Diabetic Emergencies

Diabetic Ketoacidosis

- Type 1 DM

- +ve ketones +

art. pH < 7.30 +

bicarb. - <15

MEDICAL EMERGENCY

Pathogenesis

Insulin deficiency

excess breakdown adipose stores

Inc. fatty acids

oxidised

ketone bodies (rate of production>rate of degradation)

Precipitating factors

- Acute infection

- Poor control

- Prepubertal girls – monthly intervals

- Failure of compliance

Epidemiology

Commonest causes of DKA….

- Infections (30%)

- Non-compliance with treatment (20%)

- Newly diagnosed diabetes (25%)

GP Investigations- BM + serum glucose

- Urine dipstick - ?ketones

- Bloods –

Na+ (low usually)

K+ (high on blood test, total body K+ invariably low)

Urea (raised)

Clinical features

• Acute onset

Vomiting

Abdominal pain

Headache

Thirst

Polyuria

Hyperventilation

Drowsy/coma

Clinical features cont…

• Gradual onset

Nocturia (nocturnal enuresis in children)

Weight loss

Lethargy

Clinical features cont…

Severly ill – can be in shock, oliguric/anuric

NOTE – Breath may smell of ketones

Detecting dehydration in children

Useful indicators –

- Capillary refill time

- Abnormal skin turgor

- Respiratory pattern (Kussmaul breathing – deep sighing)

Management in GP

1. Make diagnosis

2. Fluid replacement (if poss.)

3. Oxygen

4. Consider NG (to stop aspiration/gastric dilatation)

5. Insulin (give 10u iv whilst pump is being set up)

Prognosis

MORTALITY –

Developed countries – 2-5%

Developing countries – 6-24%

Under 28 years old – susceptible to cerebral oedema during treatment (0.7-1.0%)

HONK (Hyperosmolar non-ketotic hyperglycaemia)

DIAGNOSIS

- Very HIGH blood glucose - > 30mmol/l

- Only trace/1+ ketones in urine

- Very HIGH plasma Osmolarity

2(Na + K) + Urea + Glucose

Accounts for 10-15% diabetic decompensation

NOTE – serum Na+ may be low – due to redistribution of fluid into the extracellular fluid (secondary to high glucose level)

Precipitating Factors

• Infection

• High Carbohydrate intake

• Thiazide diuretics

• Steriods

• Propranolol

Clinical Features

Consider HONK in…

- ELDERLY

- Hyglycaemia

- Dehydration with excessive thirst

- Marked drowsiness

Clinical features cont…

Other features…

1. Convulsions

2. Coma

3. Focal CNS signs

HONK predisposes to thrombosis

Hyperventilation is NOT a feature of HONK