Diabetic Emergencies

CUCMS Final Year

Teaching Module

Dr Nor Shuhaila Shahril

CASE 1
 Case 1
• 20 year old college student, brought in by mother
• Known case of type 1 diabetes mellitus (DM)
• Just returned from trip to Langkawi island
• c/o 3 days history of fever and diarrhoea with
nausea and vomiting
• Unable to eat
• Only tolerate sips of fluids
• Has not taken her insulin for past 3 days as she
was not able to eat
What other information would you like to know?

• How was her glucose control for past 3 days?

• Any glucometer readings?
• What has she been drinking?
• How many times has she been vomiting?
• How frequent is her urination?
• Any change in mental status?
 Case 1
• Appeared weak, drowsy
• Tongue coated
• Respiration deep and rapid
• Breath fruity smell

CAN YOU EXPLAIN THE PHYSICAL SIGNS?

WHAT MAY THE UNDERLYING DIAGNOSIS?

 Physical examination
• Signs of dehydration
• Nausea and vomiting can worsen both dehydration
and electrolyte losses which often precede the onset
of coma (occurring in 10% of cases)
• Fruity breath smell
• Smell of ketones (like nail varnish remover)
• Rapid and deep breaths
• Air hunger(Kussmaul’s breathing)
• Suggesting acidosis
 Case 1
• BP 90/ 60 mmHg
• HR 124/min
• RR 36/min COMMENT PLEASE.
• T 39C, Skin warm and flushed
• CVS S1S2
• Lungs minimal creps Lt base
• PA soft, mild epigastric tenderness but no
rebound or guarding, BS+
 Physical examination
• Hypovolaemia at presentation is usually at least
5L deficit
• Check for postural hypotension
– Exacerbated by peripheral vasodilatation due to
acidosis
• Electrolyte losses of:
• 300 -700 mmol of sodium
• 200 – 700 mmol of potassium
• 350 – 500 mmol of chloride
Note: daily intake of Na and K is 60 mmol
 Physical examination
• Examine for signs/ source of infection.
• E.g. Pneumonia/ UTI/ Cellulitis
 Precipitants of DKA
Infection 30 – 40%
Non-compliance to treatment 25%
Inappropriate alterations in insulin 13%
(i.e. errors by patient or doctor)
Newly diagnosed diabetes 10 – 20%
Myocardial infarction 1%
 Case 1
• Dextrostix reading: 23 mmol/l.
• You made a diagnosis of DKA.
• What investigations would you like to send?
 Investigation in DKA
• FBC
– Leucocytosis (infection/ DKA)
• Renal profile
– Elevated urea/ creatinine (dehydration), pseudohyponatraemia,
baseline K level
• ABG
– low pH and HCO3 (acidosis), pCO2 low due to hyperventilation
• RBS
– Quantify serum glucose level
• Blood/ urine cultures
– Detect infection (precipitating factor)
• CXR
– Look for signs of pneumonia (precipitating factor)
• ECG
– Changes suggestive of MI (precipitating factor)
 Diagnosis of DKA
• Usually based on a collection of biochemical
abnormalities:-
• Hyperglycaemia > 11.1 mmol/l
• Acidosis
• pH < 7.3
• serum bicarbonate HCO3 < 15 mmol/l
• base excess BE < -10
• Ketonuria
• Dipstix only check for acetoacetate and acetone (not -
hydroxybutyrate)
 Case 1
• FBC: Hb 11.9 TWC 19.2 Plt 365
• BU 15 Na 132 K 4.0 Cl 90 Creat 154
• RBS 24
• pH 7.2 pO2 100 mmHg pCO2 25 mmHg
• HCO3 9 BE – 13 O2 sats 98%
• CXR Lt LZ consolidation
• ECG sinus tachycardia
• UFEME ketones 3+, glucose 4+, prot 1+, RBC nil.
Correction for hyponatraemia = Na+ + 2.4 [(glucose – 5.5)/ 5.5)]
 Case 1
• What is the next step of management?
a. Start IV antibiotics
b. Rehydrate patient
c. Give insulin
d. Add potassium supplement
e. Monitor blood glucose every hour
f. Monitor urine output every hour
g. All of the above.
 Intravenous hydration
• IV 0.9% saline
• Run 2L in 2 hrs (15 – 20 ml/kg for first 1 hr)
• Then 1L in 2 hr,
• Then 2L in 8 hr,
• Then maintain 4L/day
• Convert to dextrose saline or D5% when blood
glucose < 11 mmol/l (usually need 3 – 6 units/hr)
– Dextrose-based fluids to prevent further ketosis
 If in profound shock
• SBP < 80 mmHg with severe dehydration or
sepsis or oliguric
• Fluids may need to be given more rapidly
• Colloids may be needed
• If elderly or signs of heart failure or cerebral
oedema – give fluids more slowly.
– Consider setting in a central venous line.
 Case 1
• Which insulin regime are you going to use?
a. SC Actrapid 8 iu TDS
b. SC Actrapid 10 iu TDS with SC Insulatard 14 iu
ON
c. IV Actrapid infusion 6 iu/hr
d. IM Actrapid 10 iu stat
 Insulin
• Continuous IV infusion
• 50 units of soluble insulin in 50 ml of 0.9%
saline
• Give at 6 – 8 units/hr (0.1 iu/kg/hr)
• Aim to drop glucose by about 5 mmol/l per
hour
• Adjust to keep blood glucose around 8 – 11
mmol/l
 Potassium supplement
• K+ deficit around 3-5
mmol/l
• But acidosis increases K+
• Plasma K+ falls as K+ K+ to be added K+ level (mmol/l)
enters cells with 40 mmol <3
treatment 30 mmol 3.0 – 4.0
20 mmol 4.1 – 5.0
• Add to saline drip (1g KCl
= 10 mmol/l)
• Replace only when there
is urine output
 Case 1
• How should you monitor the patient?
• Dextrostix hourly
• BUSE/RBS 2hrly
• ABG 2-4 hrly

• Reduce frequency of tests once stabilized

• Check RP at least daily for next 72 hrs.
• Also check Mg and PO4 levels (may be low)
 Case 1
• General condition of patient improved over
next 18 hours.
• She is more alert. Taking sips of clear fluids.
• Her dextrostix ranges around 9 – 10 mmol/l
on IVD D/Saline with IVI Actrapid 3 iu/hr
• BU 7.6 Na 140 K 4.1 Creat 67
• ABG pH 7.35 HCO3 23 BE – 2
• What is the next step of management?
 Subsequent treatment
• Change to SC insulin regime when:-
• Blood glucose stable in 10 – 15 mmol/l range
• Ketoacidosis settled
• Patient eating and drinking normally
• Overlap IV and first dose of SC Actrapid by 2
hrs
• Once IV potassium supplements have
stopped, give oral supplements for at least 48
hrs with regular serum monitoring.
 Case 1
• Her dextrostix ranges around 9 – 10 mmol/l
on IVD D/Saline with IVI Actrapid 2 iu/hr
• So how much of SC Insulin are you going to
give?
a. SC Actrapid 12 iu tds
b. SC Actrapid 8 iu TDS and SC Insulatard 24 iu ON
c. SC Actrapid 12 iu 6hrly
d. SC Insulatard 12 iu BD
 Changing from IVI to SC Insulin
• Total insulin requirement per day
• IVI Actrapid 2 iu/hr
• Total requirement = 2 X 24 = 48 iu/day
• Divide by 2
• 1st half = total dose of short-acting insulin – so
divide further by 3 to get each pre-meal insulin
dose
• 2nd half = dose of bedtime intermediate insulin
• Hence SC Actrapid 8 iu TDS, SC Insulatard 24 iu
ON.
 Additional therapies (1)
• IV bicarbonate rarely indicated
• Can cause hypokalaemia and paradoxically worsen
intracellular acidosis
• Use if pH < 6.9
• Give 250 ml of 1.26% NaHCO3 over 30 – 60 mins
initially (or 1 ml/kg of 8.4% NaHCO3)
– Avoid 8.4% NaHCO3 as its high Na load can rapidly alter
electrolyte levels and precipitate pulmonary oedema as
well as causing local tissue necrosis if it extravasates.
• Do ABG to assess response, aim for pH no greater than
7.1
 Additional therapies (2)
• SC Heparin prophylactic dose in the
unconscious or immobile patient
• Cerebral oedema typically presents 8 – 24 hrs
after starting IV fluids
– Declining conscious level
– Mortality as high as 90%
– If this occurs, may give dexamethasone (12 – 16
mg/day) and mannitol (1-2g/kg body weight)
CASE 2
 Case 2
• 60 year old Malay man
• Known type 2 Diabetes for past 7 years
• Brought into Casualty in a drowsy state.
• Wife who was with claimed that he had
complained of central chest pain early that
morning.
• He had been having poor appetite for past 8
days with fever and dysuria.
 Case 2
• According to the wife, he has been having
polydipsia and polyuria for past 2/52.
• He was recently seen in the Endocrine Clinic
3/52 ago.
• He was started on basal bolus insulin regime
after several years of treatment with oral
hypoglycaemic agents.
• However, his wife reported that he has not
been taking his insulin regularly.
 Case 2
• Drowsy, mumbling irrelevantly
• Febrile 39C
• Tongue coated
• 120/87 mmHg, PR 100/min regular small volume
• CVS S1 S2
• Lungs clear
• PA soft, non-tender, no organomegaly, BS+
• No focal neurological deficit
 Case 2
• Dextrostix done: HI
• FBC Hb 15.4 Plt 410 TWC 20.9 Neut 92%
• BU 23.4 Na 145 K 5.2 Creat 124
• RBS 45
• pH 7.39 pO2 98 PCO2 38 HCO3 21 BE -3
• UFEME prot 4+, RBC 2+, leuc numerous, nitrite
positive
• What other investigations would you like to do?
 Calculate the serum osmolarity
• 2X (Na + K) + urea + glucose
• 2 (145 + 5.2) + 23.4 + 45 = 368.8

• What is the underlying diagnosis?

1. Acute anterior myocardial infarction

2. Hyperosmolar Hyperglycaemia State (HHS)
3. Urinary Tract Infection
 Diagnosis of HHS
• Hyperglycaemia (usually 30 – 70 mmol/l)
• High serum osmolarity (> 350 mmol/kg)
• No acidosis
– arterial pH 7.35 – 7.45
– HCO3 > 18 mmol/l
– But lactic acidosis with infection or MI may alter
this
• No ketonuria
– May have 1+ with starvation and vomiting.
 Case 2
• How do you manage this patient?
a. IV antibiotics
b. Admit CCU and give streptokinase
c. IV hydration with 0.9% saline
d. IVI Actrapid
e. All of the above
 Management of HHS
• Similar to ketoacidosis
• Fluid, electrolyte and insulin replacement
• But HHS occur in older patients, hence:-
• Fluid regime less rapid. Consider CVP monitoring.
1L 0.9% saline over 1 hr, 1L 2 hrly for next 2 hrs,
then 1L 4 -6 hrly
• Fluid deficit 9 – 10 L
 Management of HHS
• If hypernatraemic (Na > 155 mmol/l) consider
0.45% saline (to reduce risk of cerebral
oedema – serum osmolality/ sodium altered
to rapidly)
• A gentler insulin regime needed with 3-6
units/hr IV
• Aim to reduce blood glucose by a maximum of
5 mmol/hr
– To avoid precipitating cerebral oedema.
 Subsequent treatment of HHS
• Continue IV fluids and insulin for at least 24
hrs after initial stabilization
• Then convert to maintenance therapy such as
SC Insulin or oral hypoglycaemic agents.
• Educate patient to avoid further episodes.
CASE 3
 Case 3
• 82 year old Chinese lady
• 9 year history of type 2 diabetes mellitus
• Brought in by family
• Noted unarousable at breakfast with profuse
sweating.
• Poor appetite for past 2 days
• Nausea with 3 episodes of vomiting.
 Case 3
• Denies fever/ cough/ diarrhoea
• Compliant to her diabetic medication
(Glibenclamide 10 mg BD and Metformin 1 gm
BD) but did not take any medication on day of
admission.
• Has been complaining of numbness of her feet
for past 1 year with deteriorating vision.
• Had laser therapy to both eyes 2 months ago.
 Case 3
• She also has underlying hypertension on
propanolol 40 mg BD (had history of
palpitations)
• No history of thyroid disease.
• Non-smoker, no alcohol.
 Case 3
• Unconscious, laboured breathing
• Eye opening to pain, incomprehensible sounds
and localizing to pain.
• Sweaty, cold peripheries
• Afebrile
• BP 100/70 mmHg, PR 100/min irregular
• CVS/ Lungs/ Abdomen – unremarkable.
• Negative Babinski.
 Case 3
• What is the differential diagnosis?
1. Hypoglycaemic coma
2. Stroke (in view of AF)
3. Encephalitis
• What simple bedside test would you like to
do?
– Dextrostix
 Case 3
• Dextrostix : 1.9 mmol/l
• What is your next step of management?
a. Send for RBS stat
b. IV Dextrose 50% bolus
c. IV Dextrose 5% infusion
d. Consider CT scan
e. All of the above.
 Hypoglycaemia
• Biochemical diagnosis
• Blood glucose < 2.5
mmol/l
• Send serum for blood
glucose, insulin and C-
peptide will confirm
diagnosis and may help to
determine the cause.
Signs and symptoms of hypoglycaemia

AUTONOMIC NEUROGLYCOPENIA
• Sweating • Confusion
• Pallor • Tiredness
• Anxiety • Lack of concentration
• Nausea • Headache
• Tremor • Dizziness
• Shivering • Altered speech
• Palpitations • Incoordination
• Tachycardia • Drowsiness
• Aggression
• Coma
 Hypoglycaemia symptoms
• Autonomic symptoms usually occur first when
blood glucose < 3.6 mmol/l
• But some drugs such as non-selective B-
blockers and alcohol may mask these with
neuroglycopenia (at blood glucose < 2.6
mmol/l) then causing confusion without
warning
• Some patients lose these predominantly
autonomic warning – higher risk of injury.
 Case 3
• How much dextrose would you give?
a. Bolus 50 – 100 mls D50%
b. Bolus 200 – 300 ml of D10%
c. Infuse D5% 50 mls/hr
d. Any of the above.

Other option:
IM/ IV Glucagon 1 mg (does not work for drunk patients)
 Case 3
• What other blood investigation would you like
to do in her?
 FBC: leucocytosis to suggest underlying infection
 RP: renal impairment (CRF)
 LFT: liver failure
 TFT: concurrent thyroid disease
 Case 3
• After D50% 50 mls, patient became more
arousable.
• Able to open her eyes and answering simple
commands. Breathing back to normal.
• Dextrostix reading = 3.0 mmol/l
• What would you do next?
a. Start IVI D10%
b. Encourage orally
 Management of hypoglycaemia
• Conscious patient
– Oral carbohydrate (20 – 30g)
often sufficient
– Glass of milk or orange juice
– Having raised the sugar
rapidly, then give something
to maintain a normal blood
glucose level such as 2
digestive biscuits
 Management of hypoglycaemia
• Unconscious patient
– 25 – 50 mls D50% or IM/ SC Glucagon
• Glucagon mobilizes glycogen from liver and will not
work if given repeatedly or in starved patients with no
glycogen stores.

– If prolonged treatment needed or starved patient,

maintain on IV glucose D10%
 Case 3
• 2 hours later, she became drowsy again.
• Dextrostix 1.4 mmol/l
• Another 50 mls D50% bolus given
• Why do you think this has happened?

RECURRENT HYPOGLYCAEMIA
 Case 3
• FBC Hb 12 TWC 13 Plt 365
• BU 15 Na 135 K 3.9 Creat 300
• LFT AST 23 ALT 24 Bili 10 Alb 42
• TFT normal limits
• Urine prot 4+, Leuc 5+, nitrite present.
• Please comment.
Subsequent management
• If recurrent hypoglycaemia,
– suspect renal or liver failure.
• Sulfonylurea therapy can cause hypoglycaemia
due to beta cell stimulation.
– Most commonly seen from glibenclamide,
especially in the elderly and those with reduced
renal excreting ability.
– But can occur in anyone taking this therapy and
fasts, especially with longer acting agents such
chlorpropamide.