diabetic emergencies. diabetic ketoacidosis -type 1 dm -+ve ketones + art. ph < 7.30 + bicarb. -
TRANSCRIPT
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Diabetic Emergencies
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Diabetic Ketoacidosis
- Type 1 DM
- +ve ketones +
art. pH < 7.30 +
bicarb. - <15
MEDICAL EMERGENCY
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Pathogenesis
Insulin deficiency
excess breakdown adipose stores
Inc. fatty acids
oxidised
ketone bodies (rate of production>rate of degradation)
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Precipitating factors
- Acute infection
- Poor control
- Prepubertal girls – monthly intervals
- Failure of compliance
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Epidemiology
Commonest causes of DKA….
- Infections (30%)
- Non-compliance with treatment (20%)
- Newly diagnosed diabetes (25%)
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GP Investigations- BM + serum glucose
- Urine dipstick - ?ketones
- Bloods –
Na+ (low usually)
K+ (high on blood test, total body K+ invariably low)
Urea (raised)
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Clinical features
• Acute onset
Vomiting
Abdominal pain
Headache
Thirst
Polyuria
Hyperventilation
Drowsy/coma
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Clinical features cont…
• Gradual onset
Nocturia (nocturnal enuresis in children)
Weight loss
Lethargy
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Clinical features cont…
Severly ill – can be in shock, oliguric/anuric
NOTE – Breath may smell of ketones
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Detecting dehydration in children
Useful indicators –
- Capillary refill time
- Abnormal skin turgor
- Respiratory pattern (Kussmaul breathing – deep sighing)
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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)
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Prognosis
MORTALITY –
Developed countries – 2-5%
Developing countries – 6-24%
Under 28 years old – susceptible to cerebral oedema during treatment (0.7-1.0%)
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HONK (Hyperosmolar non-ketotic hyperglycaemia)
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DIAGNOSIS
- Very HIGH blood glucose - > 30mmol/l
- Only trace/1+ ketones in urine
- Very HIGH plasma Osmolarity
2(Na + K) + Urea + Glucose
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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)
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Precipitating Factors
• Infection
• High Carbohydrate intake
• Thiazide diuretics
• Steriods
• Propranolol
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Clinical Features
Consider HONK in…
- ELDERLY
- Hyglycaemia
- Dehydration with excessive thirst
- Marked drowsiness
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Clinical features cont…
Other features…
1. Convulsions
2. Coma
3. Focal CNS signs
HONK predisposes to thrombosis
Hyperventilation is NOT a feature of HONK