Diabetic Emergencies

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Diabetic Emergencies

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Diabetic Ketoacidosis

• Type 1 DM
• ve ketones
• art. pH lt 7.30
• bicarb. - lt15
• MEDICAL EMERGENCY

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Pathogenesis

• Insulin deficiency ?
• excess breakdown adipose stores ?
• Inc. fatty acids ?
• oxidised ?
• ketone bodies (rate of productiongtrate of
  degradation)

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Precipitating factors

• Acute infection
• Poor control
• Prepubertal girls monthly intervals
• Failure of compliance

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Epidemiology

• Commonest causes of DKA.
• Infections (30)
• Non-compliance with treatment (20)
• Newly diagnosed diabetes (25)

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GP Investigations

• BM serum glucose
• Urine dipstick - ?ketones
• Bloods
• Na (low usually)
• K (high on blood test, total body K
  invariably low)
• Urea (raised)

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Clinical features

• Acute onset
• Vomiting
• Abdominal pain
• Headache
• Thirst
• Polyuria
• Hyperventilation
• Drowsy/coma

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Clinical features cont

• Gradual onset
• Nocturia (nocturnal enuresis in children)
• Weight loss
• Lethargy

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Clinical features cont

• Severly ill can be in shock, oliguric/anuric
• NOTE Breath may smell of ketones

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Detecting dehydration in children

• Useful indicators
• Capillary refill time
• Abnormal skin turgor
• Respiratory pattern (Kussmaul breathing deep
  sighing)

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Management in GP

• Make diagnosis
• Fluid replacement (if poss.)
• Oxygen
• Consider NG (to stop aspiration/gastric
  dilatation)
• Insulin (give 10u iv whilst pump is being set up)

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Prognosis

• MORTALITY
• Developed countries 2-5
• Developing countries 6-24
• Under 28 years old susceptible to cerebral
  oedema during treatment (0.7-1.0)

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HONK (Hyperosmolar non-ketotic hyperglycaemia)
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DIAGNOSIS

• Very HIGH blood glucose - gt 30mmol/l
• Only trace/1 ketones in urine
• Very HIGH plasma Osmolarity
• 2(Na K) Urea Glucose

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• Accounts for 10-15 diabetic decompensation
• NOTE serum Na may be low due to
  redistribution of fluid into the extracellular
  fluid (secondary to high glucose level)

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Precipitating Factors

• Infection
• High Carbohydrate intake
• Thiazide diuretics
• Steriods
• Propranolol

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Clinical Features

• Consider HONK in
• ELDERLY
• Hyglycaemia
• Dehydration with excessive thirst
• Marked drowsiness

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Clinical features cont

• Other features
• Convulsions
• Coma
• Focal CNS signs
• HONK predisposes to thrombosis
• Hyperventilation is NOT a feature of HONK