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12.12.19 Diabetic emergencies

DKA
  • Don't forget - it might be a first presentation of diabetes!
  • Diagnosis
    • Hyperketonaemia (>5 mM)
      • Acetoaldehyde
      • 3-hydroxybutyrate
    • Metabolic acidosis
    • Hyperglycaemia
  • Differentials
    • Drugs
      • Methanol
      • Ethylene glycol
      • Salicylate
    • Alcohol
    • Starvation
    • Lactic acidosis
    • CRF
  • Unusual symptoms
    • Blurred vision
      • Change in lens shape
    • Breathlessness
      • Kussmaul
  • Mortality
    • Increases with age
    • >50% at 80 years
  • Depletion - Huge losses
    • 300-1000 mmol K+
    • 500 mmol Na+
  • Management
    • Fluids
      • Deficit may be 5-10 litres
      • Normal saline + K+
      • Check glucose 4-hourly and switch to 5% or 10% dextrose if <15 mM
    • Insulin
      • Constant infusion of soluble insulin
      • NO sliding scale
      • Aim for a glucose drop of 3 mM per hour
      • Continue UNTIL ACIDOSIS IS FIXED
      • Continue basal insulin if known T1DM
    • Electrolytes
      • The danger is hypokalaemia, as K+ drawn into cells
        • K+ might be almost normal on admission, but will drop quickly
    • Bicarb
      • Only if in extremis, with senior support
      • Risk of cerebral oedema

HONK/HHS
  • Differences with DKA
    • Glucose is higher (50 - 100 mM)
    • Hyperosmotic
    • Develops slowly (days - weeks)
    • No ketosis
    • No acidosis
  • Again, beware of first presentations
  • Cause
    • Steroids
    • Diuretics
    • Unknown
  • Much more dangerous than DKA - 30-50% mortality
  • Management
    • Slow insulin - 3 U/hr


Hypoglycaemia
  • Aetiology
    • Medications
      • Insulin
      • Sulphonylureas (act on beta cells)
    • Not eating
    • Alcohol
    • Weight loss
    • Adrenocorticoid, thyroid, pituitary failure
    • Renal failure
      • Reduced excretion of medications
  • Subacute symptoms
    • Slow movement and thoughts
    • Automatism + amnesia
    • Drowy
    • Manic 
    • Confusion
  • Management
    • Mild
      • 15-20 g of glucose
    • Unable to swallow
      • 50 ml of 50% dextrose IV
      • 1 mg IM glucagon
  • Sulphonylurea hypos
    • Tend to be very prolonged
    • Require hours/days of IV glucose

References

Notes
  • 10% of people can't smell ketones
  • Hypos can be asymptomatic
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