DIABETIC EMERGENCIES

Dr A Panahloo

www.sghms.ac.uk / addison

1. Diabetic Ketoacidosis
2. Hyper-osmolar non-ketotic
coma (HONK)
3. Hypoglycaemia

Diabetic Ketoacidosis (DKA)

Definition:
Severe uncontrolled diabetes requiring
emergency treatment with insulin and IV
fluids, and with a blood ketone body
(acetoacetate and 3-hydroxybutyrate)
concentration >5mmol/l

Diabetic Ketoacidosis (DKA)

Biochemical features:
Hyperketonaemia
Metabolic acidosis
Hyperglycaemia

Incidence and mortality

Annual incidence 1-5 episodes per 100
Type-1 diabetic patient
Peak in adolescence
Twice as common in females
Average mortality 5-10%
Mortality rises with age, 50% > 80 years

Precipitating Factors

Infection (30%)
New cases of type-1 diabetes (10%)
Insulin error (patient or doctor) (13%)
Myocardial infarction (1%)
Unknown cause (40%)
Miscellaneous (6%)

Differential Diagnosis
Causes of anion-gap acidosis:
Ketoacidosis
Type-1 diabetes
Alcoholic abuse
Starvation (acidosis is mild)

Lactic acidosis
Chronic renal failure
Drug toxicity
Methanol (metabolized to formic acid)
Ethylene glycol (metabolized to oxalic acid)
Salicylate poisoning

Clinical features-symptoms:
Polyuria and polydipsia
Weight loss and malaise
Weakness
Anorexia
Blurred vision
Nausea and vomiting
Abdominal pain, especially in children
Breathless (acidotic respiration)
Confusion and drowsiness
Coma (10% of cases)

Clinical signs:

Dry mouth
Facial flush
Ketotic breath
Postural hypotension
Tachycardia
Kussmaul breathing (deep rapid resps.)
Depression of consciousness
Coma

Fluid and Electrolyte Depletion:

Sodium
Chloride
Potassium
Calcium
Phosphate
Magnesium

500 mmol
350 mmol
300-1000 mmol
50-100 mmol
50-100 mmol
25-50 mmol

Management

Rapid confirmation of diagnosis:

BM,smell ketones,urine ketostix

Blood:
Glucose, U+E,FBC,gases, blood cultures

Look for precipitating cause eg infection

Asses severity of dehydration
If comatosed nurse in coma position, nasogastric tube and urinary catheter

Other Investigations:

Ketone bodies
ECG
Chest X-ray
Urine and sputum for culture

Management
Fluid replacement
Insulin
Correction of electrolyte imbalance

Fluids
Deficit my be 5-10 litres
If systolic BP < 100mmhg or shocked
colloid or 500 mls N/saline over 15 min
then 1000 mls N/saline over 1 hour (no K+)

If not shocked
1000 mls N/saline over 1 hour

Fluids
Continue N/saline +K according to need
Asses BP, CVP and urine output
Repeat Glucose, U+E, blood gases
4 hourly
Convert to 5% dextrose infusion when
BG < 15 mmol

Insulin
Soluble insulin via a pump
No indication for bolus dose or s/c or IM
injections
No indication for sliding scale
Aim to reduce glucose by 3 mmol/h
When glucose <15 mmol use dextrose
Continue insulin and dextrose until acidosis
clears

Potassium
Total deficit may be very high
K is intracellular, insulin and rising pH
cause entry of K in cells
Serum levels may be high, low or normal
and do nor reflect total body status
Main danger hypokalaemia
Replace 20-40 mmol K per litre of fluid

Bicarbonate
Controversial
Contraindicated unless severe acidosis +
cardio-respiratory collapse imminent
Shifts K+ into cells
Worsens hypokalaemia
CO enters brain reduces CSF pH
Cerebral oedema results
adverse O2 tissue delivery

Complications

Cerebral oedema
Arterial and venous thrombosis
Secondary infection in urine, chest
Adult respiratory distress syndrome
Thrombophlebitis
Rhabdomyolysis

Prevention
Sick day rules:
Never stop insulin and check for ketones
Measure BMs 4 times a day
If BM < 11 mmol continue normal insulin
If BM 11-17 mmol add extra 4 u with meals
If BM > 17 mmol add extra 6 u with meals Drink
milk, fruit juice, 5 pints sugar free fluid /day
If nausea and vomiting and BM >17 call Dr.

Hyperosmolar non-ketotic coma

(HONK)

Non-ketotic hyperglycaemia
Relative insulin deficiency
BG much higher than DKA (>50 mmol)
Develops slowly over weeks
Severe dehydration
Impaired Consciousness
High serum Na >150 mmol/l

HONK- Diagnosis
Raised plasma glucose (50- 100 mmol)
Increased plasma osmolality (> 340
mosm/l, measured in lab or calculated:
P.osmolality (mosmol/l) =
2 x [plasma Na+ + plasma K+] + plasma
[glucose] + plasma [urea]
No ketosis and no acidosis

HONK- incidence and mortality

Accounts for 10-30% of hyperglycaemic
emergencies
Mortality 30% due to associated conditions
and complications
Most patients age >50 years
Higher incidence in Afro-Caribbean
patients
50% undiagnosed diabetes

HONK- Clinical features

Develops over several weeks

Polyuria, polydipsia
Gradual clouding of consciousness
Severe dehydration
Hypotension
Reversible neurological signs
Comatosed

Comparison DKA:HONK
DKA

HONK

AGE
CAUSE

YOUNG TYPE-1
INSULIN DEFFICIENCY

Na
GLUCOSE
BICARBONATE
KETONES
MORTALITY
COURSE

NORMAL / LOW
< 40 mmol
< 14 mmol/l
POSITIVE
5-10%
TYPE-1

OLDER TYPE-2
DIURETICS
STEROIDS
50% UNKNOWN DM
HIGH
> 40 mmol
NORMAL
NEGATIVE
30-50 %
OFTEN DIET ALONE

Fluids in HONK
Initial fluid, electrolyte and insulin therapy is
similar to DKA
If Na >150 mmol/l half normal saline
Patients more sensitive to insulin
Start insulin infusion at slower rate
eg 3 units / hour
Fewer K+ problems
Anticoagulation

Hypoglycaemia
Common side-effect of treatment with
insulin or sulphonylureas
Does not occur with Metformin or diet
alone
Each year 25-30% of all insulin treated
patients have one or more episodes of
severe hypoglycaemia

Hypoglycaemia
Predisposing factors
Inadequate food intake
Excess dosage, error by patient or Dr
Exercise
Weight loss
Alcohol
Adrenocortical, thyroid or pituitary failure
Renal failure

Hypoglycaemia
Asymptomatic (biochemical), awake or
asleep
Mild symptomatic- patient able to treat
themselves
Severe symptomatic- help needed to
treat hypoglycaemic attack
Coma

Hypoglycaemia- hierarchy of events

Blood glucose:

4.6 mmol Inhibition of insulin secretion

3.8 mmol Release of glucagon and
adrenaline
3.0 mmol Hypoglycaemic symptoms
< 2.8 mmol
Cognitive function
progressively impaired

Hypoglycaemia - symptoms
1.

Autonomic
Sympathetic or parasympathetic
eg sweating, palpitations, tremor or hunger

2.

Neuroglycopenic
eg confusion, clumsiness, behavioural
changes, temper tantrums in children

Hypoglycaemia - symptoms
Acute
Lassitude
light headed
tremor
restless
cold sweat (diversion of blood from skin
and kidneys to brain, liver and muscle)

Hypoglycaemia - symptoms
Sub-acute
Slow movement and thoughts
Immobility
Slow speech
Detachment
Automatism and amnesia
Confusion
Drowsy
Manic

Hypoglycaemia - symptoms
Chronic
Rare
Obsessional control of diabetes
Symptoms absent
Personality disorder
Apparent dementia

Hypoglycaemia - treatment
Mild
Treat immediately with oral glucose (15-20g)

If patient unable to swallow

IV 50% dextrose 30-50 mls)
IM glucagon (1mg)

Patients should recover immediately

Failure to recover may be due to cerebral
oedema, postictal state or other causes of
coma

Hypoglycaemia - treatment
Hypoglycaemia induced by
sulphonylureas may be very prolonged
May need IV glucose for hours or even
days