HYPERGLYCEMIA

CRISES
Compiled by:
Choirotussanijjah 0910710048
Feros Rachmi S 0910714072
Geneung Patridina 0910714035

Supervisor:
dr. Ali Haedar, SpEM

Emergency Medicine Department
Medical Faculty
Brawijaya University
2014

CONTENTS
INTRODUCTION
CASE REPORT
DISCUSSION
LESSON LEARNT
INTRODUCTION
37.4
53.2
+42%
55.2
66.2
+20%
76.7
112.8
+47%
58.7
101.0
+72%
26.5
51.7
+94%
12.1
23.9
+98%
16.0
29.6
+65%
Africa
Middle East and
North Africa
Europe
North America
South and Central America
South-East Asia
Western Pacific
IDF Regions and global
projections for the
number of people with
diabetes (20-79 years),
2010-2030 IDF. Diabetes Atlas 4
th
Edition 2009
Worldwide:
284.6 million people in 2010
438.4 million projected for 2030
54% increase
Diabetes is an increasing healthcare
epidemic throughout the world
Diabetic ketoacidosis (DKA) and hyperosmolar
hyperglycemic state (HHS) are two of the most serious acute
complications of diabetes. These hyperglycemic emergencies
continue to be important causes of morbidity and mortality
among patients with diabetes.
BACKGROUND
Kitabchi et al, 2009
Annual incidence rate DKA 4.6 - 8 episodes per 1,000
(Kitabchi et al, 2006).
Hospitalizations (Kitabchi et al, 2006).
Mortality rate DKA 5%, and HHS still remains high at 11%
(Kitabchi et al, 2009).
Prognosis worsened at the extremes of age and
in the presence of coma and hypotension (Kitabchi
et al, 2009).


BACKGROUND
Similar outcomes of treatment of DKA have been noted in both
community and teaching hospitals, and outcomes have not been
altered by whether the managing physician is a family physician,
general internist, house officer with attending supervision, or
endocrinologist, so long as standard written therapeutic
guidelines are followed (Kitabchi et al, 2009).


BACKGROUND

Standar Kompetensi Dokter Indonesia, 2012
BACKGROUND

PURPOSE
To present practical approach and updated
recommendation to the diagnosis and management
of patients presenting with sign and symptom of DKA
and HHS

Kirabchi et al, 2009
50% were
female,
45% were
nonwhite.

ages of 18-44
years (56%)
45-65 years
(24%)
18% of patients
20 years of age.

2/3 patients type 1 DM
34% type 2 DM
Adult mortality is 1%;
5% reported in elderly and
patients with concomitant
life-threatening illnesses.
AGE SEX
DM
&
MORTALITY
EPIDEMIOLOGY:
DKA

PATHOGENESIS
DIABETES CARE, VOLUME 29, NUMBER 12, DECEMBER 2006

Triad of DKA (hyperglycemia, acidemia, and ketonemia)
and other conditions with which the individual
components are associated.
Kitabchi A E et al. Dia Care 2001;24:131-153
Copyright 2011 American Diabetes Association, Inc.


PRECIPITATING FACTOR:
DKA
Manning et al, 2004

PRECIPITATING FACTOR:
HHS
Kivlehan et al, 2013

Andrew E. Edo . Nigerian Medical Journal | Vol. 53 | Issue 3 |
July-September | 2012
FREQUENCY OF PRESENTING SYMPTOM
IN PATIENTS WITH DKA AND HHS
SYMPTOMS
Manning et al, 2004

DIAGNOSIS CRITERIA
DIABETES CARE, VOLUME 32, NUMBER 7, JULY 2009

Tlaleletso. Guidelines update: diabetes mellitus
Emergency Management. 2012

Tlaleletso. Guidelines update: diabetes mellitus
Emergency Management. 2012


Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes: a consensus
statement from the American Diabetic Association. Diabetes Care. 2009;32:1335-1343.
Once the Patient Stabilized

Tlaleletso. Guidelines update: diabetes
mellitus Emergency Management. 2012
Hemphill, 2012
deep coma at
the time of
diagnosis
Hypothermia
Oliguria

Overall MR: 2%
POOR,
If:
Older age
presence of
concurrent illnesses
severity of the
metabolic
derangements

Overall MR: 10-20%
DKA HHS
Name : Mr. J
Gender : male
Age : 75 years old
Address : Jl. Bumirejo RT 3/5 Dampit Malang

Occupation : Unemployment
Reg. number : 140606xxxx
Body weight : 55 kg

Patient came to the emergency department on June 6th, 2014
at 2.10 pm.
PATIENTS IDENTITY
Patient came to the emergency department due to
chest pain and burning sensation suddenly lasted for
more than 30 minutes that happened 4 hours ago
before admission while patient working in the field.
Chest pain worse when he breathing, chest pain is not
spread, shortness of breath, cold sweat, cough (-),
fever (-), nausea (-), vomit (-)

History of past illness : patient have experienced
similar pain since 1 years ago. Chest pain when patient
walking away (2 kilometers), relief with rest.
SUMMARY OF CASE
Family history : there is no family relatives with chest
pain or the same complain.
Social history : patient is married and has 2 children.
He works at the field as foreman. He smoked 6 bar
per day and has stopped for 35 years ago.
Upon the arrival at the emergency department, the patient
had chest pain with GCS 456, increasing respiratory rate (26
times per minute), increasing pulse rate (108 times per
minute).
The patient then placed at P1 and got O2 10 lpm via NRBM, IV
lines with IVFD NaCl 0,9% 30 tpm. Patient got Aspirin 320 mg,
Clopidogrel 300 mg via oral, and also ranitidin 25 mg IV.
From physical examination, it was found that the
patient looked unstable, increase breath sounds in
both lung fields.
Then we did further diagnostic evaluation: laboratory
(complete blood count, ureum/creatinine,
SGOT/SGPT, RBS, serum electrolyte, cardiac marker),
radiology (chest x-ray) and ECG.
After performed the primary survey and gave initial treatment
for the patient, we did secondary survey wich include
anamnesis, physical examination and also further diagnostic
evaluation.
From the summary of te case that have already read before,
we suspected that the cause of the typical chest pain due to
miocard infarct.
So we did further diagnostic evaluation.
DISCUSSION
Patient came to the emergency department with chief complain chest pain
and primary survey as mentioned below :

A : patent
B : respiratory rate 26 times per minute with O2 NRBM 10 lpm, increase sound breat
in both lung fields.
C : blood pressure 150/70 mmHg, pulse rate 108 times per minute, weak and
regular, warm acral, CRT <2 seconds
D : GCS 456
E : axillary temperature 37
0
C

Patient then placed at P1
A : -
B : O2 10 lpm via NRBM
C :IV lines with IVFD NaCl 0,9% 30 time per minutes
D : -
INITIAL TREATMENT
What we did is according to the theory that
patient with acute miocard infarct should be managed
initially in the critical care area (P1).

The initial priorities of the patient with acute
miocard infarct include evaluation and management of
A, B, C and patient must be managed in a monitored
area.



MANAGEMENT OF
HYPERGLYCEMIA CRISES
MANAGEMENT OF
HYPERGLYCEMIA CRISES
At first, we can distinguish whether the condition is DKA or HHS.
So we can suspect the patient to certain diagnosis with:
1. Presenting symptom of patient: polydipsi, polyuria,
hyperventilation (Kusmaul breathing), and ketone breath odor.
2. Urgent investigation : CBC, urinalysis (ketones and leucocytes),
blood glucose, renal function test, BGA, electrolytes, Ca, Mg, P.
3. Labs: later show diagnosis criteria meet the criteria DKA or HHS
4. Other investigation, chest x-ray, ECG
5. Monitoring: ECG, Pulse oximetry, VS every 15-30 min, RBS,
potassium and acid base balance every 2 hours.

Immediate management hyperglycemia crises in emergency :
1. IV access
2. Start IV fluids (NaCl 0,9% 1 lt/hours), kalium and insulin
(rapid acting insulin 0,1 unit/kg IV, continuous (IV) infusion
of insulin with syringe pumps), monitor blood pressure, ECG
and give O2.
What we did is fit with the theory:
1. We checked the cardiac marker, the result was normal.
2. We checked electrocardiogram, the result ..
3. We checked the serum electrolyte, for further diagnostic
evaluation.
4. For the management we give oksigen 10 lpm via NRBM, IV
fluids (NaCl 0,9% 30 times per minutes), Aspirin 320 mg,
clopidogrel 300 mg oral, also ranitidin 25 mg IV.

After performed the primary survey and gave initial treatment
for the patient, we did SECONDARY SURVEY which
include anamnesis, physical examination and also further
diagnostic evaluation.
From the summary of the case that patient have experienced
similar pain since 1 years ago. Chest pain when patient walking
away (2 kilometers), relief with rest.
So, we did further diagnostic evaluation such as laboratory,
radiology, and ECG.

Laboratory Findings
Lab Value Lab Value
Leukocyte 11830 4700-11300/uL SGOT
SGPT
4
5
0-32 U/L
0-33 U/L
Hemoglobine 13,00 11,4-15,1 g/dL Troponin I 0,10 < 1,0
Trombocyte 228000 142000-424000 CK-NAC
CK-MB
66
17
39 308
7 - 25
Hematocrit 40% 38-42 RBS 109 <200 g/dL
Natrium
Kalium
Cloride
134
3,80
111
136-145 mmol/L
3,5-5 mmol/L
98-100 mmol/L
Ureum
creatinin
66,1
1,61
16,6-48,52
<1,2
LABS FINDING
Serum osmolarity = 352, 78 mOsm/kg > 320 mOsm/kg
Mix KAD HHS
ECG Result
Sinus rhythm, with heart rate 110 bpm
Frontal axis : Normal
Horizontal axis : slightly CCW rotation
PR interval : 0, 12
QRS complex : 0, 08
QT interval : 0,16
Conclusion : sinus tachycardia with HR 110 bpm
ECG Results
Chest X-Ray
AP position, symetric,
enough KV
Soft tissue & bone normal
Left & right phrenicostalis
angle sharp
Left & right hemidiapragm
dome-shaped
Trachea in the middle
Pulmo : infiltrate in the R/L
pulmo
Aorta: Normal
Cardiac : enlargement to
the left side
Chest X-Ray
Pedis X-Ray
Position AP lateral
aligment : normal
Bone : periosteal reaction (-),
litik (-), fracture (-), blastik (-)
Cartilage : normal
Soft tissue : normal

Conclusion: periostium intact,
perioteal reaction (-)

Pedis X-Ray
Cruris X-Ray
position AP lateral
aligment : normal
Bone : litik (-), fracture (-), blastik (-)
Cartilage : normal
Soft tissue : normal

Cruris X-Ray
AMS dt Hyperglycemia crises


DISPOSITION Internal Medicine Department

WORKING DIAGNOSIS
LESSON LEARNT
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic
state (HHS) are two of the most serious acute complications of
diabetes.

Both disorders are associated with absolute or relative insulin
deficiency, volume depletion, and acid-base abnormalities.

Management of hyperglycemia crises requires correction of
dehydration, hyperglycemia, and electrolyte imbalances,
identification of comorbid precipitating events, and close
monitoring.
Thank you