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