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DIABETIC EMERGENCIES

DIABETIC EMERGENCIES. Dr A Panahloo. www.sghms.ac.uk / addison. 1. Diabetic Ketoacidosis 2. Hyper-osmolar non-ketotic coma (HONK) 3. Hypoglycaemia. Diabetic Ketoacidosis (DKA). Definition:

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DIABETIC EMERGENCIES

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  1. DIABETIC EMERGENCIES Dr A Panahloo

  2. www.sghms.ac.uk / addison

  3. 1. Diabetic Ketoacidosis 2. Hyper-osmolar non-ketotic coma (HONK) 3. Hypoglycaemia

  4. Diabetic Ketoacidosis (DKA) Definition: ‘Severe uncontrolled diabetes requiring emergency treatment with insulin and IV fluids, and with a blood ketone body (acetoacetate and 3-hydroxybutyrate) concentration >5mmol/l’

  5. Diabetic Ketoacidosis (DKA) Biochemical features: • Hyperketonaemia • Metabolic acidosis • Hyperglycaemia

  6. Incidence and mortality • Annual incidence 1-5 episodes per 100 Type-1 diabetic patient • Peak in adolescence • Twice as common in females • Average mortality 5-10% • Mortality rises with age, 50% > 80 years

  7. Precipitating Factors • Infection (30%) • New cases of type-1 diabetes (10%) • Insulin error (patient or doctor) (13%) • Myocardial infarction (1%) • Unknown cause (40%) • Miscellaneous (6%)

  8. Differential DiagnosisCauses of anion-gap acidosis: • Ketoacidosis • Type-1 diabetes • Alcoholic abuse • Starvation (acidosis is mild) • Lactic acidosis • Chronic renal failure • Drug toxicity • Methanol (metabolized to formic acid) • Ethylene glycol (metabolized to oxalic acid) • Salicylate poisoning

  9. Clinical features-symptoms: • Polyuria and polydipsia • Weight loss and malaise • Weakness • Anorexia • Blurred vision • Nausea and vomiting • Abdominal pain, especially in children • Breathless (acidotic respiration) • Confusion and drowsiness • Coma (10% of cases)

  10. Clinical signs: • Dry mouth • Facial flush • Ketotic breath • Postural hypotension • Tachycardia • Kussmaul breathing (deep rapid resps.) • Depression of consciousness • Coma

  11. Fluid and Electrolyte Depletion: • Sodium 500 mmol • Chloride 350 mmol • Potassium 300-1000 mmol • Calcium 50-100 mmol • Phosphate 50-100 mmol • Magnesium 25-50 mmol

  12. Management • Rapid confirmation of diagnosis: • BM,smell ketones,urine ketostix • Blood: • Glucose, U+E,FBC,gases, blood cultures • Look for precipitating cause eg infection • Asses severity of dehydration • If comatosed nurse in coma position, naso-gastric tube and urinary catheter

  13. Other Investigations: • Ketone bodies • ECG • Chest X-ray • Urine and sputum for culture

  14. Management • Fluid replacement • Insulin • Correction of electrolyte imbalance

  15. Fluids • Deficit my be 5-10 litres • If systolic BP < 100mmhg or shocked • colloid or 500 mls N/saline over 15 min • then 1000 mls N/saline over 1 hour (no K+) • If not shocked • 1000 mls N/saline over 1 hour

  16. Fluids • Continue N/saline +K according to need • Asses BP, CVP and urine output • Repeat Glucose, U+E, blood gases 4 hourly • Convert to 5% dextrose infusion when BG < 15 mmol

  17. Insulin • Soluble insulin via a pump • No indication for bolus dose or s/c or IM injections • No indication for sliding scale • Aim to reduce glucose by 3 mmol/h • When glucose <15 mmol use dextrose • Continue insulin and dextrose until acidosis clears

  18. Potassium • Total deficit may be very high • K is intracellular, insulin and rising pH cause entry of K in cells • Serum levels may be high, low or normal and do nor reflect total body status • Main danger hypokalaemia • Replace 20-40 mmol K per litre of fluid

  19. Bicarbonate • Controversial • Contraindicated unless severe acidosis + cardio-respiratory collapse imminent • Shifts K+ into cells • Worsens hypokalaemia • CO enters brain reduces CSF pH • Cerebral oedema results • adverse O2 tissue delivery

  20. Complications • Cerebral oedema • Arterial and venous thrombosis • Secondary infection in urine, chest • Adult respiratory distress syndrome • Thrombophlebitis • Rhabdomyolysis

  21. Prevention • Sick day rules: • Never stop insulin and check for ketones • Measure BMs 4 times a day • If BM < 11 mmol continue normal insulin • If BM 11-17 mmol add extra 4 u with meals • If BM > 17 mmol add extra 6 u with meals Drink milk, fruit juice, 5 pints sugar free fluid /day • If nausea and vomiting and BM >17 call Dr.

  22. Hyperosmolar non-ketotic coma(HONK) • Non-ketotic hyperglycaemia • Relative insulin deficiency • BG much higher than DKA (>50 mmol) • Develops slowly over weeks • Severe dehydration • Impaired Consciousness • High serum Na >150 mmol/l

  23. HONK- Diagnosis • Raised plasma glucose (50- 100 mmol) • Increased plasma osmolality (> 340 mosm/l, measured in lab or calculated: • P.osmolality (mosmol/l) = 2 x [plasma Na+ + plasma K+] + plasma [glucose] + plasma [urea] • No ketosis and no acidosis

  24. HONK- incidence and mortality • Accounts for 10-30% of hyperglycaemic emergencies • Mortality 30% due to associated conditions and complications • Most patients age >50 years • Higher incidence in Afro-Caribbean patients • 50% undiagnosed diabetes

  25. HONK- Clinical features • Develops over several weeks • Polyuria, polydipsia • Gradual clouding of consciousness • Severe dehydration • Hypotension • Reversible neurological signs • Comatosed

  26. Comparison DKA:HONK DKAHONK AGE YOUNG TYPE-1 OLDER TYPE-2 CAUSE INSULIN DEFFICIENCY DIURETICS STEROIDS 50% UNKNOWN DM Na NORMAL / LOW HIGH GLUCOSE < 40 mmol > 40 mmol BICARBONATE < 14 mmol/l NORMAL KETONES POSITIVE NEGATIVE MORTALITY 5-10% 30-50 % COURSE TYPE-1 OFTEN DIET ALONE

  27. Fluids in HONK • Initial fluid, electrolyte and insulin therapy is similar to DKA • If Na >150 mmol/l half normal saline • Patients more sensitive to insulin • Start insulin infusion at slower rate eg 3 units / hour • Fewer K+ problems • Anticoagulation

  28. Hypoglycaemia • Common side-effect of treatment with insulin or sulphonylureas • Does not occur with Metformin or diet alone • Each year 25-30% of all insulin treated patients have one or more episodes of severe hypoglycaemia

  29. Hypoglycaemia • Predisposing factors • Inadequate food intake • Excess dosage, error by patient or Dr • Exercise • Weight loss • Alcohol • Adrenocortical, thyroid or pituitary failure • Renal failure

  30. Hypoglycaemia • Asymptomatic (biochemical), awake or asleep • Mild symptomatic- patient able to treat themselves • Severe symptomatic- help needed to treat hypoglycaemic attack • Coma

  31. Hypoglycaemia- hierarchy of events Blood glucose: • 4.6 mmol Inhibition of insulin secretion • 3.8 mmol Release of glucagon and adrenaline • 3.0 mmol Hypoglycaemic symptoms • < 2.8 mmol Cognitive function progressively impaired

  32. Hypoglycaemia - symptoms 1. Autonomic • Sympathetic or parasympathetic • eg sweating, palpitations, tremor or hunger 2. Neuroglycopenic • eg confusion, clumsiness, behavioural changes, temper tantrums in children

  33. Hypoglycaemia - symptoms • Acute • Lassitude • light headed • tremor • restless • cold sweat (diversion of blood from skin and kidneys to brain, liver and muscle)

  34. Hypoglycaemia - symptoms • Sub-acute • Slow movement and thoughts • Immobility • Slow speech • Detachment • Automatism and amnesia • Confusion • Drowsy • Manic

  35. Hypoglycaemia - symptoms • Chronic • Rare • Obsessional control of diabetes • Symptoms absent • Personality disorder • Apparent dementia

  36. Hypoglycaemia - treatment • Mild • Treat immediately with oral glucose (15-20g) • If patient unable to swallow • IV 50% dextrose 30-50 mls) • IM glucagon (1mg) • Patients should recover immediately • Failure to recover may be due to cerebral oedema, postictal state or other causes of coma

  37. Hypoglycaemia - treatment • Hypoglycaemia induced by sulphonylureas may be very prolonged • May need IV glucose for hours or even days

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