Diabetic Emergencies



Diabetic Emergencies


Amina Lalani



Introduction



  • Type 1 diabetes accounts for 5-10% of all diabetes


  • 50% of type 1 DM present in childhood


  • Trend toward lower age at presentation


  • Pancreatic β-cell destruction results in insulin deficiency


  • Often associated with other autoimmune diseases: thyroid disorders, Addison’s disease, celiac disease, vitiligo


  • Major emergencies



    • Diabetic ketoacidosis


    • Intercurrent illness


    • Hypoglycemia


  • Complications:



    • Microvascular: retinopathy, nephropathy, neuropathy


    • Macrovascular: cardiovascular, cerebrovascular, peripheral vascular


  • Hemoglobin A1c: Measure of glycemic control over last 90-120 days


Canadian Diabetes Association Clinical Practice Guidelines



  • Insulin is given as multiple daily injections: NPH or ultralente given once or twice daily with boluses of regular insulin before meals


  • Recently fast-acting (insulin aspart and insulin lispro) and very long acting insulin analogs (insulin glargine or detemir) available


  • Use of insulin pumps is increasing: fast-acting insulin provided at a continuous rate, with boluses before meals









Table 43.1 Targets for Plasma Glucose and HbA1c



















AGE (YRS)

PLASMA GLUCOSE (mmol^L)

HBA1C (%)


<5

6-12

≤9


5-12

4-10

≤8


13-18

4-7

≤7



Diabetic Ketoacidosis (DKA)



  • Most frequent cause of death due to diabetes in children


  • Risk of mortality < 0.5%


  • Rate of presentation in DKA ˜ 25%; more likely to present in DKA at younger age


  • Causes of DKA in known diabetics:



    • Omitting insulin dose (most frequent cause)


    • Infection or illness


    • Malfunction of insulin pump: catheter displacement


  • Most deaths are due to cerebral edema


Clinical Presentation



  • Polyuria, polydipsia, nocturia, weight loss, polyphagia, abdominal pain, vomiting


  • May appear as an acute abdomen


  • Signs of dehydration: tachycardia, decreased capillary refill, cool extremities, dry mucous membranes, poor skin turgor


  • Metabolic acidosis stimulates tachypnea with classic Kussmaul respirations (deep sighing respirations)


  • Acetone production produces fruity breath odor


  • Usually normal or minimal decrease in level of consciousness


Investigations



  • Immediate capillary glucose


  • Serum glucose, electrolytes, venous gas, urea, creatinine


  • Intravenous access


  • Urine for ketones and glucose



Diagnosis



  • Hyperglycemia: glucose > 11 mmol/L


  • Acidosis: pH < 7.30


  • Serum bicarbonate < 18 mmol/L


  • Ketonuria


Electrolyte Changes

Glucose:



  • Variable serum glucose may be due to degree of hydration


  • Severe dehydration results in higher glucose concentrations

Metabolic acidosis:



  • Increased anion gap metabolic acidosis due to ketones and lactate

Serum sodium:



  • Decreased due to fluid movement into intravascular space as a result of hyperglycemia

Serum potassium:



  • Potassium moves from intracellular to extracellular space due to acidosis, therefore serum measurements are normal


  • Total body potassium concentration is decreased due to urine losses


  • Serum potassium drops rapidly with insulin therapy

Serum phosphate:



  • Concentrations are normal initially but fall with treatment

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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Diabetic Emergencies

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