DIABETIC EMERGENCIES IN IMCU

1. DIABETIC EMERGENCIES IN IMCU DR.P.DHARMARAJAN M.D., Dip. Diab., Asst. Prof. of Diabetology, Dept. of Diabetology, Madras Medical College & Govt. General Hospital, Chennai – 600 003.

2. INTRODUCTION Management of Diabetes and Hyperglycemia in IMCU setting involves the diagnosis and management of two different situations. • Non-DM – a non-diabetic patient admitted to the IMCU and detected to have hyperglycemia for the first time. • DM – a known diabetic patient admitted to the IMCU with complications which may or may not be related to diabetes.

3. 1. Non-DM: A non-diabetic patient admitted to the IMCU and detected to have hyperglycemia for the first time may have one of the following: • Undiagnosed DM • Stress hyperglycemia

4. FH positive Symptoms + Ketosis + Not benign Irreversible GHb elevated FH negative Symptoms – Ketosis – Benign Reversible GHb normal Undiagnosed DMStress HG Management – control of HG with insulin, preferably

5. 2. DM: The differential diagnosis of a known diabetic patient admitted to the IMCU in a semicomatose or comatose state includes the following. • Hypoglycemia • DKA • HNAD (HNKC) • Lactic Acidosis • Alcoholic ketoacidosis • Other acute complications – AMI / CVA – Stroke / Head injury or Trauma / Drug overdosage or Poisoning

6. HYPOGLYCEMIA

7. HYPOGLYCEMIA • Diagnosis of hypoglycemia is essentially clinical. • Documentation of hypoglycemia requires the presence of Whipple’s triad namely, symptoms of hypoglycemia, biochemical documentation of low plasma glucose values and prompt resolution of symptoms with administration of glucose. • If prompt clinical recovery is not seen or if the patient has a prolonged coma for more than one hour think of irreversible cerebral damage or other alternative causes for coma thus revising the diagnosis.

17. DIABETIC KETOACIDOSIS

39. HNKC

41. Formula for calculating osmolarity - 2(Na+ K+) + PG in mmol + BU in mmol • Normal value - 290 to 310 mOsm / l • Level of consciousness worsens with increasing osmolarity

42. TREATMENT • Fluid management (Loss of TBW – 25%) • Insulin therapy • Management of Electrolyte disturbances • Treatment of the precipitating cause

43. LACTIC ACIDOSIS

44. LACTIC ACIDOSIS • Definition - Arterial WB lactate more than 5mmol/L -Arterial pH < 7.3 • May coexist with DKA • Classified into Type A & Type B • Can be caused by biguanides • Carries a high mortality rate

45. Persistence of increased AG in a case of DKA even after resolution of ketones indicates co-existent LA • Treatment – treat the underlying cause Vasodilators / Vasoconstrictors / Sodabicarb / Sodium dicloroacetate / Carbicarb Dialysis for MALA

46. ALCOHOLIC KETOACIDOSIS

47. ALCOHOLIC KETOACIDOSIS • May follow a heavy alcoholic binge • Can co-exist with DKA / LA • Treatment – treatment of acidosis

48. OTHERS - AMI • Prevalence and incidence more • Comp. younger age group affected • Males and Females equally affected • Severity and extent more • Morbidity and Mortality more

49. General principles of treatment of AMI in DM does not differ from Non-DM • Relief of pain / O2 / ABC / Thrombolytic therapy / Antiplatelet therapy / Anticoagulant therapy / ACEI / Beta blockers / Supportive measures • In complicated cases treatment of arrythmias / LVF / Shock / Emergency PTCA and CABG

50. GIK • GIK infusion – High Dose - Low Dose • HD – 25 % Dex. + 50 U PI + 80 mmol KCl at 1.5 ml/kg/hr – 24hrs • LD – 10 % Dex. + 20 U PI + 40 mmol KCl at 1 ml/kg/hr – 24 hrs