Page 215 - TNFlipTest

Toronto Notes 2019 Medical Emergencies
■ potassium
◆ essential to avoid hypokalemia: replace KCl (20 mEq/L if adequate renal function and initial K+
<5.5 mmol/L)
◆ use cardiac monitoring if potassium levels normal or low
■ insulin
◆ critical, as this is the only way to inhibit gluconeogenesis/ketosis
◆ do not give insulin if K+ <3.3 mmol/L
◆ followed by continuous infusion at 5-10 U (or 0.1 U/kg) per h
◆ once the blood glucose <14 mmol/L, patient should receive their regular insulin SC injection
and the infusion should be stopped in 1 h
◆ add D5W to IV fluids when blood glucose <15 mmol/L to prevent hypoglycemia
■ bicarbonate is not given unless patient is at risk of death or shock (typically pH <7.0)
Hyperosmolar Hyperglycemic State
• stateofextremehyperglycemia(44-133.2mmol/L)duetorelativeinsulindeficiency,counter-regulatory hormones excess, gluconeogenesis, and dehydration (due to osmotic diuresis)
• clinicalpresentation
■ often older, Type 2 DM patients with more co-morbid illnesses and larger fluid losses with
symptoms evolving over days to weeks, fewer GI symptoms and more neurological deficits than
DKA including: mental disturbances, coma, delirium, seizures ■ polyuria, N/V
• investigations
■ blood work: CBC, electrolytes, Ca2+, Mg2+, PO43-, Cr, BUN, glucose, ketones, osmolality ■ urine: glucose and ketones
■ ABGorVBG
■ find underlying cause: ECG, CXR, blood and urine C&S
• management
■ rehydration with IV NS (total water deficit estimated at average 100 cc/kg body weight) ■ O2 and cardiac monitoring, frequent electrolyte and glucose monitoring
■ insulin is controversial
■ identify and treat precipitating factors, if present (the 5 Is)
Hypoglycemia
• characterizedbyWhipple’striad:lowplasmaglucose,symptomssuggestiveofhypoglycemia,prompt resolution of symptoms when glucose administered
• clinicalpresentation
■ neuroglycopenic symptoms: headaches, confusion, seizures, coma
■ autonomic symptoms: diaphoresis, nausea, hunger, tachycardia, palpitations
• historyandphysicalexam
■ last meal, known DM, prior similar episodes, drug therapy, and compliance ■ liver/renal/endocrine/neoplastic disease
■ depression, alcohol or drug use
• management
■ IV access and rapid blood glucose measurement
■ D50W 50 mL IV push, glucose PO if mental status permits
■ if IV access not possible, glucagon 1-2 mg IM, repeat x 1 in 10-20 min
■ O2, cardiac, frequent blood glucose monitoring
■ thiamine 100 mg IM (if alcohol abuse is suspected)
■ full meal as soon as mental status permits
■ if episode due to long-acting insulin, or sulfonylureas, watch for prolonged hypoglycemia due to
long t1/2 (may require admission for monitoring)
■ search for cause (common causes include exogenous insulin, alcohol, or sulfonylureas)
Emergency Medicine ER35
4 Criteria for DKA Dx
• Hyperglycemia
• Metabolic acidosis • Hyperketonemia
• Ketonuria
Signs and Symptoms of DKA
D: Diuresis, dehydration, drowsy, delirium, dizziness
K: Kusmaul’s breathing, ketotic breath A: Abdominal pain, anorexia
Precipitating Factors in DKA
The5Is Infection Ischemia Infarction Intoxication Insulin missed
Causes of Hypoglycemia
Most common: excessive insulin use in setting of poor PO intake
Common: alcohol intoxication, sepsis, liver disease, oral anti-hyperglycemics
Rare: insulinomas, hypopituitarism, adrenal insufficiency, med side effects
Cerebral edema may occur if hyperosmolality is treated too aggressively