INTESSAR SULTAN MD, FRCP PROF. OF MEDICINE @ TAIBAH UNIVERSITY Concultant endocrinologist and Diabetologist King Fahd Hospital, Madinah.

1. Diabetes and Emergency
INTESSAR SULTAN
MD, FRCP
PROF. OF MEDICINE @ TAIBAH UNIVERSITY
Concultant endocrinologist and Diabetologist King
Fahd Hospital, Madinah.

2. Outlines
• Emergency plan
• What to do during emergency
• SICK DAY ROLES
• Performing Hajj
• Hypoglycemia emergency
• Hyperglycemia emergency

4. Emergency plan BY diabetic patients.
• Wear identification card .
• Ask during a regular visit what to do in an
emergency if drugs are not available.
• Prepare an emergency supply of food and water.
• Prepare emergency kit with supply of medicines
enough to last at least 3 days.
• Ask about storing prescription medicines.
• Make a plan for how to handle insulin that
requires refrigeration.

5. • Change medical supplies in emergency kit
regularly.
• Check expiration dates.
• Keep copies of prescriptions, medical
information, phone numbers for health care
provider in emergency kit.
• Keep a list of the type and model number of
medical devices as insulin pump in emergency kit.
• Pts on dialysis should know about their
emergency plans.
• For children with diabetes, parents should MAKE
SURE YOU KNOW THE SCHOOL’S EMERGENCY
PLAN (if any???).

6. During Emergencies and natural
disasters
• let others know that you have diabetes or other health
problems, such as chronic kidney disease or heart disease
• DRINK PLENTY OF FLUIDS, ESPECIALLY WATER:
Heat, stress, hyperglycemia, and metformin can cause fluid
loss
• Keep something containing sugar with you at all times
• You may not be able to check blood sugar levels, so be
aware of warning signs of hypoglycemia.
• Pay special attention to your feet.
– Stay out of contaminated water
– wear shoes
– examine feet carefully for any sign of infection or injury.
– Get medical treatment quickly for any injuries.

7. • In type 1 diabetes
–Decrease CHO if insulin is not available +
–maintain adequate intake of fluids +
–immediate intake of insulin when
available even if different type
–Restart ALL RX as soon as possible.
• Requirements for the medications may
be very different due to significant
changes in diet and activity levels.

8. Sick day rules
• Glucose monitoring 4 hourly or more
• Test ketonuria once or more
• Maintain CHO intake 150–200 g to prevent starvation
ketosis. (sugary drinks, soups if nauseating )
• Glass of water/ hour ( 3L/d)

9. KETONURIA
• Continue usual doses of insulin
• Extra doses of rapid acting insulin/ 4 hours
(10-20% of total usual daily dose).
• Hospitalization if vomiting.

10. SICK DAY ROLE
Pitfall
• Sick day rules are not taught to the pts
especially type 1 from the first day

11. Protect Your Health During
Hajj & Ziyarat
Haj Diabetes was the cause of death in 2% of total
mortality in the pilgrims in 1 year

12. Hyperglycemic emergencies in Haj
• 18 DKA CASES admitted in Medina with severe
biochemical disturbances.
• Poor compliance (94%).
• Main ppt factor is Respiratory infections
• So diabetic patients should receive influenza
vaccine annually.
• Only 4.7% pilgrims admitted to hospital had
received the influenza vaccine.
Yusuf M, Chaudhry S. International Diabetes Digest. 1998;8:14–16.
Balkhy HH, Memish ZA, Bafaqeer S, Almuneef MA. J Travel Med. 2004;11:82–86.

13. Hypoglycaemia during Haj
High risk of hypoglycaemia is mainly due to
• Change in physical activities
• Change in meals (Smaller, unusual or timing)
• Excessive heat enhances insulin absorption
(conversely it interferes with insulin storage
and cause hyper-glycaemia).

14. • INSULIN DOSES, WHICH MAY BE OPTIMAL
DURING A SEDENTARY LIFE, PROVE EXCESSIVE
DURING HAJ, DUE TO THE MODERATE TO
SEVERE EXERTION REQUIRED.

15. Foot problems and macrovascular
disease during Haj
• Al-Qattan reported 12 cases of foot burn
sustained from standing or walking barefoot
on the street following the ‘Friday prayers’.
• Diabetics with neuropathy developed deep
burns that involved the entire weight-bearing
area of the sole.
Al-Qattan MM. Burns. 2000;26:102–5.[

16. • Acute appendicitis and diabetic foot were the
most common causes of admission.
• Skin infections [both fungal and bacterial] are
recognized complications of diabetes
particularly in patients with poorly controlled
diabetes and poor hygiene.
Al-Salamah SM. Saudi Med J. 2005 Jul;26(7):1055–1057

17. Practical management of people with
diabetes intending to perform Haj
• Formal education courses
• Full assessment (including ECG) and
management
• well-controlled diabetics slightly reduce
morning dose of oral hypoglycemic agent or
insulin
• mid-morning snacks when exercise is expected

18. • Awareness of hypoglycaemia presentation and
management
• The diabetic emergency kit
– Honey/ glucagon for ready use in insulin treated patients.
– medication, needles, pens, and glucometers
– protective shoes and identifying wristbands.
– Prescription
• Control and monitor hypertension
• Patients with nephropathy
– avoid dehydration
– carry water bottles: drink 2 liters daily.
• Early medical consultation in case of diarrhea or
vomiting, chest pain, SOB, etc
• Avoid self-prescription.
• Avoid walking bare foot.

19. HYPOGLYCEMIC EMERGENCY

20. How to identify emergency
Warning Signs that Require Action
Hypoglycemia
•Sweating
•Shakiness
•Anxiety
•Confusion
•Difficulty speaking
•Uncooperative behavior
All cases are emergency
•Paleness
•Irritability
•Dizziness
•Inability to swallow
•Seizure
•Loss of consciousness

21. Recommendations for Hypoglycemia
<70 mg/dl
• Ingestion of 15–20 g glucose
(½ can sugared SODA, Honey (3 tsp) and fruit
juice.
• The response within 10–20 min
• Continue sugar source/15 min until BG > 70
• Check plasma glucose after ∼60 min.
• AVOID Fat: prolong acute glycemic response.
• AVOID Protein: does not help hypoglycemia.
• If unconscious or seizures: call emergency
– SC Glucagon or
– 50 ML D50 IV over 2 min. (AT HOPSITAL).

22. • if hypoglycemia occurs shortly
before meals patients should
take the carbohydrate portion of
that meal immediately.
• if there has been an error with
the insulin dose or a missed
meal, the glucose requirements
may be four to five times higher
to manage Hypoglycemia at
night.

23. Important points in Hypoglycemic
management
• Warning symptoms should be known by pts, relatives, friends,
teachers, and coworkers .
• Check blood glucose level after suspected hypoglycemia
• Treat even in doubt
• All hypoglycemic episodes, even asymptomatic require
treatment.
• Treatment should increase blood glucose without rebound
hyperglycemia
• For Witnesses (UNCONSCIOUS PT)
• DO NOT inject insulin.
• DO NOT provide food or fluids.
• DO NOT put hands in pt’s mouth.
• DO inject glucagon.
• DO call for emergency help.

24. common pitfall in hypoglycemia
management in practice
• Pt decides he is hypoglycemic without BG
checking and receive an extra amount of calories.
• Large amount of sugar and carbohydrate given to
hypoglycemic patients with rebound
hyperglycemia
• no trained family member to inject unconscious
patient with glucagon
• Most of us never inject glucagon as this is the job
of family member who should be trained by us
!!!!!!!

25. – Glucagon at home 1 mg subcutaneously
• nausea and vomiting so monitor till pt can eat.
• Pitfall: severe hypoglycemia after strenuous
exercise, decreased food intake , fasting,
alcohol , insulin overdose: glucagon injection
may not be effective because of depleted
glycogen stores

26. HYPERGLYCEMIC MANAGEMENT

27. How to identify emergency
Warning Signs that Require Action
Hyperglycemia
•Flushed skin
•Labored breathing
•Confusion
•Cramps
•Very weak
•Sweet breath
•Nausea
•Loss of consciousness

28. In pts not known with diabetes
• People experiencing diabetes emergencies
may:
• –Appear intoxicated
• –Appear under the influence of drugs
• –Appear uncooperative
• When in doubt, ask the person or his/her
companions if the person has diabetes and
check for medical identification bracelet,
necklace.

29. Hyperglycemia and borders of
emergency
• High blood glucose level can be lowered by
– exercising.
– changes in meal plan.
– If both fail: changes in anti-diabetic medications.
• If blood glucose is > 240 mg/dl
– Check urine for ketones.
– If ketonuria, no exercise.

31. DKA Diagnostic criteria
• Blood glucose: > 250 mg per dL (13.9 mmol per L)
• pH: <7.3
• Serum bicarbonate: < 15 mEq per L
• Urinary ketone: ≥3+ †
• Serum ketone: positive at 1:2 dilutions†
• Serum osmolality: variable
Typical deficits
• Water: 6 L, or 100 Ml/ kg
• Sodium: 7 to 10 mEq / kg
• Potassium: 3 to 5 mEq / kg
• Phosphate: ~1.0 mmol / kg

32. Confusing results in DKA
• False hyponatremia .
– Corrected sodium = Na + 1.6 x glucose (mmol/l) – 5.5/5.5
• False high BUN and creatinine
• Low renal blood flow.
– Acetoacetate raises creatinine (colorimetric assay)
• Normal pH (mixed) metabolic acidosis and alkalosis:
– Diuretics - Vomiting .
• Low PH is due to coexisting COPD
• Plasma glucose may be <250 mg/dl if:
– Alcohol
– Starvation.
– Received SC insulin repeatedly at home

33. Intensive Care Unit Admission
• ICU)is the preferred setting and necessary for
• HCO≤10 meq/l, pH ≤7.20, 4.0 > K+ ≥6.0 meq/l;
• hypotension despite rapid volume repletion
• renal failure or oligo-anuria
• CNS dysfunction
• heart failure; age ≥65 years
• concurrent comorbid condition such as sepsis
• Hyperosmolality (> 330 mOsm/kg of water) in HHN
• If ICU is not available, an attending physician or resident
should personally monitor the patient’s progress frequently
until the acidosis is broken
• Milder forms of DKA can be treated in ER/ HOME.

34. DKA Management
• ABC
• Obtain large bore IV (16 gauge) access
• Cardiac monitor & pulse oximetry.
• Monitor serum glucose hourly
• Electrolytes, osmolality & venous pH/2-4
hours until the patient is stable.
• Determine and treat any underlying cause

35. Important points
• Fluid replecement should be completed in
12–24 h ( 6-8 h in mild cases)
• Deaths have resulted from hypokalemia
and, more rarely, from hyperkalemia.
• Maintain plasma potassium of at least 3.5–4.0
meq/l at all times.

36. Managing DKA
Fluids (6L deficit + 2 L maintenance)
• 2–3 liters 0.9% saline over first 3 h (1 L/h)
• Subsequently, 0.45% saline at 150–300 ml/h (3L deficit+ 2 L maintenance)
until pt can receive meals. It is similar in composition to the fluid lost
• Add 5% glucose 100-200 ml/h when plasma glucose is 250 mg/dl
Insulin
• 0.1 units/kg/h (10 units) regular insulin/h by continuous intravenous
infusion
• Increase 2- to 10-fold if no response by 4 h
• Decrease to 1–2 units/h when acidosis is corrected
• Maintain plasma glucose at 150–250 mg/dl
K+
• 10–20 meq/h when plasma K+ <6.0, ECG normal, urine flow documented
• 40–80 meq/h when plasma K+ <3.5 or if bicarbonate is given
• addition of K+ to isotonic saline results in hyperosmolality

37. Dilemma
• Insulin allergy,??
• Cardiac pt ??? And fluids
• History of congestive heart failure indicate the
need for more hypotonic fluids.

38. Bicarbonate treatment
Indications:
• pH <7.0 or HCO3 < 5.0 meq/l
• Hyperkalemia (K+ >6.5 meq/l)
• Hypotension unresponsive to fluid replacement
• Severe left ventricular failure
• Respiratory depression
• Late hyperchloremic acidosis
Doses of 50–100 meq in 250–1,000 ml 0.45% saline in 30–60 min.
• Arterial pH should be rechecked
• continue until the pH is 7.10.
• Add 10 meq potassium chloride to each dose of bicarbonate

39. Acidosis and Monitoring ABG
• Urinary or serum ketone levels by the nitroprusside method
are limited as with improvement Beta-hydroxybutyrate is
converted to acetoacetate (increaseing ketones)
• Repeat ABG are unnecessary
• Venous pH is 0.03 units lower than arterial pH
• Monitor serum bicarbonate (to assess metabolic acidosis)
• Monitor serum anion gap (to assess ketoacidemia).
Serum anion gap = sodium – (chloride + bicarbonate)

40. RESOLUTION
• In DKA:
1. S. glucose < 200 mg/dL
2. Serum anion gap < 12 meq/L
3. Serum bicarbonate ≥ 18 meq/L
4. Venous pH >7.30
5. Pt can eat (morning hours)

41. HHS: Hyperosmolar Hyperglycemic
Nonketotic Coma
• Effects elderly with Type 2 Diabetics
• plasma glucose should be >600 mg/dl
• Osmolarity >320 mOsm/kg
• Extreme Dehydration
• No acidosis except in lactic acidosis or uremia

42. • An intensive care setting is more necessary for
HHS compared with DKA because of
– older-aged patients
– more precarious volume status
– greater CNS dysfunction
– Comorbidities
– threat of thromboses

43. HHS: Hyperosmolar Hyperglycemic state
• Physical Signs
– Tachycardia
– Orthostatic Vitals
– Poor Skin Turgor
– Drowsiness and lethargy
– Delirium
– Coma
• Symptoms
– Nausea/vomiting
– Abdominal pain
– Polydipsia
– Polyuria

44. Managing DKA
Fluids (6L deficit + 2 L maintenance)
• 2–3 liters 0.9% saline over first 3 h (1 L/h)
• Subsequently, 0.45% saline at 150–300 ml/h (3L deficit+ 2 L maintenance)
until pt can receive meals. It is similar in composition to the fluid lost
• Add 5% glucose 100-200 ml/h when plasma glucose is 250 mg/dl
Insulin
• 0.1 units/kg/h (10 units) regular insulin/h by continuous intravenous
infusion
• Increase 2- to 10-fold if no response by 4 h
• Decrease to 1–2 units/h when BG is 250-300 is corrected
• Maintain plasma glucose at 200–250 mg/dl
K+
• Because initial oliguria is more common potassium may not be needed at
the outset and the rates of administration should be more cautious (10–20
meq/h).

45. RESOLUTION
IN HHS:
1. S. glucose 250 to 300 mg/dl
2. Mentally alert
3. plasma effective osmolality < 315
mosmol/kg.
• Insulin infusion is overlaps SC insulin (usual
dose) for 1-2 HOURS.
• Return to reg treatment as OAD