Diabetic Emergencies Flashcards
(36 cards)
1
Q
When do hypoglycaemic symptoms typically occur?
A
Glucose - 3.6mmol/L
2
Q
What is false hypoglycaemia?
A
- patients with consistently high glucose levels experience hypo at higher level than someone with good glycaemic control
3
Q
Causes of hypoglycaemia
A
- imbalance between carb and insulin or sulfonylurea therapy
- exercise with too much insulin or not enough carbs
- alcohol (even in non-diabetics)
- vomiting
- breastfeeding
- other medical causes
4
Q
Other medical causes of hypoglycaemia
A
- liver disease
- progressive renal impairment
- hypoadrenalism
- hypothyroidism
- hypopituitarism (rare)
- insulinoma (rare)
5
Q
Autonomic symptoms of hypoglycaemia
A
- sweating
- shaking/tremor
- anxiety
- palpitations
- hunger
- nausea
6
Q
Neuroglycopenic symptoms
A
- confusion
- slurred speech
- visual disturbances
- drowsiness
- aggression
7
Q
Define neuroglycopenia
A
When glucose reaches 2.7mmol/L
8
Q
What is hypoglycaemia unawareness?
A
- loss of early warning signs
- increased risk of having severe hypo
- associated with increased risk of death/road traffic accidents
- caused by increased duration of diabetes, tight glycaemic control, autonomic neuropathy
- reverse by hypo - holiday
9
Q
What is hypo holiday?
A
- strict hypoglycaemia avoidance
- relax glycaemic control
- use analogue insulin
- continuous subcutaneous insulin infusion
10
Q
Hypoglycaemia Stages
A
MILD = conscious, can self treat MODERATE = conscious, cannot self administer and need help SEVERE = unconscious
11
Q
Mild hypoglycaemia treatment
A
- sugary drink (coke, OJ, Lucozade)
- 5-7 glucose tablets
- 3-4 heaped teaspoons of sugar in water
12
Q
Moderate hypoglycaemia treatment
A
- glucogel/jam/honey/treacle massage into cheek
- IM glucagon
13
Q
Severe hypoglycaemia treatment
A
- do not put anything in mouth
- recovery position
- 0.5-1mg glucagon IM
- call 999 is unable to administer glucagon
- in hospital = IV glucose
14
Q
What is the IV glucose dose in hospital?
A
- 75ml of 20% glucose over 15 mins OR
- 150mls of 10% glucose over 15 mins
- 50mls of 50% can be given but be careful with veins as extravasation can cause chemical burns
15
Q
Post hypo treatment
A
- once glucose above 4mmol/L
- long acting carbs needed = slice of toast, 2 biscuits, milk 200-300ml, normal meal if due containing carbs
16
Q
Hypoglycaemia and driving
A
- insulin use does not prohibit
- advice = plan in advance, carbs in car, check glucose before driving and every 2 hours, first sign of hypo stop as soon as safe, leave driver seat and remove key, do not drive again until full recovery
- DVLA inform and insurance company
- if 1 or more severe hypo licence revoked requiring 3rd party assistance
17
Q
Nocturnal hypo when
A
- if patient wakes up with high blood glucose, headaches
- confirm by testing blood glucose levels during night 3am or continuous glucose monitoring sensor over 5 days subcutaneously
18
Q
Management of nocturnal hypo
A
- analogue insulins
- pre bed snack
- change timing of insulin
- insulin pump therapy
19
Q
Define DKA
A
- state of absolute or relative insulin deficiency resulting in hyperglycaemia and accumulating of ketoacids in blood with subsequent metabolic acidosis
20
Q
3 requirements/defining factors of DKA
A
- hyperglycaemia so >14mmol/L
- acidosis so ph<7.3 and bicarb <15mmol/L
- elevated serum or urine ketones
21
Q
Pathogenesis of DKA
A
- insulin deficiency inhibiting gluconeogenesis
- catecholamines in excess promote lipolysis and stimulate gluconeogenesis
- FFA metabolism = ketosis
- ketone bodies accumulate (3-OH-butyric acid and acetoacetic acid) = acidosis
- insulin terminates ketosis
22
Q
Clinical features of DKA
A
- abdominal pain
- vomiting
- Kussmaul’s respiration (deep sighing respirations)
- ketones on breath
- drowsiness/confusion
- dehydration
- tachycardia
23
Q
What fluids and electrolytes are lost in DKA?
A
- water 6-8L
- sodium 0.5-1L
- chloride 350mmol
- potassium 0.5-1L
- calcium 50-100mmol
- Ph 50-100mmol
- Mg 25-50mmol
24
Q
Precipitating factors of DKA
A
- insulin omission
- infection
- pregnancy
- MI
- intoxication/drugs
- unknown 40%
25
Diagnosis of DKA
- venous blood gas for acidosis and bicarb
- capillary blood glucose (can be lower than 14mmol/L if alcohol ketosis or euglycaemic ketosis)
- frequently raised urea and creatinine
- raised urine or plasma ketones
26
Investigations in DKA
- pregnancy test
- ECG/CXR
- MSU/blood cultures
- biochemical profile/lab glucose
- FBC
- HBA1c
27
What suggests greater severity of DKA?
- blood ketones >6mmol/L
- bicarb <5mmol/K
- pH < 7.1
- potassium <3.5mmol/L
- GCS <12 (Glasgow)
- O2 sats <92%
- systolic BP <90mmHg
- pulse >100 or <60
28
Monitoring/supportive management for DKA
- level 2 bed (high dependency unit)
- cardiac monitor
- nasogastric tube if impaired conscious level
- central venous pressure line (esp in elderly)
- oxygen if PaO2 <10.5kPa
- urinary catheter
- prophylactic LMW heparin
- IV AB if infection suspected
- monitor conscious level, BP, pulse, temp, glucose, urine output, potassium and acidosis frequently
29
Fluid therapy for DKA
NaCl = 0.9%
- 1L immediately
- next hour 1L
- 2hr 1L + 20mmol KCl
- 4hr 1L + KCl
- 4hr 1L + KCl
5 or 10% glucose
- when CBG < 12mmol/L and continue at 125ml/hr
- 10% glucose to increase insulin infusion
- if glucose falls below 6mmol/L increase infusion rate
30
Protocol of giving potassium in fludis for DKA
- first 1-2 bags in fluid no potassium as fluid given is too rapid
- using bag of fluid containing KCl for every subsequent bag of NaCl 0.9% or glucose 5%
if serum potassium is ≤ 5.5
- if serum K+ 3.5-5.5 20-40mmol/Luse
31
Protocol of giving insulin in DKA
- continue long acting on admission if diabetic
- commence insulin infusion by IV syringe pump
- fixed rate IV insulin infusion (0.1U/kg = 6-8U/hr for most patients, to achieve bicarb rise of 3 mmol/hr, if not achieved increase rate by 1U/hour)
32
Significance of cerebral oedema in DKA
- commonest cause of death from DKA in children
- dexamethasone or mannitol
- high mortality
33
DKA recovery
- usual subcutaneous insulin once eating and drinking reliably
- nausea and unable to eat normally until ketones clear
- persisting ketonuria if lack of adequate glucose and insulin admin
- self care and sick day rule education to prevent future DKA
34
What is hyperosmolar hyperglycemic syndrome
- T2D
- longer subacute history
- >40mmol/L hyperglycemia
- osmolality >340, hypernatremia
- ketonuria may have
- no ketoacidosis but may have lactic acidosis
- severe dehydration
35
HHS treatment
- IV fluids like DKA
- consider slower fluids if elderly/HF
- no insulin bolus
- much lower dose insulin and maybe none for first 12 hours then low doses (1U/hr)
- avoid rapid shifts in glucose as risk of rapid fluid/sodium shifts = central pontine myelinolysis
- monitor CVP?
- K+ tends to decline rapidly
- LMWH to reduce thrombosis
- correct BG at max 2mmol/L/hr
- biochem will be abnormal for days or risk hypernatremia, CPM, cerebral oedema
36
Sick day rules
If on insulin and ill
- drink fluids!!
- if unable to eat drink sugary fluids
- monitor glucose levels more regularly
- never stop tablets or insulin
- insulin may need to be increased as stressed
- if take oral agents may need insulin for duration of illness
- if unable to keep fluids down come straight to hospital
