Diabetes
- Commonest by far is hypo
- Insulin
- Alcoholics
- Don't respond to glucagon (no reserves)
- Oral hypoglycaemics
- Neonates
- Management
- 200 ml 10% glucose
- Admit if on oral hypoglycaemics
- Long acting => Rebound hypo
- Can use octreotide (off-label)
- Send home for GP / clinic f/u if due to insulin
- If they don't wake up..
- Could be long hypo => neurological damage / cerebral oedema
- Could be Addisonian
- Cbeck cortisol
- Give IV hydrocortisone
DKA / HHS | DKA
| HHS
| Glucose
| 15 - 40
| 30 - 60
| Fluid deficit | 6 - 8 L
| 7 - 9 L
| Total K+
| Low
| Low
| Serum K+
| High
| Normal
| Sodium
| Normal
| >155
| pH
| Very low
| Slightly low
| Ketones
| +++
| +
|
- Management
- Fluids
- Replace 1/3 of deficit in first 24 hrs
- 1 L in first hour
- Add 20 mM K+ to second litre if K+ < 5 (as will fall rapidly)
- Twice-normal saline may be indicated in HHS, with senior input
- Insulin (actrapid)
- 6 U per hour while glucose >20
- 2 U per hour when glucose <20
- 2 U per hour + 10% dextrose when glucose <14, until ketones gone
Hyperkalaemia
- Causes
- Acidosis
- Addisons
- Renal failure
- Esp. pre-renal due to hypovolaemia
- Potassium-sparing diuretics
- Massive transfusion
- ACEi
- Rhabdomyolysis
- Haemolysis of sample
- Management
- 10 ml 10% calcium gluconate
- Repeat up to 30 ml if ECG changes persist
- 10 mg nebulised salbutamol, while you're drawing up the..
- 50mL of 50% dextrose with 10 units of soluble human insulin, over 15 mins
- Dialysis if required
PE
- Three (and only three) possible presentations
- Isolated SOB
- Pleuritic chest pain +/- haemoptysis
- Collapse
- They like to lie FLAT to better perfuse the lungs, unlike most other causes of SOB
- Give fluids (even if heart strain/raised JVP) for the same reason
- Risk factors
- Malignancy, Pregnancy, Obesity, Age, Immobilisation, >6 hr travel in last 4 weeks, Coagulopathy, Previous PE/DVT, FHx, Hormones
- Investigations
- CXR to exclude other causes
- May see wedge-shaped infarct
- ECG
- Sinus tachy.
- Non-specific ST/T wave abnormalities
- Right heart strain (RBBB, R axis deviation)
- ABG
- Wells score
- 0-2 => D dimer (i.e. ONLY if low pre-test probability)
- >2 straight to VQ scan (if CXR normal) or CTPA
- Management
- 5000 U heparin; Switch to LMW heparin once confirmed
- Thrombolysis for massive PE ONLY once you've done an echo:
- Confirm hypokinetic RV
- Exclude pericardial effusion
SAH
- TOP/ONLY DIAGNOSIS for sudden severe headache
- Sudden more important than severe (indicates vascular cause)
- CAREFUL not to miss it
- Investigations
- 95% show on CT (if within 6-12 hrs)
- Normal CT => Wait 12 hrs then LP for xanthochromia
- Give amlodipine + refer to neuro / interventional radiology for coiling
- Beware herald bleed
- Headache may get better; Still don't ignore
Notes- Yankauer suction tip
- Supraorbital pressure as alternative to trapezius pinch
- 3rd CN pressure => Blown pupil
- SBP
- >50 => Central pulse
- >80 => Radial pulse
- 5 sites of blood loss
- Abdo
- Pelvis
- Thorax
- Long bones (esp. femur)
- External
- FAST scan
- Hepatorenal (Morison's) pouch
- Splenorenal pouch
- Pelvis
- Pericardial space
- +/- chest for pneumothorax
- Can see a large aorta on USS, but NOT blood (retroperitoneal)
- Can infer rupture if symptomatic
- Hartman's better than saline due to risk of hyperchloraemic acidosis
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