Diabetic Emergencies

1
Diabetic Emergencies

• Syed Bokhari MD
• Resident
• Internal Medicine

2
Goals and Objectives

• To outline the key elements of
• diagnosis and
• management
• of Diabetic Emergencies

3
Epidemiology

• DM is a syndrome characterized by disordered
  metabolism and inappropriate hyperglycemia due to
  ether insulin deficiency or insulin resistance or
  both.
• Estimated 16 million patients
• gt 90 of the Diabetic population has Type 2 DM.
• Remaining have Type 1 DM.

4
Diabetes Emergencies

• Diabetic Ketoacidosis (DKA)
• Hyperosmolar Non-ketotic (hyperglycemic) State
  (HONK or HHS)
• Hypoglycemia
• Complications of DM

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Definitions

• DKA Hyperglycemia
• Metabolic Acidosis
• HHS Severe hyperglycemia with no significant
  acidosis
• Hyperglycemia is more severe
• Hyperosmolarity
• Neurological symptoms more likely

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Comparison of DKA HHS (ADA)
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Precipitating factors/Causes

• Infection
• Volume Depletion (Hot weather and dehydration)
• Trauma
• Alcohol/Drug abuse
• Acute MI
• Stroke
• Drugs (Steroids and thiazides)
• Non-compliance with insulin therapy
• Pancreatitis

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Signs and Symptoms

• Polyuria, polydipsia and weight loss.
• Neurological Symptoms
• Partial Motor Seizures
• Visual Changes
• Lethargy, Coma
• Nausea. Vomiting or Abdominal pain
• Sx of precipitating event
• Fever, trauma, intoxication

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Evaluation

• Vitals Hypotensive, Tachycardic
• Airway Important in Comatose patient
• Breathing Kussmaul Breathing, Acetone breath
• Circulation Anywhere between normal vitals to
  Shock

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Physical Exam

• Signs of dehydration
• Adults Flat neck veins, decreased skin turgor,
  dry mucous membranes, lack of sweat
• Shock.
• Signs of the primary insult
• Crackles on Chest exam, Epigastric tenderness,
  trauma

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Management

• Rehydration
• Dehydration is the main concern. Estimated fluid
  deficit is
• 3-6 L in DKA
• 8-10 L in HHS
• Large Bore IV x 2
• 0.5 5 L NS over 1-5 hours. Stat with 1-2 L
  fluid bolus and then maintenance of 250 cc/hr
• More aggressive fluid resuscitation if in Shock
• Assess hydration status by Urinary output
• Watch out for Cerebral edema (worsening mental
  status despite normalizing metabolic profile)

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Lab work

• Metabolic Abnormalities
• Chem 10, VBG/ABG
• Serial Glucose and K measurements along with
  interventions
• Phosphorus
• Tests to evaluate for insult
• CBC, UA, CXR, Amylase/Lipase, Blood Alcohol
  Level, Cultures, EKG, Troponins

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Management (Contd.)

• Insulin
• 0.2 u/kg IV bolus
• Followed by 0.1u/kg/hr of Regular Insulin
  infusion
• Follow sugars closely (initially Q1 hour and the
  Q2 hours) and adjust Insulin infusion accordingly
• Glucose should fall by 100-200 mg/dl every hour
• Target is normal glucose and Ketones BOTH.
• Switch to D5 ½ NS when Glucose lt 250.

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Management (Contd.)

• Lytes!!!!
• K is elevated but you still need to replace it
• Start replacing K when K lt 5.0.
• 0.3-0.5 mEq/kg/hr of KCl
• Phosphorus will also decrease so follow it closely