Diabetic Emergencies

Mr. Ibrahim Rawhi Ayasreh RN, MSN, CNS

Diabetic Emergencies

Diabetic ketoacidosis (DKA). Hyperosmolar hyperglycemic syndrome (HHS).

Hypoglycemia.

Diabetic Ketoacidosis

DKA is a critical illness resulting from severe insulin deficiency that leads to the disordered metabolism of proteins, carbohydrates, and fats.

Management of DKA

Improve circulatory volume and tissue perfusion. Correct electrolyte imbalances. Decrease serum glucose and serum osmolality levels Correct ketoacidosis Determine precipitating events

Fluid Replacement

The first liter of 0.9% (normal) saline may be infused in 1 hour in patients with normal cardiac function. Fluid replacement continues at roughly 1 L/h until hemodynamic stability is attained. Hypotonic solutions (eg, 0.45% normal saline) can be administered at a rate of 150 to 250 mL/h after the intravascular volume has been restored, or if the serum sodium level is greater than 155 mg/dL.

Potassium and Phosphate Replacement

If the initial serum potassium level is low, IV potassium is usually started right away. This is particularly important because insulin drives potassium into cells (lowering the serum potassium level) and fluid administration dilutes the serum potassium concentrations even further. Phosphate levels usually also drop during therapy, potentially worsening tissue hypoxia by increasing red blood cell affinity for oxygen.

Insulin Therapy

Insulin is the cornerstone of management of DKA. It decreases the ketones and manages ketoacidosis, inhibits hepatic gluconeogenesis, restores cellular protein synthesis, and increases peripheral glucose utilization. Initially, insulin administration involves giving an IV bolus of regular insulin at 0.15 U/kg body weight. This is followed by a continuous infusion of regular insulin at a dose of 0.1 U/kg/h (5 to 10 U/h).

Bicarbonate Replacement

Patients with mild or moderate metabolic acidosis due to ketones who are treated with 0.9% sodium, water, and insulin eventually excrete and metabolize the ketones, thus increasing pH. Some experts recommend bicarbonate replacement with severe acidosis as indicated by an arterial pH of 7.0 or less

Hyperglycemic Hyperosmolar Syndrome (HHS)

HHS, characterized by marked hyperglycemia and hyperosmolality without ketoacidosis, may develop in patients with type 2 diabetes when they become critically ill.

Management of HHS

The amount of volume depletion is usually greater in HHS than in DKA. Some patients may require as many as 9 to 12 L of fluid overall. It is necessary to give low-dose insulin by continuous infusion (0.1 U/kg/h). As the glucose level returns close to normal (250 to300 mg/dL), the insulin infusion is decreased and dextrose is added to the IV fluids to prevent a sudden drop in the blood glucose level.

Hypoglycemia

Hypoglycemia (abnormally low blood glucose level) occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L).

Causes of hypoglycemia

Too much insulin. Too much oral hypoglycemic agents. Too little food. Excessive physical activity

Clinical manifestations of hypoglycemia

They can be categorized into: - Adrenergic symptoms. - Central nervous system (CNS) symptoms.

Mild hypoglycemia

In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in an increase of epinephrine and norepinephrine. Sweating. Tremor. Tachycardia. Palpitation. Nervousness. hunger

Moderate hypoglycemia

In moderate hypoglycemia, the fall in blood glucose level deprives the brain cells of needed fuel for functioning. Signs of impaired function of the CNS may include: - inability to concentrate. - lightheadedness. - memory lapses. - slurred speech. - emotional changes. - double vision. - drowsiness. - headache. - confusion. - numbness of the lips and tongue. - impaired coordination, - irrational or combative behavior.

Severe hypoglycemia

In severe hypoglycemia, CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia. Symptoms may include: - Disoriented behavior. - Seizures. - Difficulty arousing from sleep. - Loss of consciousness

Management of hypoglycemia

For patients who are unconscious and cannot swallow, an injection of glucagon 1 mg can be administered either subcutaneously or intramuscularly. A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening to prevent recurrence of hypoglycemia.

In the hospital or emergency department, patients who are unconscious or cannot swallow may be treated with 25 to 50 mL 50% dextrose in water (D50W) administered intravenously. The effect is usually seen within minutes.

Glucagon injection

Prevention of hypoglycemia

DM patients must carry some form of simple sugar with them at all times. Patients are advised to refrain from eating highcalorie, high fat dessert foods (eg, cookies, cakes, doughnuts, ice cream) to treat hypoglycemia. The high fat content of these foods may slow the absorption of the glucose.