FRCEMtutor

Question 10 of 166

A 55 year old attends the emergency department and discloses that he

always feels thirsty and has to pass urine every few hours. You send a
blood sample to check the patients glucose level.

Which of the following fasting plasma glucose levels is used as the cut
off for diagnosing diabetes mellitus in a symptomatic patient?

Fasting plasma glucose level ≥ 4.0 mmol/l 6%

Fasting plasma glucose level ≥ 5.1 mmol/l 13%

Fasting plasma glucose level ≥ 5.6 mmol/l 19%

Fasting plasma glucose level ≥ 7.0 mmol/l 53%

Fasting plasma glucose level ≥ 11.1 mmol/l 8%

Patients with symptoms of diabetes may be diagnosed with

diabetes if their fasting plasma glucose level ≥ 7.0 mmol/l

Patients with symptoms of diabetes may be diagnosed with diabetes by

confirming hyperglycaemia by one of the following tests:
HbA1c ≥ 48 mmol/mol (6.5%)
Fasting plasma glucose level ≥ 7.0 mmol/l
Random plasma glucose ≥ 11.1 mmol/l

Improve

Next question
Diabetes mellitus

Definition
Diabetes mellitus (DM) is a group of metabolic disorders in which
persistent hyperglycaemia (random plasma glucose more than 11.1
mmol/L) is caused by deficient insulin secretion, resistance to the action
of insulin, or both

Classification
Type 1 diabetes: absolute insulin deficiency typically the result of
autoimmune destruction of the pancreatic islet β-cells causes
persistent hyperglycaemia.
Type 2 diabetes: insulin resistance and relative insulin deficiency
result in persistent hyperglycaemia.
Gestational diabetes: hyperglycaemia develops during pregnancy
but usually resolves postpartum.
Other specific types of diabetes include monogenic diabetes,
diabetes secondary to pancreatic disease e.g. pancreatitis,
malignancy, trauma, cystic fibrosis, or haemochromatosis, diabetes
secondary to endocrine disorders e.g. acromegaly, Cushing's
syndrome, hyperthyroidism, or phaeochromocytoma & diabetes
secondary to drug treatment (usually corticosteroids).

Type 1 diabetes mellitus:

Accounts for around 5% of DM cases
Absolute insulin deficiency. GLUT-4 glucose transporters do not
incorporate into cell membranes
Autoimmune destruction of pancreas
Requires lifelong exogenous insulin

Type 2 diabetes mellitus:

Accounts for around 95% of DM cases
Insulin deficiency (but not absolute) and/or insulin resistance
Advancing age, obesity and genetic predisposition (family
history) are major risk factors
Diagnosis
Diagnosis of type 1 diabetes:
Based on clinical grounds in adults presenting with hyperglycaemia
(random plasma glucose more than 11 mmol/L).

Adults with type 1 diabetes typically present with one or more of the
following:
Ketosis.
Rapid weight loss.
Age of onset younger than 50 years.
Body mass index (BMI) below 25 kg/m2.
Personal and/or family history of autoimmune disease.

Suspect type 1 diabetes in a child or young person presenting with

hyperglycaemia and the characteristic features of:
Polyuria.
Polydipsia.
Weight loss.
Excessive tiredness.

Diagnosis of type 2 diabetes:

Suspect a diagnosis of type 2 diabetes in patients with persistent
hyperglycaemia that may or may not be accompanied by the following
features:
Polydipsia
Polyuria
Blurred vision
Unexplained weight loss
Recurrent infections
Lethargy
Acanthosis nigricans
Presence of risk factors

Persistent hyperglycaemia defining features

HbA1c ≥ 48 mmol/mol (6.5%)

 Persistent hyperglycaemia defining features

Fasting plasma glucose level ≥ 7.0 mmol/l

Random plasma glucose ≥ 11.1 mmol/l in the presence of
symptoms or signs of diabetes

Patients with persistent hyperglycaemia and clinical features of

diabetes can be diagnosed with diabetes

Patients with persistent hyperglycaemia but no clinical features

should only be diagnosed after repeat testing

Risk factors for developing type 2 diabetes mellitus

Obesity
Inactivity
Family history
Ethnicity (Asian, African, and Afro-Caribbean ethnicity are 2-4
times more likely to develop type 2 diabetes than white people)
History of gestational diabetes (women who develop gestational
diabetes have a 7 fold increase risk for developing type 2
diabetes)
Drugs (statins, corticosteroids, and combined treatment with a
thiazide diuretic plus a beta-blocker)
Polycystic ovary syndrome
Metabolic syndrome
Low birth weight for gestational age

Diabetes should not be diagnosed on the basis of a single abnormal

HbA1c or plasma glucose result. Repeat testing to confirm the diagnosis
is advised.

Note severe hyperglycaemia in people with acute infection, trauma,

circulatory or other stress may be transitory and is not diagnostic of
diabetes.
 Diagram showing the spectrum of diabetes diagnosis

Complications of diabetes

Acute metabolic osmotic emergencies

Diabetic ketoacidosis (DKA)
hyperosmolar hyperglycaemic state (HHS, previously termed HONK)

Macrovascular
Ischaemic heart disease
Angina
Myocardial infarction

Cerebrovascular ischaemia
TIA
Stroke

Peripheral vascular disease

intermittent claudication
Acutely ischaemic limbs
distal limb ischaemia e.g. toes
foot ulcers

Microvascular
Autonomic neuropathy
Resting tachycardia, postural hypotension, cardiac ischaemia,
sudden cardiac death
Gastroparesis, constipation/diarrhoea, oesophageal dysmotility
Erectile dysfunction, neuropathic bladder

Mononeuropathies
 cranial neuropathies, entrapment and pressure neuropathies and
radiculopathies.

Diabetic peripheral neuropathy

Sensory dysfunction (typically in glove and stocking distribution)
Foot ulceration
Charcot joint's

Diabetic nephropathy
Renail impairment (CKD)

Diabetic retinopathy
Blindness

Infections

Hypoglycaemia

Definition
Hypoglycaemia is a lower than normal blood-glucose concentration. It is
defined by NICE as blood glucose <3.5 mmol/L. The RCEM advises a
blood glucose level below 4.0 mmol/L in diabetic patients should prompt
treatment for hypoglycaemia.

True hypoglycaemia is defined by Whipple's triad and requires all three of

the following:
Signs and symptoms of low blood glucose
A low blood plasma glucose concentration
Relief of symptoms after correcting low blood glucose

What blood glucose level is hypoglycaemia?

Whilst NICE define hypoglycaemia in their clinical knowledge
summary as blood glucose <3.5 mmol/L there is a large degree of
inconsistency across the literature. The BNF and CDC for instance
use a threshold of ≤ 3.9 mmol/L). Diabetes Uk advise that a blood
glucose of 4.0 mmol/L should be the lowest acceptable blood
glucose level for people with diabetes. The RCEM echo's diabetes
UK and advises glucose levels below 4 mmol/L indicate
 hypoglycaemia and need treatment.

In diabetic patients glucose levels below 4 mmol/L indicate

hypoglycaemia and need treatment.

In children finding a consistent diagnosis is even more challenging.

A blood glucose level ≤2.6 mmol/L is widely considered to confirm
the diagnosis of hypoglycaemia but readings between 2.6 and 3.5
are often considered borderline.

Hypoglycaemia
Hypoglycaemia most commonly occurs in diabetic patients. It may
lead to brain damage or death so requires prompt treatment.

Signs & symptoms

Adrenergic or Non-
autonomic Neuroglycopenic specific

Sweating Confusion Hunger

Hunger Coma Headache

Tremor or shaking Convulsions Nausea

Hunger Focal neurological deficits

Speech difficulties
Nausea

Pallor Incoordination

Tachycardia Unusual behaviour including

aggression
Treatment options in adults
If able to take oral medication:
Oral carbohydrate: 15-20g of a quick acting carbohydrate should be
followed by a long acting carbohydrate. Soft drinks such as
Lucozade may be used but the carbohydrate content should be
checked carefully.
Buccal Glucose Gel: Absorbed more quickly than complex
carbohydrates and is easily administered. The patient should be
able to swallow in order for it to be fully effective.

If oral route or oral medication not available:

Glucagon: Glucagon 1 mg IV, IM or SC. Useful in situations where
behaviour, co-operation or other neuroglycopenic symptoms make
oral or IV routes difficult. Repeated doses are not advised. Glucagon
will be less effective in those with depleted glycogen reserves e.g.
sulphonylurea treatment, malnourished, or excessive alcohol
consumption.
Dextrose: 10-20% dextrose (glucose) may be used. Typical doses
are 75-80 ml 20% glucose or 150-160 ml of 10% glucose. 50%
dextrose is highly irritant and risks extravasation injury.

Glucose levels should be re-checked 15 minutes after treatment.

Treatment may be repeated following 10-15 minutes.

Treatment options in children

If able to take oral medication:
Glucose 5-20 g in liquid form (Glucogelµ, Dextrogelµ, or Rapiloseµ)
or granulated sugar or sugar lumps. May be repeated after 10-15
minutes if required. Patient should be fed to prevent recurrence of
hypoglycaemia.

if sugar cannot be given by mouth and IV access unavailable:

Glucagon (if child aged < 8, body weight < 25 kg dose is 500
microgram)
If not effective in 10 minutes give IV glucose

if sugar cannot be given by mouth and IV access available:

2 mL/kg of 10% glucose IV as bolus followed by 10% glucose IV
infusion at a rate of 5 mL/kg/hour
Carbohydrates should be given as soon as possible after treatment
 Glucose gel dose
The dose of 40% glucose gel is approximately 0.3 g/kg. Each 25g
tube contains 10g of carbohydrate. The table below shows the
number of tubes of glucose gel to use based on weight:

Weight up to Dose in number of tubes

20 kg ½ tube

30 kg 1 tube

40 kg 1½ tubes

50 kg 1½ tubes

60 kg 2 tubes

The bnf also suggests dosing by age as follows (keep in mind that
children who weigh over 60kg should receive adult dose i.e. 20g / 2
tubes):

Age Dose

Children <5 5g or ½ tube

Child 5-11 years old 10g or 1 tube

Child 12-17 years old 15g or 1½ tubes

Treatment of neonatal hypoglycaemia

Treat with glucose IV infusion 10% given at a rate of 5 mL/kg/hour.
An initial stat dose of 2 mL/kg over five minutes may be required if
hypoglycaemia is severe enough to cause loss of consciousness or
fitting.
Mild asymptomatic persistent hypoglycaemia may respond to a
single dose of glucagon.
If hypoglycaemia is caused by an oral anti-diabetic drug the patient
should be admitted as the hypoglycaemic effects of these drugs
may persist for 12-24 hours and ongoing glucose infusion or other
therapies such as octreotide may be required

Patients who have a hypoglycaemic episode with a loss of warning

symptoms should not drive. It is the doctor's duty to inform the
patient of this and to explain their responsibility to notify the DVLA.
This should be documented in the patient notes and wherever
possible, written advice should be provided and the patient's GP
informed.

Next question

              

Textbooks

High-yield textbook

Links

RCEM Learning 0 0

Hypoglycaemia

NICE 0 0

Diabetes type 2
 Report broken link

Score: 40%

1
2
3
4
5
6
7
8
9
10

All contents of this site are © 2024 FRCEMtutor Back to top