SIMMAN - Emergency conditions Flashcards
(38 cards)
What is the diagnosis?
- Brief: Pt has T1DM, blurred vision, headache, and lethargy, rapid breathing (Kussmaul), sweet/fruity/acetone breath.
- (confusion, reduced consciousness, tachycardia, hypotension, abdominal pain and or vomiting)
Diabetic ketoacidosis
Investigations for DKA
- Blood glucose: > 11.1 mmol/l
- Ketones: urine (2+ or more on dipstick), blood (> 3 mmol/l)
- VBG: metabolic acidosis (low bicarbonate and low pH)
- U&Es: assess renal function + monitor for any electrolyte imbalances (particularly potassium)
- Urinalysis: to look for UTI (can be precipitating factor for DKA)
Acute management of DKA
- Fluid replacement - 0.9% sodium chloride 1L over 1hr
(If hypotensive then give fluid bolus)
- IV insulin fixed rate infusion - e.g 50 units ACTRAPID in 50ml 0.9% NaCl (0.1 unit/kg/hour)
(continue long-acting insulin (eg. Lantus, Tresiba), stop short-acting insulin)
- Once blood glucose < 14 mmol/L, ADD 10% DEXTROSE AS A SEPARATE IV INFUSION
- Potassium replacement - unless K+ > 5.5 mmol/l
SIMMAN - DKA
Why is there a risk of cardiac arrhythmias in a pt with DKA?
due to significant electrolyte imbalances (particularly hypokalemia)
SIMMAN - DKA
How would blood glucose lvls be measured in this scenario?
point of care testing using a finger prick sample
SIMMAN - DKA
Urine dipstick for ketones or blood testing?
blood ketone testing preferred due to greater sensitivity and specificity
SIMMAN - DKA
Triggers for DKA
- non-compliance with insulin treatment
- acute infections (increases insulin requirements)
- new-onset diabetes
SIMMAN - DKA
Why is fluid replacement first priority in a DKA patient?
dehydration drives hyperglycaemia, worsening ketosis and acidosis
SIMMAN - DKA
Why is insulin given as an infusion and not a bolus?
if insulin given too quickly —> rapid glucose drop —> cerebral oedema risk
SIMMAN - DKA
Why is potassium replacement required?
insulin drives K+ into cells —> risk of hypokalemia and arrhythmias
SIMMAN - DKA
Why is dextrose 10% given once blood glucose < 14 mmol/l?
allows continued insulin administration without causing hypoglycaemia (need to continue insulin infusion to clear ketones and correct acidosis)
SIMMAN - DKA
DKA resolution criteria
- pH > 7.3
- blood ketones < 0.6 mmol/L
- bicarbonate > 15.0 mmol/L
.
(if this criteria met and pt is eating/drinking again then switch them back to subcutaneous insulin)
What is the diagnosis?
Brief: most likely a diabetic patient, sweating, tachycardia, pallor, tremors, hunger, confused, dizziness
Blood glucose: < 3.3 mmol/l
Hypoglycaemia
Acute management of hypoglycaemia
- If pt is alert: oral glucose 10-20g should be given in liquid form or sugar lumps
- If pt is confused, but conscious: Glucogel or Dextrogel (buccal absorption) - quick-acting carbs
- If pt is unconscious or unable to swallow: subcut or IM glucagon (1mg)
- Further management: IV 20% glucose solution
(note: if pt on IV insulin infusion —> STOP)
SIMMAN - hypoglycaemia
Causes of hypoglycaemia in a diabetic patient
- too much insulin
- sulfonylureas (eg. gliclazide)
- missed meals/fasting
- excessive exercise, alcohol, infection
SIMMAN - hypoglycaemia
Why do sulfonylureas increase the risk of hypoglycaemia in diabetic patients?
they act by increasing the secretion of insulin from beta-cells
SIMMAN - hypoglycaemia
Why can alcohol cause hypoglycaemia?
due to its inhibitory effect on gluconeogenesis and glycogenolysis
- gluconeogenesis = metabolic process that produces glucose in the liver and kidneys (triggered by low blood glucose lvls)
- glycogenolysis = process of breaking down glycogen into glucose, which the body uses for energy
SIMMAN - hypoglycaemia
Diagnosis of hypoglycaemia (Whipple’s triad)
- symptoms/signs of hypoglycaemia
- low blood glucose
- resolution of symptoms with correction of blood glucose
SIMMAN - hypoglycaemia
What is a ‘HypoKit’?
often prescribed to diabetic patients, contains a syringe and vial of glucagon for IM or subcut injection at home
SIMMAN - hypoglycaemia
Once hypoglycaemia has been acutely managed, what are your next steps in management?
once blood glucose > 4.0 mmol/l, give a long-acting carbohydrate (eg. toast, biscuits) + monitor closely + identify the cause and educate patient on hypoglycaemia
SIMMAN - hypoglycaemia
Contraindications for IM glucagon + what should be used instead?
glycogen depletion (eg. liver disease) - glucagon requires liver glycogen to raise blood glucose, if stores are depleted it will be ineffective —> use IV glucose instead
What is the diagnosis?
- Brief: fatigue, lack of energy, weight loss, low blood pressure, abdominal pain, vomiting, cramps, skin pigmentation
- PMH: adrenal insufficiency receiving exogenous steroids and type 1 diabetics
Addisonian crisis
Investigations in an Addisonian crisis
- electrolytes
- blood glucose
- ABG/VBG
- BP
- GCS
- Hyponatraemia and hyperkalaemia
- Hypoglycaemia
- metabolic acidosis
- Hypotension
- Reduced GCS
Acute management of an Addisonian crisis
- IM or IV hydrocortisone - 100mg STAT, followed by 200mg infusion over 24hrs (need to admit)
- IV fluids - fluid resuscitation first if needed
- IV 10% dextrose - if hypoglycaemic
- Correct underlying cause - eg. infection (antibx for sepsis), supportive care
(monitoring of electrolytes (esp. Na+ and K+) and fluid balance)
