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