Hyperglycaemic emergencies

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are diabetes emergencies.

Figure 1 : Diabetic Ketoacidosis
Source - dtc.ucsf.edu

Presentation

DKA

• Ketonuria
• Rapid and deep sighing respirations
• Smell of ketones
• Vomiting/ abdominal pain
• Drowsiness/ reduced conscious level
• Intra and extra-vascular volume depletion with reduced skin turgor, tachycardia and hypotension

(Goguen J. & Gilbert J. 2013)

Figure 2 : Symptoms of DKA
Source - healthy-ojas.com

HHS

• Dry, parched mouth
• Extreme thirst
• Warm, dry skin that does not sweat
• High fever (over 101 degrees Fahrenheit)
• Sleepiness or confusion
• Loss of vision
• Hallucinations
• Weakness on one side of the body

(American Diabetes Association. 2013)

Figure 3 : Syptoms of HHS
Source - elearning.educationforhealth.org

Causes

• Diabetes Mellitus
• Pancreatitis
• Pancreatic cancer
• Hyperthyroidism
• Cushing's syndrome
• Unusual tumors that secrete hormones (glucagonoma,pheochromocytoma, or growth hormone-secreting tumors)
• Severe stresses on the body (heart attack, stroke, trauma, or severe illnesses) can temporarily lead to hyperglycemia
• Certain medications (Prednisone, estrogens, beta-blockers, glucagon, oral contraceptives, phenothiazines)

(Medicine NET. 2014)

Investigations

• Plasma levels of electrolyte
• Glucose
• Creatinine
• Osmolality and beta-hydroxybutyric acid (beta-OHB)
• Blood gases
• Serum and urine ketones
• Fluid balance
• Level of consciousness

(Goguen J. & Gilbert J. 2013)

Stepwise Management

Management of DKA

In the early stages, where patient is fully conscious and able to take adequate oral fluids, an increased insulin dose may stabilise the situation. However in most cases an emergency admission to hospital is required where the treatment with intravenous insulin, fluids and electrolytes is required to restore the metabolic equilibrium

Management of HHS

• Airway management - Endotracheal intubation may be indicated for comatose patients.
• Rapid and aggressive IV volume replacement
• Cervical spine immobilization
• IV insulin
• Recheck glucose concentrations every hour.
• Electrolytes and venous blood gases should be monitored every 2-4 hours or as indicated.
• Nasogastric tube placement
• Thoracentesis
• Paracentesis
• Spinal tap

(Goguen J. & Gilbert J. 2013)

Figure 4 : Thoracentesis
Source - rnspeak.com

REFERENCES

Goguen J. & Gilbert J. 2013. Canadian Diabetic Association. [ONLINE] Available at:  http://guidelines.diabetes.ca/browse/Chapter15 [Accessed 27^th April 15].

American Diabetes Association. 2013. American Diabetes Association. [ONLINE] Available at:  http://www.diabetes.org/living-with-diabetes/complications/hyperosmolar-hyperglycemic.html# sthash.5CkFJ6Jy.dpuf [Accessed 27^th April 15].

Medicine NET. 2014. Medicine NET. ONLINE] Available at: http://www.medicinenet.com/hyperglycemia/page3.htm  [Accessed 27^th April 15].