Diabetic Emergencies

Hypoglycemia
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Diabetic Ketoacidosis
Hyperglycemic Hyperosmolar State
 Hypoglycemia
• Causes
• Signs and Symptoms
• Workup
• Differential Diagnoses
• Management
 Causes
. Delay in eating after taking insulin, or general
malnutrition or inadequate caloric intake from
acute nausea and vomiting or gastroparesis.
. Increased or unusual physical exertion.
. Increased physiologic stress resulting from
illness (most commonly infection or sepsis),
injury or emotional upset.
• Excessive insulin/OHA administration
• Pancreatic Beta cell tumor
 Signs and symptoms
• Catecholamine : sweating, tachycardia,
hunger, irritability, decreased concentration.
• Neuroglycopenia: altered mental status, visual
disturbance (blurred, diplopia, hallucination),
seizure like activity ( tremor, myoclonus), and
seizure, focal neurological deficit transiently,
syncope, coma.
 Investigations
• CBS (<3.0)
• RBS more reliable.
• Cause? Infection, MI, CVA
 Management
• Depends on conscious state and degree of
cooperation of patient
• Give 15-20 g simple and complex
carbohydrates eg sweets,3 tbsp sugar etc
• When mental function impaired:
1.Give IV D50% 25-50ml
2.Repeat every 10-15 minutes until mental
function recovers or CBS normalize
• Followed by IV D5/D10 infusion
• Glucagon 1 mg IM or deep S/C can be given to
treat severe hypoglycemia if IV access is
difficult (not suitable for hypoglycemia
secondary to sulphonylurea drugs, chronic
alcoholism or liver failure)
• Patient who remain unconscious after
prolonged hypoglycemia need to be given
treatment for cerebral oedema with IV
dexamethasone 4 mg 6 hourly or IV mannitol
or consider other causes of coma
• Proceed to head CT and laboratory test if
hypoglycemia has not recurred and longer
than 30 minutes after glucose admistration.
• Investigate and treat the underlying cause to
prevent recurrence
. Decreased clearance of insulin and OAD
secondary to renal failure
. Liver failure, sepsis, cardiac failure
. Others : insulinoma, addison’s disease,
hypopituitarism
 Diabetic Ketoacidosis
• A state of absolute/relative insulin bankruptcy
• Can occur in both type 1 and type 2 DM
• Usually due to:
Stopping insulin or reduction in dose
New onset T1 DM
Stress eg infection, trauma, surgery, MI,
stroke
 Signs and symptoms
• Polyuria, polydipsia
• Tachypnea (Kussmaul respiration), Acetone
breath
• Abdominal pain, vomiting
• Dehydration
• Hypotension
• Drowsiness, coma
 Diagnosis
• Hyperglycemia : RBS> 14
• Acidosis: pH <7.3, HCO3 <15
• Ketonemia/Ketonuria
 Other investigations
• FBC – often raised to 15-20 x 10^9/L but not
necessarily indicate infection ( any fever
however indicate sepsis and warrant antibiotic
therapy)
• Serum Na and K: K usually raised despite total
body deficit. Na normal or reduced
• Urea & Creat:often raised due to dehydration
• Others: CXR, UFEME,ECG, serum amylase
 Management
• Correct hypovolaemia/ dehydration
• Insulin therapy
• Potassium replacement
• Bicarbonate therapy ( if indicated)
• Investigate and treat underlying cause
• Watch out for complications of DKA and its
treatment
• Give N/S at 15-20 ml/kg/hr
• Then, if patient not hypotensive/hypoNa, give
½ N/S at 10-20ml/kg/hr over 2-4 hr
• Change to D5% when CBS <14
• Monitor hourly urine output
• Restoration of electrolyte imbalance:
• Serum K⁺< 3.3 mmol/l, give 20-40 mEq K⁺per
hour(1 g KCL = 14 mEq)
• Serum K⁺ 3.3-4.9 give 10-20 mEq K⁺ per hour
• Serum K⁺ > 5, withhold potassium but check
serum K⁺ 2 hourly
• If pH is <6.9 give 100ml 8.4% NaHCO3 dilute in
400ml NS and run over 2 hour
• Phosphate replacement indicated if serum
phosphate <0.3 mmol/l, or if patient anemic
or in cardiorespiratory distress
( IV KPo4 contain 15mmol/250ml, give at
0.5mmol/kg over 4-6 hours)
• Insulin administration:large
l doses not needed
to reverse DKA
• Hypoglycemia and hypokalemia more likely to
occur with large dose insulin
• Give bolus of 0.15 u/kg IV insulin followed by
low dose continuous infusion of 0.1u/kg/hr in
both adult and children
• Hourly CBS
Hyperglycemic Hyperosmolar State
• History of this condition runs to days rather
than hours for DKA
• Fluid loss tend to be greater than DKA
• Associated with high mortality, need to be
identified early.
• Most symptoms relate to severe dehydration.
• Kussmaul respiration and abdominal pain are
unusual findings.
• Absence of acidosis, small or absent serum
ketones, and hyperglycemia usually > 33.
 Diagnostic criteria
• CBS >33
• Arterial Ph >7.3, bicarb >15.
• Absence of severe ketonemia or ketonuria
• Serum total osmolality >330 mOsm/kg h20 or
effective serum osmolality (2 x Na + glucose
level + urea)> 320 mOsm/kg H20.
 Management
• Average fluid deficit 6-10 L
• One half of the estimated fluid deficit need to
be replaced over first 12 hours
• Give rapid bolus N/S until perfusion improve,
and BP stabilizes.
• Give 2 pint N/S in 1st hour, then 1 pint N/S
hourly, and switch to ½ NS over next 4 hrs.
• If patient hypertensive or significant
hypernatremia, use ½ NS
• Change to D5% when CBS <16
• Potassium depletion in HHS generally more
severe than DKA
• Serum K⁺< 3.3,give 20-40 mEq KCL in 1 hour
• Serum K⁺ 3.3-5, give 10-20 mEq KCL in 1 hour
• Serum K⁺>5 , withhold K⁺ but check serum
potassium every 1-2hour.
• Bolus insulin not needed since these patients
can be sensitive to insulin
• Give IV insulin at 0.1 u/kg/hr
• Adjust insulin infusion to keep CBS 14-16, until
serum osmolality < 315 mOsm/l and patient
mentally alert.