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Diabetic Emergency 糖尿病急症

Diabetic Emergency 糖尿病急症. 新光吳火獅紀念醫院 急診醫學科 林秋梅 醫師. Diabetes mellitus 糖尿病 ( 高血糖症 ). 定義 : 第一種是凡病人出現明顯之症狀　　　　　　如多尿、多渴、多吃、體重減輕、疲倦等加上任意血糖值在 200 mg/dl 以上即可。第二種是二次空腹血糖在 140mg/dl 或以上 分型 : Type I and Type II

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Diabetic Emergency 糖尿病急症

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  1. Diabetic Emergency 糖尿病急症 新光吳火獅紀念醫院 急診醫學科 林秋梅 醫師

  2. Diabetes mellitus 糖尿病(高血糖症) • 定義:第一種是凡病人出現明顯之症狀　　　　　　如多尿、多渴、多吃、體重減輕、疲倦等加上任意血糖值在200 mg/dl以上即可。第二種是二次空腹血糖在140mg/dl或以上 • 分型: Type I and Type II • Type I: inability of the pancreas to secrete insulin because of autoimmune destruction of the beta cells. • Type II: caused by other illnesses or medications

  3. 如何思考臨床問題? 你要問什麼?

  4. Diabetic Emergency • Types of diabetes mellitus • History: occur, clinical course, therapy • Duration of diabetes • Diabetes care • Clinical manifestation • Others

  5. 病例討論個案

  6. 病例一: • 22歲男性警察，2日來感到容易疲倦，喘，上腹疼痛，噁心想吐，數星期來消瘦許多 • Vital signs: BP:110/68 mmHg, PR: 120/min, RR: 22/min, BT:36.8 • Triage: II • 接下來，你會怎麼做?

  7. 病例一: history &PE • Past history: denied diabetes, hypertension, or other systemic disorder • Present illness: progressively dyspnea for 2 days, nausea and vomiting, epigastragia, poor appetite • P.E.: 上腹微微壓痛 • 接下來，你會怎麼想?

  8. 病例一: 分析並處置 • 喘:有何原因? 如何診斷和排除?證據何在? • 心臟 • 肺臟 • 腦部受創或出血壓迫 • 血液循環 • 腎臟 • 內分泌合併電解質異常 • 其他

  9. 病例一: 分析並處置 • 上腹微微疼痛合併噁心想吐 • Ulcer • Pancreatitis • AMI • Pneumonia • Cholecystitis • GB stones • … (傷腦筋) (笨蛋—護士小姐說:我ㄧ眼就看出來了!)

  10. 病例一: 分析並處置 • “馬爺”口訣: 乾瘦渴喘吐—測血糖 • F/S: high (爆錶!) • Arterial gas: PH: 7.102, PCO2: 16 mmHg, PO2: 98 mmHg, HCO3: 8.4 Na: 128, K: 5.7, urine ketone: 3+ 病人是什麼問題? 如何處置呢?

  11. 病例一: Diabetic ketoacidosis (DKA) • DKA is typically characterized by hyperglycemia over 300 mg/dL, low bicarbonate (<15 mEq/L), and acidosis (pH <7.30) with ketonemia and ketonuria. • Counterregulatory hormones, such as glucagon, growth hormone, and catecholamines, enhance triglyceride breakdown into free fatty acids and gluconeogenesis

  12. 病例一: Diabetic ketoacidosis • beta-oxidation of free fatty acids deplete extracellular and cellular acid buffers • hyperglycemia-induced osmotic diuresis depletes sodium, potassium, phosphates, and water as well as ketones and glucose

  13. 病例一: Diabetic ketoacidosis • Clinical manifestations; • Thirst, polyuria, polydipsia, nocturia • Generalized weakness, malaise/lethargy • Nausea/vomiting • Decreased perspiration • Anorexia or increased appetite • Confusion • Fever • Dysuria • Chills • Chest pain • Abdominal pain • Shortness of breath

  14. 病例一: Diabetic ketoacidosis • 誘發因素: • underlying or concomitant infection (40%), missed insulin treatments (25%), and newly diagnosed, previously unknown diabetes (15%). Other associated causes make up roughly 20% in the various series. • AMI • CVA • Trauma • Pregnancy • Others

  15. 病例一: Diabetic ketoacidosis • Management: • ABC stable • Hydration • Insulin • 計算Na, K 的缺少和假象 • Acidosis correct • Monitor: ABG, sugar, Na, K, urine output

  16. DKA management • Hydration: 1-2 L normal saline /half saline challenge • Monitor urine output • NPO initially

  17. DKA management • Insulin injection: • Continuous infusion: 0.1 u/kg/hr • F/S sugar >600, injection insulin?爭議 • F/S sugar 多少時要注意?

  18. Na 的計算 • Sodium: The osmotic effect of hyperglycemia moves extravascular water to the intravascular space. For each 100 mg/dL of glucose over 100 mg/dL, the serum sodium is lowered by approximately 1.6 mEq/L. When glucose levels fall, the serum sodium will rise by a corresponding amount

  19. K 的計算 • Potassium: This needs to be checked frequently, as values drop very rapidly with treatment. An ECG may be used to assess the cardiac effects of extremes in potassium levels

  20. NaHCO3 的補充 • PH <7.0-7.1 • HCO3 < 10 meq/ml • Basis excess: negative, 補充一半 • Monitor

  21. 病例二: • 65歲老太太，糖尿病10年。今天早上被發現意識不清而送急診。 • 診察病人，發現BP: 140/72 mmHg, PR: 92/min, RR: 24/min, BT: 39, GCS: E1M4V2, no trauma history • Triage: I • 接下來，你會如何做?

  22. 病例二: history and PE • DM history with oral hyperglycemic agents for 10 years • Malaise for 3 days • Fever was noted this morning • SOB without cough • P.E.: nothing special

  23. 病例二: 檢查 (Lab data) • Finger sting: high • BUN: 42, Cr: 1.7, Na: 120, K: 5.2 • U/A: WBC >100/HPF • 你還想知道什麼?

  24. 病例二: 檢查 (Lab data) • Sugar control • Chest X-ray • ECG • Serum WBC • Brain CT? • DM foot?

  25. 病例二: Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK) • Definition: 一般sugar >250 mg/dL, blood Osm.>320 • 你知道blood Osm.如何算嗎? • 你知道coma的病人，如何快速找到原因嗎?

  26. 病例二: HHNK • Calculated blood osm.: 2(Na+K)+sugar/18+BUN/2.8 有何意義?

  27. 病例二: HHNK • Patient present with Conscious change • 口訣:“ TIPS AEIOU” • 口訣: MODS • 口訣: sugar-O2-opioate-thiamine (Tx: DONE-dextrose, O2, naloxone, thiamine)

  28. 病例二: HHNK • Clinical manifestation • Precipitating factors: vomiting with dehydration, AMI, infection… • Neurologic deficits: drowsiness, delirium, coma, seizure, hemiparesis… • tachycardia, tachypnea, hyponatremia, hyperkalemia… • Hyperglycemia >600 mg/dL

  29. 病例二: HHNK • Precipitating factors correct: infection, AMI… • Management: • ABC 穩定 • Hydration: 0.5-1 L • Insulin infusion? • Underlying disease treat • Urine output monitor • O2, if necessary

  30. Thank you for your attention!

  31. Question and comment?

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