ENDO - Diabetic emergencies Flashcards
What are the symptoms and signs associated with diabetic (hyperglycaemic and hypoglycaemic) emergencies?
DKA
- early: polyuria, polydipsia, malaise, nocturia, weight loss
- late: anorexia, nausea, vomiting, dyspnea (often due to acidosis), fatigue, abdominal pain, drowsiness, stupor, coma, Kussmaul’s respiration, fruity acetone breath
HHS
- mental disturbances, coma, - delirium, seizures
- polyuria
- nausea, vomiting
Hypoglycaemia
- Shakiness, anxiety, nervousness
- Palpitations, tachycardia
- Sweating, feeling of warmth (sympathetic muscarinic rather than adrenergic)
- Pallor, coldness, clamminess
- Dilated pupils (mydriasis)
- Hunger, borborygmus
- Nausea, vomiting, abdominal discomfort
- Headache
list possible causes for diabetic emergencies (for DKA, HHS, hypoglycaemia)
Ketoacidosis •New onset type 1 diabetes •Inadequate/inappropriate insulin therapy •Alcohol abuse •Infections
Hyperglycaemic hyperosmolar state
- forgetting to take insulin
- relative lack of insulin
Hypoglycaemia
- Sulphonylurea esp with renal impairment
- exogenous insulin
- alcohol
- lack of carbohydrate diet
What are the principles of management, and treatment plans for diabetic emergencies (DKA, HHS, hypo)?
Ketoacidosis
1) Rehydration
2) Correct electrolyte imbalance (Potassium)
3) Insulin therapy
4) Search for an underlying cause
Hyperglycaemic hyperosmolar state (HHS)
1) Fluids: 2L hypotonic saline (0.45%) over 1 to 2 hours or 1L 2 to 3 hourly
2) Monitor urine output and CVP if indicated
3) Insulin
4) Potassium
5) Prophylactic heparin (no evidence, but a good idea)
6) Search for an underlying cause
Hypoglycaemia:
1) Consider ability to take oral intake safely
2) Treat the hypoglycaemia
3) Sort out why the hypo happened
How do you advise patients on how to avoid developing diabetic emergencies?
- regular sugar checks
- regular meal times & appropriate dosing of exogenous insulin depending on carbohydrate intake
- tell people around pt of their diabetes emergency plan
- always carry some carbs with them (lollies)
What are the precipitating factors for ketoacidosis?
•New onset type 1 diabetes •Inadequate/inappropriate insulin therapy •Alcohol abuse •Infections –pneumonia –septicaemia –urinary tract •Myocardial Infarction/CVA •Inappropriate Insulin therapy •Pancreatitis •Drugs- corticosteroids & thiazides •No cause found - 20%
How do you treat ketoacidosis? 4 step principles
1) Rehydration
2) Correct electrolyte imbalance (Potassium)
3) Insulin therapy
4) Search for an underlying cause
How do you manage fluids in ketoacidosis treatment?
Must be individualized for each patient (modify if significant cardiac failure)
–1L N Saline over 30 minutes
–1L N saline over 1 hour
–1L N saline over 2 hours
Might use plasma-lyte (only has 100 mM chloride but does contain K+)
- CVP monitoring if significant cardiovascular disease
- Change to 5% Dextrose when glucose
How do you manage potassium in ketoacidosis treatment?
- Aim to maintain potassium between 3.5 and 5 mM
- If K+ 3.5 mM
- If K= > 5 mM, do not give K+, but check K+ every hour
- If K between 3.5 and 5 mM give 30 mM KCL in every liter of fluid to maintain K+ between 4-5 mM
- Make use that patient is not anuric before starting K replacement
How do you replace other electrolytes than K+ in ketoacidosis treatment?
- Bicarbonate - if very severe acidosis (pH 6.8).
* Phosphate- probably a good idea to replace in an ICU setting (no evidence to support it use)
How do you treat ketoacidosis with insulin?
- IM regimen- 0.1 units/kg/hour (regular insulin)
- IV infusion regimen- initially 6 to 8 units hourly via pump, then adjust according to BSLs
- Continue infusion until acidosis has resolved
- Then switch to sc insulin, eg Novorapid/Humalog 4-6 units tds & glargine/detemir 6 units nocte
What are the 4 rules for treating DKA?
- Rehydrate
- Do not give insulin until you know what the K+ level is
- Correct hyperglycaemia
- Diagnose a precipitating factor (if possible) and treat it
Describe Hyperglycaemic Hyperosmolar State (HHS)
- Severe hyperglycemia
- Minimal ketosis or ketoacidosis
- Profound dehydration
- Depressed sensorium or coma
- Effective Osmolarity > 330m Osm/kg
How do you treat Hyperglycaemic Hyperosmolar State (HHS)?
•Fluids:
- 2L hypotonic saline (0.45%) over 1 to 2 hours
- 1L 2 to 3 hourly
•Monitor urine output and CVP if indicated
•Insulin
•Potassium
•Prophylactic heparin (no evidence, but a good idea)
•Search for an underlying cause
What factor determines conscious state in Hyperglycaemic hyperosmolar state?
Osmolarity (GUN2)
Not the degree of acidosis
If a patient has a severely depressed conscious state and their osmolarity is not > 330 mosM, look for another cause
What are the 2 hyperglycaemic diabetic emergencies?
Diabetic ketoacidosis:
- T1D
- result of an absolute insulin lack
Hyperosmolar state
- T2D
- relative lack of insulin
