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