question 25

Describe HHS

Answer 25

Hyperosmolar hyperglycaemic state - there is little or no ketoacid accumulation the serum glucose often exceeds 50mmol/L plasma osmolality may reach 380mosmol/kg neurological abnormalities are frequently present insulin levels are insufficient to allow appropriate glucose utilisation but are adequate to prevent lipolysis and subsequent ketogenesis

Question 26

In what population does HHS usually occur

Answer 26

elderly patients with type 2 diabetes

Question 27

What are the clinical presentations of HHS

Answer 27

insidious onset of polyuria and polydipsia severe dehydration neurological symptoms

Question 28

What investigations are required for HHS

Answer 28

serum glucose serum sodium

Question 29

what is the treatment for HHS

Answer 29

rehydration until rehydrated potassium is given in each litre of IV fluid IV insulin at a rate of 203U per hour Treat underlying cause thromboprophylaxis with low molecular weight heparin

Question 30

Describe how hypoglycaemia arises in diabetics

Answer 30

insulin is supplied exogenously and its release cannot be turned off The glcoagon and adrenaline response to hypoglycaemia becomes impaired later in the course of diabetics

Question 31

What are some symptoms of sympathetic overactivity

Answer 31

``` sweating anxiety tremor tachycardia palpitations pallor nausea hunger ```

Question 32

What are some signs of neuroglycopenia

Answer 32

``` dizziness headache visual disturbances focal neurological defect difficulty speaking inability to concentrate abnormal behaviour confusion drowsiness loss of consciousness or seizure ```

Question 33

What is hypoglycaemic unawareness

Answer 33

When the plasma glucose falls without any warning

Question 34

What does diabetic nephropathy do in terms of insulin requirements

Answer 34

it decreases them as insulin is partly degraded by the kidney

Question 35

What is the treatment for hypoglycaemia in a patient that is conscious sad cooperative

Answer 35

50g of oral glucose | Lucozade, milk or 3 dextrose tablets

Question 36

What is the treatment for hypoglycaemia in a patient with reduced levels of consciousness

Answer 36

50ml of 50% glucose IV | If no IV access then 1mg of glucagon IM

Question 37

What should be given in those with a history of excess alcohol intake

Answer 37

IV thiamine prior to dextrose to reduce the risk of precipitating Wernicke's encephalopathy