DIABETIC EMERGENCIES

A GUIDE FROM THE CASUALTY

CREW

WHERE DOES ONE BEGIN

DIABETIC EMERGENCIES ARE SOME OF THE MOST COMMON LIFE THREATENING EMERGENCIES WE SEE

HOWEVER MOST INTERNS AND JUNIOR MO’S ARE POORLY EQUIPPED TO HANDLE THESE PATIENTS

WHY? BECAUSE WE HAVE VAST VOLUMES OF JUMBLED KNOWLEDGE ABOUT DIABETES IN OUR HEADS

IN THIS PRESENTATION I WILL HOPE TO SIMPLIFY THIS PROBLEM FOR YOU, STARTING WITH HYPERGLYCAEMIA IN THIS PRESENTATION AND TEACHING YOU HYPOGLYCAEMIA IN ANOTHER SHORTER SESSION

HYPERGLYCAEMIC EMERGENCIES

AT THIS STAGE I COULD BORE YOU WITH LONG DISCUSSIONS ON THE PATHOPHYSIOLOGY AND PRESENTATION OF PATIENTS

INSTEAD LET ME SAY THIS, YOU HAVE THREE POSSIBLE DIAGNOSIS AND YOU HAVE THREE PARAMETERS YOU NEED TO CHECK

HUH? WAIT WHAT?!!

YES, LETS GOOOOO………….

THE THREE DIAGNOSES

1:- SIMPLE HYPERGLYCAEMIA (SH)

2:- DIABETIC KETOACIDOSIS (DKA)

3:- HYPEROSMOLAR NON KETOTIC COMA (HONKC)

NB, WE WILL USE SH, DKA AND HONKC FOR THE REST OF THE PRESENTATION

THE THREE PARAMETERS

1:- URINE, A SIMPLE DIPSTIX

2:- LEVEL OF CONSCIOUSNESS , THE GLASGOW COMA SCALE

3:- BLOOD

3.1:- GLUCOMETER READINGS

3.2:- ARTERIAL BLOOD GAS

THE DIPSTIX

WE ASSUME IN THESE SCENARIOS THAT THE PATIENT HAS AN ELEVATED BLOOD GLUCOSE LEVELS

THE FIRST STEP IS THE URINE DIPSTIX, ARE THERE KETONES OR NOT

YES:- DKA

NO:- HONKC OR SH

LEVEL OF CONSCIOUSNESS

NORMAL :- SH OR DKA

DECREASED:- HONKC

THE ABG

SERVES A TWO FOLD PURPOSE

IT GIVES YOU A DEFINITE ANSWER ON THE SEVERITY OF THE CONDITION, ASSISTS IN MONITORING

IT TELLS YOU YOUR POTASSIUM LEVEL (WE WILL DISCUSS SOON)

SO IF A PT HAS A NORMAL LEVEL OF CONSCIOUSNESS WITH NO KETONES IN THE URINE IT IS AN SH

A PT WITH A NORMAL OR DECREASED LOC WITH KETONES IN THE URINE IS A DKA

A PT WITH A DECREASED LOC AND NO KETONES IN THE URINE IS A HONKC

GOT IT?!!

I KNOW I HAVE TO DO AN ABG FOR HONKC AND DKA, DO I HAVE TO DO ONE FOR SH?

YES!!

WHY?

A FEW REASONS

DEFINITELY EXCLUDE ACIDOSIS

HYPERNATRAEMIA, THESE PTS ARE OFTEN INTRAVASCULAR DEPLETED OF FLUID, HYPONATRAEMIA IS LESS COMMON

POTASSIUM LEVELS, MAY BE HIGH OR LOW DEPENDING ON THE STAGE OF THE ILLNESS OR PRODROMAL ILLNESSES SUCH AS AGE

LACTATE LEVELS MAY CAUSE AN ACIDOSIS THAT REQUIRES TREATMENT

CONFIRM GLUCOSE LEVELS

YOUR HAEMATOCRIT IS A GOOD INDICATION OF HYDRATION STATUS, HIGH IS BAD, LOW IS GOOD

SO NOW I CAN MAKE THE DIAGNOSIS

EASILYWHATS MY FIRST STEP IN

TREATMENT?

FLUIDS, FLUIDS, FLUIDS

THERE ARE VARIOUS REGIMENS DESCRIBED IN THE LITERATURE, I WILL DESCRIBE ONE I HAVE USED SUCCESSFULLY IN MANY PATIENTS

FIRST GIVE A BOLUS OF EITHER N SALINE OR RINGERS LACTATE, 250 ML IV AS QUICK AS POSSIBLE +- 15 MINS

THEN GIVE THE REMAINING 750 ML OVER THE NEXT 45 MIN, FOR 1 LT IN 1 HR

THEN GIVE ANOTHER LITRE OVER TWO HOURS

A THIRD LITRE OVER 6 HRS

A FOURTH LITRE OVER 12 HOURS

GIVING APPROXIMATELY 4LTRS OVER 24 HRS

THESE CAN BE ADJUSTED UPWARD OR DOWNWARD DEPENDING ON THE SEVERITY OF THE DEHYDRATION, BECAUSE REMEMBER, ALL THREE CLASSES ARE DEHYDRATED

IT IS IMPORTANT NOT TO OVER-HYDRATE AS T HIS WILL LEAD TO CEREBRAL OEDEMA WHICH HAS A HIGHER MORTALITY RATE THEN THESE EMERGENCIES

SO PLEASE DON’T ‘OPEN THE TAP’ AND ABANDON YOUR PATIENT, MONITOR YOUR FLUIDS

REMEMBER YOUR URINE OUTPUT IS

ALSO A GREAT GUIDE, CATHETERISE

EACH PATIENT

1ML/KG/HR IS A GOOD

GUIDE, A 100KG MAN

SHOULD MAKE 100ML

OF URINE IN AN HOUR

MOST OF YOUR PATIENTS WILL RESPOND WELL

TO IV FLUIDSDON’T RUSH TO BRING DOWN

THE PLASMA GLUCOSE

SOME SH PATIENTS WILL RESOLVE

ON FLUIDS ONLY BEFORE YOU

EVEN GIVE INSULIN THERAPY

BUT HOW SHOULD I BRING DOWN THE

PLASMA GLUCOSE ONCE THE FLUIDS HAVE

STARTED?

NOW THAT YOU'VE GIVEN FLUIDS YOU MAY CORRECT AN ACIDOSIS AND HIGH GLUCOSE LEVELS

ACIDOSIS IS TREATED VIA THE ADMINISTRATION OF SODIUM BICARBONATE ( DON’T ADMINISTER TOO QUICKLY, 50ML OVER 30 MIN, IT WILL ALSO PUSH UP SODIUM LEVELS!)

HOW DO YOU BRING DOWN GLUCOSE LEVELS? INSULIN OF COURSE,BUT….

WHAT ELSE DOES INSULIN LOWER?

POTASSIUM OF COURSE!!

I’VE HEARD RUMOURS THAT POTASSIUM IS QUITE ESSENTIAL, STILL HAVE TO VERIFY THAT (JUST KIDDING)

THIS IS WHY YOU DON’T START INSULIN IMMEDIATELY, AND WHY YOUR ABG IS SO IMPORTANT

IT DOES NOT POSE A HUGE PROBLEM IN HYPERKALAEMIA, AS YOU WOULD ONLY A OMIT GLUCOSE FROM YOUR K+ SHIFT REGIMEN, GIVING ONLY INSULIN (10U IV ACTRAPID FOR EG) AND CALCIUM GLUCONATE (10 ML)

HOWEVER IN HYPOKALAEMIA……

YOU HAVE TO SUPPLEMENT POTASSIUM WHILE GIVING YOUR INSULIN

AGAIN THERE ARE A FEW REGIMENS IN THE LITERATURE, I WILL GIVE YOU THE ONE WE USE CURRENTLY

K+ 0-2 , 60MMOL OF K+ SUPPLEMENTATION

K+ 2-3 , 40 MMOL K+

K+ 3-4 , 20 MMOL K+

K+ 4-4.5 , 10 MMOL OF K+

RUN IT IN AT 10 MMOL/HR

DON’T FORGET YOU WILL NEED AN ABG AFTER EACH INSULIN, K+, K+ SHIFT, INSULIN INFUSION, CONSIDER AN ARTERIAL LINE IN CONSULTATION WITH PHYSICIANS AND ICU STAFF FOR SERIOUS CASES

WHAT IF THE GLUCOSE LEVEL IS NOT DROPPING?

THERE MAY BE A FEW REASONS…

LOOK FOR UNDERLYING SEPSIS, A WET GANGRENE OF A LIMB CAUSING HONKC WILL BE VERY RESISTANT TO THERAPY

HAVE YOU GIVEN FLUIDS CORRECTLY?

IN SOME PTS WITH HONKC THE DEFICIT MAY BE UP TO 10L, AND YOU MAY HAVE TO GIVE MUCH MORE FLUID, AS MUCH AS 500ML/HR, OR REPEATED 250ML BOLUSES, IDEALLY UNDER DIRECTION OF THE PHYSICIAN

DOES THE PT NEED AN INSULIN INFUSION?

IF YES, DO I HAVE AN INFUSER?

IS THERE AN ICU OR HCU TO MONITOR THE PATIENT?

IF THE ANSWER IS YES THEN YOU MAY GIVE AN INFUSION

IF YOU HAVE THESE FACILITIES YOU CAN GIVE 0.1U OF INSULIN PER KG BODY WEIGHT PER HOUR

SO A 50KG PT WILL RECEIVE 5U PER HOUR, AND NO PATIENT SHOULD RECEIVE MORE THAN 10U PER HR

IN OUR PARTICULAR SETTING THE INFUSIONS ARE STARTED IN ICU, BUT IN HIGHER LEVELS HOSPITALS THE A&E COMMENCES TREATMENT

LETS TRY A CASE

27 YR OLD KNOWN DIABETIC PRESENTS WITH A GCS OF 14/15 AND GLUCOSE OF 32.

FAMILY REPORTS SHE HAS HIV AND HAS HAD SEVERE DIARRHOEA FOR TWO DAYS

WHAT ARE YOU TWO POSSIBLE DIAGNOSIS?

WHAT DO YOU DO?

THE URINE SHOWS 3+ KETONES.

WHAT IS YOUR DIAGNOSIS?

NOW FORMULATE YOUR TREATMENT PLAN BASED ON WHAT YOU HAVE LEARNED.

REMEMBER….

FLUIDS

THEN AN ARTERIAL BLOOD GAS

THEN INSULIN DEPENDING ON YOUR POTASSIUM LEVELS

HER BLOOD GAS SHOWS (I’ve only put the relevant parameters)

PH= 7.12, NA= 134, K= 2.2, HCT= 65% (HIGH), GLUC=33, LACTATE=2.3

DESCRIBE HOW YOU WOULD TREAT HGT AND K+ BASED ON WHAT YOU’VE LEARNED

SHALL WE TRY ONE MORE?

A 54 YR OLD NEWLY DIAGNOSED DIABETIC, IS RUSHED INTO THE A&E BY THE OUTPATIENT SISTER BECAUSE THE HGT IS HI !!

THE PATIENT IS FULLY CONSCIOUS

WHAT ARE YOUR TWO POSSIBLE DIAGNOSIS?

WHAT DO YOU DO NEXT?

THE URINE DIPSTIX SHOWS NO KETONES.

WHAT IS YOU DIAGNOSIS?

NOW TELL ME YOUR TREATMENT PLAN FOR THIS PATIENT

(or write it down) AND DON’T FORGET TO DO THE ABG!!!!

LAST ONE

A 67 YEAR OLD FEMALE PATIENT IS BROUGHT IN WITH A GCS 0F 9/15, A HISTORY OF A SEVERE UTI AND AN HGT OF HI

WHAT ARE YOUR TWO POSSIBLE DIAGNOSIS?

WHAT DO YOU DO NEXT?

THE URINE HAS NO KETONES.

WHAT IS YOUR DIAGNOSIS?

AGAIN, DESCRIBE YOUR TREATMENT PLAN BASED ON WHAT YOU HAVE LEARNED

IT IS IMPOSSIBLE TO COVER ALL THE INTRICACIES OF MANAGING SUCH PATIENTS IN A SHORT TEACHING PRESENTATION SUCH AS THIS

BUT I HOPE YOU WILL FIND IT MUCH EASIER TO APPROACH HYPERGLYCAEMIA IN THE FUTURE ,AND WILL LEARN THE SUBTLETIES AS YOU SPEND MORE YEARS IN THE FIELD

THANK YOU