Diabetic Emergencies

Hypoglycemia

Diabetic

Causes:

  • Iatrogenic (too much insulin)
  • exercising too much
  • eating too little
  • SEPSIS

Manage:

Coma? ⚠ emergency:
give IV Glucose load 🍬🍬🍬

  • D50

Awake? Give oral glucose load. 🍬

  • pixie sticks, jelly beans
  • recheck until return to normal

Dx: blood Glucose <70
Tx: Correct w/ glucose
F/u: find out cause

  • lower Rx
  • counseling

✏(some pts may tolerate <70, some may experience s/s @ >70, still hypoglycemia, needs correcting)

✏Pt usually knows s/s:

  • Palpitations 💕
  • Diaphoresis 💦
  • Presyncope
  • progression to Coma 🛌🏻

Non-diabetic (w/ s/s)

Cause:

  • Insulinoma (exam, not real life)
  • factitious

Dx: Wait until hypoglycemic

  • C peptide
  • Proinsulin
  • Secretagogue screen

C peptide elevated?

❎ No, Factitious 🏁

  • injecting insulin
  • tell pt to stop wasting my time

✅ Yes, endogenous production
Secretagogue screen (sulfonureas 🥚)

✅ Sulfonurea positive, Factitious 🏁

  • tell pt to stop wasting my time

❎ no sulfonureas
Suspect Insulinoma

72 hr fast, inpatient

  • CT MRI to find tumor

🏁Inslinoma

Hyperglycemia

DKA: Type 1 diabetics

Path: no insulin.

  • Hi glucose 🍬
  • hi urine output
  • severe dehydration
  • Acidosis

Pt: Diabetic coma/AMS 🛌🏻

  • Ketones w/ Acidosis

Dx: confirm, then send to ICU

  • blood glucose >300-500
  • UA: positive ketones (good initial)
  • blood/serum: Ketones ( 🌠 Best test)
  • ABG: Acidosis
  • BMP: see Gap, see K

Tx: DKA protocol

Potassium 🍌
⚠ need to check K before correcting glucose, otherwise crashes K

  • K must be above 4
  • replace K whenever it drops below 4, using BMP

Glucose

  • Insulin 10U IV
  • then Insulin drip
  • checking blood glucose while doing

Anion Gap

  • Gap is fixed by insulin
  • Fix dehydration: bolus, vigorously : saline or lactated ringers 🌊
  • Follow Gap w/ BMP

dr price: correct fluids first then get VBG
then close electrolyte gap and BG w insulin
5:5, 5 L down at the door, 5U/hr volume resuscitation

✏Sugars may correct before Gap closes, but still need ICU until Gap closes

If so, give sugar 🍬(D5 1/2 saline) to close the gap

Then bridge w/ Long acting SubQ insulin

  • remove drip
  • let them eat, and watch 😮

✅Gap reopens?

Restart process

✅Gap stays closed?

d/c 🏁

HHS: Type 2 diabetics

Path: no insulin (well some insulin, so no ketones)

  • won't present acutely since sugars need to skyrocket first

Pt: Diabetic coma 🛌🏻

  • but 🚫no ketones
  • 🚫no Acidosis

Dx: Blood glucose 800-1000

  • UA: no ketones
  • ABG: no acidosis
  • BMP: K, no Gap

Tx: Same as DKA (fluids 💧)

  • fluids 🌊 & IV insulin