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â–º Med Misc 43 > ENDO - Diabetic emergencies > Flashcards

Flashcards in ENDO - Diabetic emergencies Deck (22):
1

What are the symptoms and signs associated with diabetic (hyperglycaemic and hypoglycaemic) emergencies?

DKA
- early: polyuria, polydipsia, malaise, nocturia, weight loss
- late: ŠŠanorexia, nausea, vomiting, dyspnea (often due to acidosis), fatigue, ŠŠabdominal pain, ŠŠdrowsiness, stupor, coma, ŠŠKussmaul’s respiration, ŠŠfruity acetone breath

HHS
- ƒƒmental disturbances, coma, - delirium, seizures
ƒƒ- polyuria
ƒƒ- 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

2

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

3

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

4

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)

5

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%

6

How do you treat ketoacidosis? 4 step principles

1) Rehydration
2) Correct electrolyte imbalance (Potassium)
3) Insulin therapy
4) Search for an underlying cause

7

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

8

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

9

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)

10

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

11

What are the 4 rules for treating DKA?

1.Rehydrate

2.Do not give insulin until you know what the K+ level is

3.Correct hyperglycaemia

4.Diagnose a precipitating factor (if possible) and treat it

12

Describe Hyperglycaemic Hyperosmolar State (HHS)

•Severe hyperglycemia
•Minimal ketosis or ketoacidosis
•Profound dehydration
•Depressed sensorium or coma
•Effective Osmolarity > 330m Osm/kg

13

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

14

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

15

What are the 2 hyperglycaemic diabetic emergencies?

Diabetic ketoacidosis:
- T1D
- result of an absolute insulin lack

Hyperosmolar state
- T2D
- relative lack of insulin

16

Explain the pathophysiology of DKA

Insulin deficiency -> Increased lipolysis -> Increased FFA (free fatty acids) -> ketone bodies -> DKA

17

Explain the pathophysiology of hyperglycaemic hyperosmolar state

Insulin deficiency -> Hyperglycaemia -> Glycosuria -> Polyuria -> Volume depletion -> Hyperosmolar -> HHS

18

How do you manage a hypoglycaemic episode in 3 steps?

Step 1. You need to ask- Is he alert and capable of taking oral intake safely

Step 2 – Treat the hypoglycaemia

Step 3 – Sort out why the hypo happened

19

How do you treat the hypoglycaemia (depending on the conscious state)?

•If conscious and cooperative
–oral fluids containing sugar eg. Orange juice, lemonade/ coke, milk with sugar

•If unconscious or risk of aspiration
–IV 50% dextrose (25-50 ml) via antecubital vein
–IM/SC Glucagon 1mg (if no IV)

•Administer longer acting CHO eg. sandwich

•Recheck glucose 20-30 minutes later and administer further treatment if required

20

Hypoglycaemia associated with (what) can be prolonged?

Sulfonylureas (Glibenclamide)

especially in the elderly with renal impairment (BSLs can still dip after initial correction of hypoglycaemia)

21

What are the early & late symptoms of DKA?

- early: polyuria, polydipsia, malaise, nocturia, weight loss

- late: ŠŠanorexia, nausea, vomiting, dyspnea (often due to acidosis), fatigue, ŠŠabdominal pain, ŠŠdrowsiness, stupor, coma, ŠŠKussmaul’s respiration, ŠŠfruity acetone breath

22

What is a normal blood ketone level & what should you seek help immediately?

Normal: 1.5 mmol/L (++ urine ketone level)

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