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Diabetes and EmergencyINTESSAR SULTANMD, FRCPPROF. OF MEDICINE @ TAIBAH UNIVERSITYConcultant endocrinologist and Diabetologist KingFahd Hospital, Madinah.
Outlines• Emergency plan• What to do during emergency• SICK DAY ROLES• Performing Hajj• Hypoglycemia emergency• Hyperglycemia emergency
Emergency plan BY diabetic patients.• Wear identification card .• Ask during a regular visit what to do in anemergency if drugs are not available.• Prepare an emergency supply of food and water.• Prepare emergency kit with supply of medicinesenough to last at least 3 days.• Ask about storing prescription medicines.• Make a plan for how to handle insulin thatrequires refrigeration.
• Change medical supplies in emergency kitregularly.• Check expiration dates.• Keep copies of prescriptions, medicalinformation, phone numbers for health careprovider in emergency kit.• Keep a list of the type and model number ofmedical devices as insulin pump in emergency kit.• Pts on dialysis should know about theiremergency plans.• For children with diabetes, parents should MAKESURE YOU KNOW THE SCHOOL’S EMERGENCYPLAN (if any???).
During Emergencies and naturaldisasters• let others know that you have diabetes or other healthproblems, such as chronic kidney disease or heart disease• DRINK PLENTY OF FLUIDS, ESPECIALLY WATER:Heat, stress, hyperglycemia, and metformin can cause fluidloss• Keep something containing sugar with you at all times• You may not be able to check blood sugar levels, so beaware 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.
• In type 1 diabetes–Decrease CHO if insulin is not available +–maintain adequate intake of fluids +–immediate intake of insulin whenavailable even if different type–Restart ALL RX as soon as possible.• Requirements for the medications maybe very different due to significantchanges in diet and activity levels.
Sick day rules• Glucose monitoring 4 hourly or more• Test ketonuria once or more• Maintain CHO intake 150–200 g to prevent starvationketosis. (sugary drinks, soups if nauseating )• Glass of water/ hour ( 3L/d)
KETONURIA• Continue usual doses of insulin• Extra doses of rapid acting insulin/ 4 hours(10-20% of total usual daily dose).• Hospitalization if vomiting.
SICK DAY ROLEPitfall• Sick day rules are not taught to the ptsespecially type 1 from the first day
Protect Your Health DuringHajj & ZiyaratHaj Diabetes was the cause of death in 2% of totalmortality in the pilgrims in 1 year
Hyperglycemic emergencies in Haj• 18 DKA CASES admitted in Medina with severebiochemical disturbances.• Poor compliance (94%).• Main ppt factor is Respiratory infections• So diabetic patients should receive influenzavaccine annually.• Only 4.7% pilgrims admitted to hospital hadreceived 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.
Hypoglycaemia during HajHigh 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 storageand cause hyper-glycaemia).
• INSULIN DOSES, WHICH MAY BE OPTIMALDURING A SEDENTARY LIFE, PROVE EXCESSIVEDURING HAJ, DUE TO THE MODERATE TOSEVERE EXERTION REQUIRED.
Foot problems and macrovasculardisease during Haj• Al-Qattan reported 12 cases of foot burnsustained from standing or walking barefooton the street following the ‘Friday prayers’.• Diabetics with neuropathy developed deepburns that involved the entire weight-bearingarea of the sole.Al-Qattan MM. Burns. 2000;26:102–5.[
• Acute appendicitis and diabetic foot were themost common causes of admission.• Skin infections [both fungal and bacterial] arerecognized complications of diabetesparticularly in patients with poorly controlleddiabetes and poor hygiene.Al-Salamah SM. Saudi Med J. 2005 Jul;26(7):1055–1057
Practical management of people withdiabetes intending to perform Haj• Formal education courses• Full assessment (including ECG) andmanagement• well-controlled diabetics slightly reducemorning dose of oral hypoglycemic agent orinsulin• mid-morning snacks when exercise is expected
• Awareness of hypoglycaemia presentation andmanagement• 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 orvomiting, chest pain, SOB, etc• Avoid self-prescription.• Avoid walking bare foot.
How to identify emergencyWarning Signs that Require ActionHypoglycemia•Sweating•Shakiness•Anxiety•Confusion•Difficulty speaking•Uncooperative behaviorAll cases are emergency•Paleness•Irritability•Dizziness•Inability to swallow•Seizure•Loss of consciousness
Recommendations for Hypoglycemia<70 mg/dl• Ingestion of 15–20 g glucose(½ can sugared SODA, Honey (3 tsp) and fruitjuice.• 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).
• if hypoglycemia occurs shortlybefore meals patients shouldtake the carbohydrate portion ofthat meal immediately.• if there has been an error withthe insulin dose or a missedmeal, the glucose requirementsmay be four to five times higherto manage Hypoglycemia atnight.
Important points in Hypoglycemicmanagement• 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 requiretreatment.• Treatment should increase blood glucose without reboundhyperglycemia• 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.
common pitfall in hypoglycemiamanagement in practice• Pt decides he is hypoglycemic without BGchecking and receive an extra amount of calories.• Large amount of sugar and carbohydrate given tohypoglycemic patients with reboundhyperglycemia• no trained family member to inject unconsciouspatient with glucagon• Most of us never inject glucagon as this is the jobof family member who should be trained by us!!!!!!!
– Glucagon at home 1 mg subcutaneously• nausea and vomiting so monitor till pt can eat.• Pitfall: severe hypoglycemia after strenuousexercise, decreased food intake , fasting,alcohol , insulin overdose: glucagon injectionmay not be effective because of depletedglycogen stores
How to identify emergencyWarning Signs that Require ActionHyperglycemia•Flushed skin•Labored breathing•Confusion•Cramps•Very weak•Sweet breath•Nausea•Loss of consciousness
In pts not known with diabetes• People experiencing diabetes emergenciesmay:• –Appear intoxicated• –Appear under the influence of drugs• –Appear uncooperative• When in doubt, ask the person or his/hercompanions if the person has diabetes andcheck for medical identification bracelet,necklace.
Hyperglycemia and borders ofemergency• 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.
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: variableTypical 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
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
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 residentshould personally monitor the patient’s progress frequentlyuntil the acidosis is broken• Milder forms of DKA can be treated in ER/ HOME.
DKA Management• ABC• Obtain large bore IV (16 gauge) access• Cardiac monitor & pulse oximetry.• Monitor serum glucose hourly• Electrolytes, osmolality & venous pH/2-4hours until the patient is stable.• Determine and treat any underlying cause
Important points• Fluid replecement should be completed in12–24 h ( 6-8 h in mild cases)• Deaths have resulted from hypokalemiaand, more rarely, from hyperkalemia.• Maintain plasma potassium of at least 3.5–4.0meq/l at all times.
Managing DKAFluids (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/dlInsulin• 0.1 units/kg/h (10 units) regular insulin/h by continuous intravenousinfusion• 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/dlK+• 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
Dilemma• Insulin allergy,??• Cardiac pt ??? And fluids• History of congestive heart failure indicate theneed for more hypotonic fluids.
Bicarbonate treatmentIndications:• 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 acidosisDoses 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
Acidosis and Monitoring ABG• Urinary or serum ketone levels by the nitroprusside methodare limited as with improvement Beta-hydroxybutyrate isconverted 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)
RESOLUTION• In DKA:1. S. glucose < 200 mg/dL2. Serum anion gap < 12 meq/L3. Serum bicarbonate ≥ 18 meq/L4. Venous pH >7.305. Pt can eat (morning hours)
HHS: Hyperosmolar HyperglycemicNonketotic 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
• An intensive care setting is more necessary forHHS compared with DKA because of– older-aged patients– more precarious volume status– greater CNS dysfunction– Comorbidities– threat of thromboses
Managing DKAFluids (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/dlInsulin• 0.1 units/kg/h (10 units) regular insulin/h by continuous intravenousinfusion• 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/dlK+• Because initial oliguria is more common potassium may not be needed atthe outset and the rates of administration should be more cautious (10–20meq/h).
RESOLUTIONIN HHS:1. S. glucose 250 to 300 mg/dl2. Mentally alert3. plasma effective osmolality < 315mosmol/kg.• Insulin infusion is overlaps SC insulin (usualdose) for 1-2 HOURS.• Return to reg treatment as OAD