Tasty Morsels of EM 122 – #FRCEM DKA and diabetic emergencies

9 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

When should we diagnose DKA in adults?

  • Ketnoaemia:
    • urine ++ ketones
    • >3mmol/l
  • Glucose
    • >11
    • known diabetes
  • Bicarbonate < 15 or venous pH <7.3

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How should we manage DKA in adults?

this is of course a superficial summary of the bits that have changed in recent years and that I’m likely to forget…

  • venous gases rather than arterial
  • can also be used for electrolytes with intermittent lab confirmation
  • bedside blood ketone and glucose monitoring encouraged
  • use fixed rate insulin infusions (0.1unit/kg/hr) (note no bolus)
  • aim for
    • reduce ketones 0.5/hr
    • reduce glucose 3/hr
    • keep K between 4 and 5.5
  • add 10% glucose infusion when glucose <14 (continue the saline too)
  • continue the patients normal long acting insulin
  • they suggest systolic of 90 as the trigger for fluid boluses otherwise it’s a bit slower (1000 in first hour, 1000 over the following 2 hours etc…)
  • don’t forget the euglycaemic DKA with the new meds

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What is HHS and how should we treat it?

(2012 Guideline)

  • Features
    • hypovolaemia
    • glucose >30 without significant ketonaemia or acidosis
    • osmoloality >320
  • Fluid losses 10-20 litres!
  • give 0.9% saline and expect a small rise in sodium initially
    • only use 0.45% if sodium not falling or rising AND sugar not falling
    • the key is osmolality, when 0.9% saline given the sodium often rises but the sugar drops much more and overall osmolality goes down which is the important bit
  • don’t reduce the sodium more than 10 in 24 hrs
  • aim +ve fluid balance of 3-6 littres at 12 hours
  • aim to reduce sugar no more than 5/hr
  • only introduce insulin IV if the sugar stops falling with fluids (and even then at 0.05units/kg, half that of DKA)
  • most patients should have VTE prophylaxis
  • they highlight the frequency of foot ulceration in these folk

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What about DKA in kids?

BSPED 2015

  • Diagnosis
    • pH<7.3, Bicarb <18
    • Ketonaemia >3
    • usually glucose >11
  • pH<7.1 = severe DKA
  • Management
    • do not give fluid bolus unless shocked, even if pH<7.1
    • if giving it in a shocked DKA kid give a single 10ml/kg bolus
    • Fluid requirement = deficit + maintenance
      • they acknowledge that estimating deficit is witchcraft inaccurate so give this guide
        • 5% deficit if pH>7.1
        • 10% deficit if pH<7.1
        • replace this over 48 hrs
      • Maintenance is lower than normal (and not the usual APLS)
        • <10kg = 2ml/kg/hr
        • 10-40kg = 1ml/kg/hr
        • >40kg = fixed 40ml/hr
      • they note that all fluids should contain potassium (0.9% saline 500mls with 20mmol KCL)
    • Insulin
      • give 1-2 hrs after fluid starts
      • use 0.05-0.1 unit/kg
    • Once glucose under 14 then need to add glucose. The concentration depends a bit on the ketone level. See the guideline
  • Signs of cerebral oedema
    • headache
    • irritability
    • slowing pulse
    • increasing pulse pressure
    • reducing GCS
  • If suspected give mannitol (20% 0.5-1 g/kg over 10-15 minutes)

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