Diabetic Emergencies

1
Diabetic Emergencies

• Diabetic ketoacidosis
• Hyperglycemic hyperosmolar
• non ketotic syndrome
• Hypoglycemia

2
30 yr old man brought to ER in semi-responsive
state
BP 80/50 Pulse 120 RR 25 T
98 Na 129 K 3.1 Cl 90 HCO3 8
BS 450 BUN 22 Creat 2.2
3
Type 1 Diabetes
Initiating event
Insulin Glucagon and counter-regulatory
hormones
Protein catabolism
Lipolysis
FFAs
Glycerol
Amino Acids
Glucose uptake
Hyperglycemia
Gluconeogenesis
Ketogenesis
Osmotic diuresis
Ketonuria
Ketonemia
Volume depletion Dehydration
Electrolyte depletion
Acidosis
Figure 1. Pathogenesis of diabetic ketoacidosis.
Absolute or relative.
4
Type 2 Diabetes
Initiating Event
Insulin Glucagon and Counter-regulatory horm
ones
Glucose uptake
Hyperglycemia Hyperosmolality
Pre-Renal Azotemia
Osomotic diuresis
Volume depletion Dehydration
Electrolyte depletion
Thirst
Figure 2. Pathogenesis of hyperglycemic
hyperosmolar nonketotic syndrome. Relative or
absolute.
5
Precipitating Factors in DKA and HHNS
CSII continuous subcutaneous insulin infusion.
6
Clinical Presentation

• DKA
• HHNS

7
Laboratory Criteria of DKA and HHNS
BUN blood urea nitrogen. Nitroprusside
reaction.
8
Clinical Management

• Evaluation and correction of metabolic and volume
  status
• Identification and treatment of precipitating
  events
• Smooth transition to long term treatment regimen
• Prevent recurrence

9
Summary of management of DKA in adults and
children

• Fluids
• Potassium
• Phosphate
• Bicarbonate
• Insulin

10
Strength of Recommendations
A consistent, good-quality patient-oriented
evidence B inconsistent or limited-quality
patient-oriented evidence C consensus,
disease-oriented evidence, usual practice,
opinion or case series.
11
Diabetic Ketoacidosis Flow Sheet

• Initial level of consciousness
• Name Alert
• Hospital No. Lethargic
• Age Initial Weight Semi comatose
• Comatose

12
Diabetic Ketoacidosis Flow Sheet
13
Diabetic Ketoacidosis Flow Sheet
14
Diabetic Ketoacidosis Flow Sheet
15
Useful Formulas for the Evaluation and Treatment
of DKA and HHNS

• 1. Calculation of the anion gap (AG)
• AG Na CI- HCO3 -
• 2. Calculation of the effective serum osmolality
• Effective Posm measured Posm (BUN/28)
• Effective Posm 2 X (Na K (glucose
  in mg/dL/18)
• 3. Correction of serum sodium
• Corrected Na Na 1.6 X (glucose in
  mg/dL 100)
• 100

16
Complications

• Hypoglycemia
• Hypokalemia
• Cerebral Edema
• Lactic Acidosis
• Hyperchloremic Acidosis

17
Special Situations

• Alcohol
• Sepsis
• CRF
• Creatinine
• Relapse
• Maintenance treatment
• Feeding
• Education

18
Hypoglycemia
19

• 40 yr old man with history of type I DM, CRF on
  hemodialysis brought to ER with altered mental
  status.
• Meds Insulin 70/30 30 u am 20 u pm
• Fingerstick B S 26 mg