This document discusses diabetic emergencies including hypoglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state. It describes the causes, symptoms, diagnostic criteria, treatment and prevention of each condition. Hypoglycemia results from low blood sugar and is treated with oral carbohydrates or intravenous dextrose. Diabetic ketoacidosis occurs due to insufficient insulin and is characterized by high blood sugar, ketones and acidosis. Hyperosmolar hyperglycemic state involves severe high blood sugar and dehydration without significant ketoacidosis. Both diabetic ketoacidosis and hyperosmolar hyperglycemic state require intravenous fluids and insulin treatment.
2. Objectives
General Objective:
• Identify the common diabetic complications in an
emergency setting.
Specific Objective:
• Describe diabetic ketoacidosis, hyperosmolar
syndrome, and hypoglycemia.
• Describe their diagnosis, treatment, and prevention.
3. Introduction
• People with diabetes suffer from diabetic
complications that may arise due to erratic blood
sugar levels, missed meals, accidental overdose of
medications, or too much strenuous exercise. These
things could affect the sensitive body of a person
with diabetes and could lead to
serious incidences of hypoglycemia or
hyperglycemia.
4. Introduction
• Uncontrolled blood sugar often contributes to the
incidence of diabetic emergencies and
complications. Individuals who experience blood
sugar levels that are too high or low for prolonged
periods of time may develop conditions that could
lead to a coma.
• Hypoglycemia results from excessively low blood
sugar levels caused by either insufficient food
consumption or the presence of too much insulin.
5. Introduction
• Diabetic ketoacidosis is a condition that occurs due
to an absence or insufficient supply of insulin, which
forces the body to burn fat and creates ketones that
subsequently accumulate in the body.
• Hyperosmolar syndrome is a diabetic condition that
results from excessively high blood sugar levels,
which cause the blood to adopt a thick consistency.
7. • Hypoglycemia or low blood glucose is a
clinical state associated with <55mg/dl or low
plasma glucose with typical symptoms.
The Journal of Clinical
Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
8. Whipples triad
Symptoms consistent with hypoglycemia
Low plasma glucose concentration
Relief of those symptoms after the plasma
glucose level is raised
The Journal of Clinical
Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
10. Risk factors
insulin doses are excessive, ill-timed, or of the wrong
type
influx of exogenous glucose
insulin-independent glucose utilization
sensitivity to insulin
endogenous glucose production
insulin clearance
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Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
11. Clinical features
MILD HYPOGLYCEMIA
- mainly adrenergic or cholinergic symptoms
Pallor
Diaphoresis
Tachycardia
Palpitations
Hunger
Paresthesias The Journal of Clinical
Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
12. Clinical features
MODERATE HYPOGLYCEMIA (<40 mg/dL)
- mainly neuroglycopenic symptoms
Inability to concentrate Confusion
Slurred speech Irrational behaviour
Slower reaction time Blurred vision
Somnolence Extreme fatigue
The Journal of Clinical
Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
13. Clinical features
SEVERE HYPOGLYCEMIA (<20 mg/dL )
Associated with severe impairment of neurologic
function
Completely disoriented behavior
LOC
Coma
Seizures
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Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
14. Treatment
MILD HYPOGLYCEMIA
Oral carbohydrates (at least 15gm)
Sources include
• Three glucose tablets (5g each)
• 2 ½ cups of fruit juice
• ½ to ¾ cup regular soda
• 1 cup of milk
If patient is unable to take orallyThe Journal of Clinical
give IV dextrose
Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
15. Treatment
MODERATE TO SEVERE HYPOGLYCEMIA
Dextrose - 50mL of 50% dextrose IV bolus after
blood draw followed by 10% dextrose
Glucagon – 1mg IM or SC can be given
Effective in treating hypoglycemia only if sufficient
liver glycogen present
These measures raise blood glucose only transiently
Patient is urged to eat as soon as possible
The Journal of Clinical
Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
16. Prevention
Patient education
Knowing signs and symptoms of hypoglycemia
Take meals on a regular schedule
Carry a source of carbohydrate
Self monitoring of blood glucose
Take regular insulin at least 30 min before eating
The Journal of Clinical
Endocrinology & Metabolism
March 1, 2009 vol. 94 no. 3 709-
18. Acute, major, life-threatening complication of
diabetes
Increase in the serum concentration of ketones
Blood glucose level of greater than 250 mg/dL
Blood pH of less than 7.2
Bicarbonate level of 18 mEq/L or less
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
19. Incidence about 1 out of 2000
Usually occurs in younger individuals but can occur
in patients with diabetes at any age
Mortality rates are around 2-5%
No sex predilection
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
20. Mechanism
Absolute or relative insulin deficiency
Increased gluconeogenesis
Elevation of counter regulatory hormones such as
glucagon, cortisol, growth hormone, and
catecholamines
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
21. Causes
• Infections
• Inadequate insulin treatment or non-compliance
• New onset diabetes
• Infarction
• Drugs
• Pregnancy
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
22. Classification
Moderate
Mild DKA Severe DKA
DKA
Plasma glucose > 250 mg/dl > 250 mg/dl > 250 mg/dl
Arterial ph 7.25-7.30 7.0-7.24 < 7.0
Serum
15-18 10-<15 < 10
bicarbonate
Urine ketones + + +
Anion gap >10 >12 >12
Alteration in
Joint British Diabetes Society guideline for the
alert Alert/drowsy stupor/coma
sensorium
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
23. Clinical presentations
• Nausea/vomiting Thirst/polyuria
• Abdominal pain Shortness of breath
• Generalized weakness Malaise/lethargy
• Confusional state
• Fever, dysuria, coughing
• Chest pain
• Palpitations
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
24. Physical findings
Tachycardia
Signs of dehydration - weak and rapid pulse, dry
tongue and skin, hypotension, and increased
capillary refill time
Tachypnea/ respiratory distress
Acetone odor in breath
Abdominal tenderness
Lethargy/ obtundation/ cerebral edema/ possibly
coma Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Fever/ Hypothermia 28, Issue 5, pages 508–515, May
Medicine Volume
25. Laboratory findings
Hyperglycemia >250mg/dL
Serum ketones +
ABG:
metabolic acidosis
low bicarbonate
low pH (<7.2)
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
26. Serum electrolytes
• Serum potassium may be mildly elevated despite
total body potassium deficit
• The serum sodium level usually is low (1.6meq
reduction in serum sodium for each 5.6mmol/L or
100mg/dL of rise in serum glucose)
• The serum chloride and phosphorus levels are low
The anion gap is elevated
Plasma osmolarity usually is increased (>290
mOsm/L).Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
27. Others
Leukocytosis (even without infection)
BUN and creatinine are frequently increased
Hypertriglyceridemia/ Hyperlipoproteinemia
Serum assays for β hydroxybutrate more accurately
reflects the true ketone body level
• ECG – for detection of hypokalemia/ hyperkalemia,
myocardial infarction (silent MI in diabetics)
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
28. Differential diagnosis
LACTIC ACIDOSIS
most common cause of metabolic acidosis in
hospitalized patients
presentation is identical to DKA
serum glucose and ketones should be normal
serum lactate concentration should be greater than
5mm
therapy is directed at the underlying cause and
optimizing tissue perfusion Society guideline for the
Joint British Diabetes
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
29. Differential diagnosis
STARVATION KETOSIS
due to inadequate carbohydrate availability, resulting
in lipolysis and ketone production
blood glucose is usually normal
blood rarely does have large amounts of ketones
arterial pH is normal
anion gap is at most mildly elevated
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
30. Differential diagnosis
ALCOHOLIC KETOACIDOSIS
• anion gap is elevated
• serum and urine ketones are present
• alcoholic ketoacidosis produces an even higher ratio
of β-hydroxybutyrate to acetoacetate than DKA does
• usually, patient is normoglycemic or hypoglycemic
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
31. Differential diagnosis
UREMIC ACIDOSIS
Extremely large elevations in the BUN (>200 mg/dL)
and creatinine (>10 mg/dL) with normoglycemia
pH and anion gap are usually only mildly abnormal
treatment is supportive, with careful attention to fluid
and electrolytes until dialysis can be performed
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
32. Treatment
IV FLUIDS
• 2-3L of 0.9% saline over first 1–3 h (10–15mL/kg per
hour)
• 0.45% saline at 150-300mL/h (if hemodynamically
stable and urine output is adequate )
• change to 5% glucose and 0.45% saline at 100–200
mL/h when plasma glucose reaches 250mg/dL
(14mmol/L).
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
33. Treatment
INSULIN
• if serum K+ is <3.3mmol/L, do not administer insulin
until it is corrected to >3.3mmol/L
• bolus of IV (0.1 units/kg) or IM (0.3 units/kg) short-
acting insulin followed by 0.1 units/kg/hr by
continuous IV infusion
• Increase 2- to 3-fold if no response by 2–4h
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
34. Treatment
INSULIN
• IV regular insulin should be given until the acidosis
resolves and the patient is metabolically stable
• Intermediate or long-acting insulin, in combination
with SC short-acting insulin, should be administered
as soon as the patient resumes eating
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
35. Treatment
MONITOR
Blood glucose every 1–2 h;
Serum electrolytes and anion gap every 4 h for first
24 h.
Blood pressure, pulse, respirations, mental
status, fluid intake and output every 1–4 h.
Joint British Diabetes Society guideline for the
management of diabetic ketoacidosis Diabetic
Medicine Volume 28, Issue 5, pages 508–515, May
37. The condition is characterized by
• Hyperglycemia
• Hyperosmolarity
• Dehydration without significant ketoacidosis
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38. Incidence is 1.7 case per 10000
Mortality rate is high (10-20%) and usually due to a
co-morbid illness
(HHS) has a mean age of onset early in the seventh
decade
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39. Pathophysiology
Relative insulin deficiency and inadequate fluid
intake
Insulin deficiency increases hepatic glucose
production (through glycogenolysis and
gluconeogenesis) and impairs glucose utilization in
skeletal muscle
Hyperglycemia induces an osmotic diuresis that
leads to intravascular volume depletion, which is
exacerbated by inadequate fluid replacement
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Lower levels of counterregulatory hormones and free
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fatty acids have been found in HHS than in DKA
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40. Clinical features
HISTORY
Usually elderly individual, type 2 DM
Mental confusion, lethargy, and coma
Absence of nausea, vomiting, abdominal pain
Frequent precipitants – pneumonia, sepsis, stroke
MI, etc.,
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41. vs DKA
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42. Treatment
IV FLUIDS
1–3L of 0.9% normal saline over the first 2–3 h. If the
serum sodium >150 meq/L, 0.45% saline should be
used.
After hemodynamic stability is achieved, the IV fluid
administration is directed at reversing the free water
deficit using hypotonic fluids (0.45% saline initially
then D5W).
The calculated free water deficit (which averages 9–
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10L) should be reversed over the next 1–2 days
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(infusion rates of 200–300 mL/h of hypotonic
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43. Treatment
INSULIN
• IV insulin bolus of 0.1units/kg followed by IV insulin
at a constant infusion rate of 0.1units/kg per hour.
• If the serum glucose does not fall, increase the
insulin infusion rate by twofold
• Glucose should be added to IV fluid when the
plasma glucose falls to 250 mg/dL, and the insulin
infusion rate should be decreased to 0.05–
0.1units/kg per hour.
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44. Treatment
INSULIN
The insulin infusion should be continued until the
patient has resumed eating and can be transferred
to a SC insulin regimen
To avoid cerebral edema the blood glucose level
should be maintained between 250-300mg/dl until
hyperosmolarity and mental status improve and the
patient becomes clinically stable
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45. Treatment
POTASSIUM REPLETION
ECG monitoring for hyperkalemia or hypokalemia
If K+ < 5.5 give 10-20mEq/hr
If K+ < 3.5 give 40-80mEq/hr
Administer half as chloride and half as phosphate
salts
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46. Monitoring
EKG
Vital signs
1-2 hourly glucose
Serum electrolytes: 2-6 hourly
BUN and creatinine: 6-24 hourly
Ketones: 6-24 hourly
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47. Pathogenesis of DKA and HHS:
stress, infection, or insufficient insulin. FFA, free fatty acid
48. Conclusion
• Diabetic emergencies are common in patients with
diabetes, and the effects can be devastating.
However, with continued emphasis on the timely
and appropriate identification and management of
diabetic emergencies, hopefully this may change.
• It is therefore important for those with diabetes to
keep their sugar levels normal to prevent
complications and to be able to live normal, healthy
lives.
Notas do Editor
The universal symbol for diabetes.The purpose of the diabetes symbol is to give diabetes a common identity.Until 2006, there was no global symbol for diabetes. It aims to:support all existing efforts to raise awareness about diabetesinspire new activities, bring diabetes to the attention of the general publicbrand diabetesprovide a means to show support for the fight against diabetes
Insulin doses are excessive, ill-timed, or of the wrong type influx of exogenous glucose (overnight fast or following missed meals or snacks)↑ insulin-independent glucose utilization (e.g., during exercise)↑ sensitivity to insulin (e.g., with improved glycemic control, in the middle of the night, late after exercise, or with increased fitness or weight loss) endogenous glucose production (e.g., following alcohol ingestion) insulin clearance (e.g., in renal failure).
The anion gap is elevated ([Na + K] - [Cl + HCO3] >13 mEq/L).Plasma osmolarity usually is increased (>290 mOsm/L). If plasma osmolarity cannot be directly measured, it may be calculated as followsPlasma osmolarity = 2 (Na + K) + BUN/3 + glucose/18.