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

• http://www.diabetes.nhs.uk/

Notes

• • 10% of people can't smell ketones

  • Hypos can be asymptomatic