a basic guide to emergency room care of hyperglycaemia in a rural/semi-rural setting of a regional hospital

1. DIABETIC
EMERGENCIES
A GUIDE FROM THE CASUALT Y
CREW

3. WHERE DOES ONE
BEGIN
DIABETIC EMERGENCIES ARE SOME OF THE MOST
COMMON LIFE THREATENING EMERGENCIES WE SEE
HOWEVER MOST INTERNS AND JUNIOR MO’S ARE
POORLY EQUIPPED TO HANDLE THESE PATIENTS
WHY? BECAUSE WE HAVE VAST VOLUMES OF JUMBLED
KNOWLEDGE ABOUT DIABETES IN OUR HEADS
IN THIS PRESENTATION I WILL HOPE TO SIMPLIFY THIS
PROBLEM FOR YOU, STARTING WITH HYPERGLYCAEMIA
IN THIS PRESENTATION AND TEACHING YOU
HYPOGLYCAEMIA IN ANOTHER SHORTER SESSION

4. HYPERGLYCAEMIC
EMERGENCIES
AT THIS STAGE I COULD BORE YOU WITH LONG
DISCUSSIONS ON THE PATHOPHYSIOLOGY
AND PRESENTATION OF PATIENTS
INSTEAD LET ME SAY THIS,YOU HAVE THREE
POSSIBLE DIAGNOSIS AND YOU HAVE THREE
PARAMETERS YOU NEED TO CHECK
HUH? WAIT WHAT?!!
YES, LETS GOOOOO………….

5. THE THREE
DIAGNOSES
1:- SIMPLE HYPERGLYCAEMIA (SH)
2:- DIABETIC KETOACIDOSIS (DKA)
3:- HYPEROSMOLAR NON KETOTIC COMA
(HONKC)
NB,WE WILL USE SH, DKA AND HONKC
FOR THE REST OF THE PRESENTATION

6. THE THREE
PARAMETERS
1:- URINE, A SIMPLE DIPSTIX
2:- LEVEL OF CONSCIOUSNESS ,THE
GLASGOW COMA SCALE
3:- BLOOD
3.1:- GLUCOMETER READINGS
3.2:- ARTERIAL BLOOD GAS

7. THE DIPSTIX
WE ASSUME IN THESE SCENARIOS THAT
THE PATIENT HAS AN ELEVATED BLOOD
GLUCOSE LEVELS
THE FIRST STEP IS THE URINE DIPSTIX,
ARE THERE KETONES OR NOT
YES:- DKA
NO:- HONKC OR SH

8. LEVEL OF
CONSCIOUSNESS
NORMAL :- SH OR DKA
DECREASED:- HONKC

9. THE ABG
SERVES A TWO FOLD PURPOSE
IT GIVES YOU A DEFINITE ANSWER ON THE
SEVERITY OF THE CONDITION, ASSISTS IN
MONITORING
IT TELLS YOU YOUR POTASSIUM LEVEL
(WE WILL DISCUSS SOON)

10. SO IF A PT HAS A NORMAL LEVEL OF
CONSCIOUSNESS WITH NO KETONES IN
THE URINE IT IS AN SH
A PT WITH A NORMAL OR DECREASED LOC
WITH KETONES IN THE URINE IS A DKA
A PT WITH A DECREASED LOC AND NO
KETONES IN THE URINE IS A HONKC
GOT IT?!!

11. I KNOW I HAVE TO DO AN ABG FOR HONKC AND DKA, DO I HAVE TO DO ONE FOR
SH?
YES!!
WHY?
A FEW REASONS
DEFINITELY EXCLUDE ACIDOSIS
HYPERNATRAEMIA,THESE PTS ARE OFTEN INTRAVASCULAR
DEPLETED OF FLUID, HYPONATRAEMIA IS LESS COMMON
POTASSIUM LEVELS, MAY BE HIGH OR LOW DEPENDING ON THE
STAGE OF THE ILLNESS OR PRODROMAL ILLNESSES SUCH AS AGE
LACTATE LEVELS MAY CAUSE AN ACIDOSIS THAT REQUIRES
TREATMENT
CONFIRM GLUCOSE LEVELS
YOUR HAEMATOCRIT IS A GOOD INDICATION OF HYDRATION
STATUS, HIGH IS BAD, LOW IS GOOD

12. SO NOW I CAN MAKE
THE DIAGNOSIS
EASILY
WHATS MY FIRST STEP IN
TREATMENT?

13. FLUIDS, FLUIDS,
FLUIDS
THERE ARE VARIOUS REGIMENS DESCRIBED IN THE LITERATURE, I WILL DESCRIBE
ONE I HAVE USED SUCCESSFULLY IN MANY PATIENTS
FIRST GIVE A BOLUS OF EITHER N SALINE OR RINGERS LACTATE, 250 ML IV AS QUICK
AS POSSIBLE +- 15 MINS
THEN GIVE THE REMAINING 750 ML OVER THE NEXT 45 MIN, FOR 1 LT IN 1 HR
THEN GIVE ANOTHER LITRE OVER TWO HOURS
A THIRD LITRE OVER 6 HRS
A FOURTH LITRE OVER 12 HOURS
GIVING APPROXIMATELY 4LTRS OVER 24 HRS
THESE CAN BE ADJUSTED UPWARD OR DOWNWARD DEPENDING ON THE SEVERITY
OF THE DEHYDRATION, BECAUSE REMEMBER, ALL THREE CLASSES ARE
DEHYDRATED

14. IT IS IMPORTANT NOT TO OVER-HYDRATE
AS T HIS WILL LEAD TO CEREBRAL
OEDEMA WHICH HAS A HIGHER
MORTALITY RATE THEN THESE
EMERGENCIES
SO PLEASE DON’T ‘OPEN THE TAP’ AND
ABANDON YOUR PATIENT, MONITOR YOUR
FLUIDS

15. REMEMBER YOUR
URINE OUTPUT IS
ALSO A GREAT
GUIDE, CATHETERISE
EACH PATIENT
1ML/KG/HR IS A GOOD
GUIDE, A 100KG MAN
SHOULD MAKE 100ML
OF URINE IN AN HOUR

16. MOST OF YOUR
PATIENTS WILL
RESPOND WELL
TO IV FLUIDS
DON’T RUSH TO BRING DOWN
THE PLASMA GLUCOSE
SOME SH PATIENTS WILL RESOLVE
ON FLUIDS ONLY BEFORE YOU
EVEN GIVE INSULIN THERAPY

17. BUT HOW SHOULD I
BRING DOWN THE
PLASMA GLUCOSE ONCE
THE FLUIDS HAVE
STARTED?

18. NOW THAT YOU'VE GIVEN FLUIDS YOU
MAY CORRECT AN ACIDOSIS AND HIGH
GLUCOSE LEVELS
ACIDOSIS IS TREATED VIA THE
ADMINISTRATION OF SODIUM
BICARBONATE ( DON’T ADMINISTER TOO
QUICKLY, 50ML OVER 30 MIN, IT WILL ALSO
PUSH UP SODIUM LEVELS!)
HOW DO YOU BRING DOWN GLUCOSE
LEVELS? INSULIN OF COURSE,BUT….
WHAT ELSE DOES INSULIN LOWER?

19. POTASSIUM OF
COURSE!!
I’VE HEARD RUMOURS THAT POTASSIUM IS QUITE
ESSENTIAL, STILL HAVE TO VERIFY THAT (JUST KIDDING)
THIS IS WHY YOU DON’T START INSULIN IMMEDIATELY,
AND WHY YOUR ABG IS SO IMPORTANT
IT DOES NOT POSE A HUGE PROBLEM IN
HYPERKALAEMIA, AS YOU WOULD ONLY A OMIT
GLUCOSE FROM YOUR K+ SHIFT REGIMEN, GIVING ONLY
INSULIN (10U IV ACTRAPID FOR EG) AND CALCIUM
GLUCONATE (10 ML)
HOWEVER IN HYPOKALAEMIA……

20. YOU HAVE TO SUPPLEMENT POTASSIUM WHILE GIVING YOUR
INSULIN
AGAIN THERE ARE A FEW REGIMENS IN THE LITERATURE, I
WILL GIVE YOU THE ONE WE USE CURRENTLY
K+ 0-2 , 60MMOL OF K+ SUPPLEMENTATION
K+ 2-3 , 40 MMOL K+
K+ 3-4 , 20 MMOL K+
K+ 4-4.5 , 10 MMOL OF K+
RUN IT IN AT 10 MMOL/HR
DON’T FORGET YOU WILL NEED AN ABG AFTER
EACH INSULIN, K+, K+ SHIFT, INSULIN INFUSION,
CONSIDER AN ARTERIAL LINE IN CONSULTATION
WITH PHYSICIANS AND ICU STAFF FOR SERIOUS
CASES

21. WHAT IF THE GLUCOSE
LEVEL IS NOT DROPPING?
THERE MAY BE A FEW REASONS…
LOOK FOR UNDERLYING SEPSIS, A WET GANGRENE OF A LIMB
CAUSING HONKC WILL BE VERY RESISTANT TO THERAPY
HAVE YOU GIVEN FLUIDS CORRECTLY?
IN SOME PTS WITH HONKC THE DEFICIT MAY BE UP TO
10L, AND YOU MAY HAVE TO GIVE MUCH MORE FLUID,
AS MUCH AS 500ML/HR, OR REPEATED 250ML BOLUSES,
IDEALLY UNDER DIRECTION OF THE PHYSICIAN
DOES THE PT NEED AN INSULIN INFUSION?
IF YES, DO I HAVE AN INFUSER?
IS THERE AN ICU OR HCU TO MONITOR THE PATIENT?

22. IF THE ANSWER IS YES THEN YOU MAY GIVE
AN INFUSION
IF YOU HAVE THESE FACILITIES
YOU CAN GIVE 0.1U OF INSULIN PER
KG BODY WEIGHT PER HOUR
SO A 50KG PT WILL RECEIVE 5U PER
HOUR, AND NO PATIENT SHOULD
RECEIVE MORE THAN 10U PER HR
IN OUR PARTICULAR SETTING THE
INFUSIONS ARE STARTED IN ICU,
BUT IN HIGHER LEVELS HOSPITALS
THE A&E COMMENCES TREATMENT

23. LETS TRY A CASE
27 YR OLD KNOWN DIABETIC PRESENTS
WITH A GCS OF 14/15 AND GLUCOSE OF 32.
FAMILY REPORTS SHE HAS HIV AND HAS
HAD SEVERE DIARRHOEA FOR TWO DAYS
WHAT ARE YOU TWO POSSIBLE
DIAGNOSIS?
WHAT DO YOU DO?

24. THE URINE SHOWS 3+
KETONES.
WHAT IS YOUR DIAGNOSIS?

25. NOW FORMULATE YOUR
TREATMENT PLAN BASED ON
WHAT YOU HAVE LEARNED.

26. REMEMBER….
FLUIDS
THEN AN ARTERIAL BLOOD GAS
THEN INSULIN DEPENDING ON YOUR
POTASSIUM LEVELS

27. HER BLOOD GAS SHOWS (I’ve
only put the relevant parameters)
PH= 7.12, NA= 134, K=
2.2, HCT= 65% (HIGH),
GLUC=33,
LACTATE=2.3
DESCRIBE HOW
YOU WOULD TREAT
HGT AND K+ BASED
ON WHAT YOU’VE
LEARNED

28. SHALL WE TRY ONE
MORE?
A 54 YR OLD NEWLY DIAGNOSED DIABETIC,
IS RUSHED INTO THE A&E BY THE
OUTPATIENT SISTER BECAUSE THE HGT IS
HI !!
THE PATIENT IS FULLY CONSCIOUS
WHAT ARE YOUR TWO POSSIBLE DIAGNOSIS?
WHAT DO YOU DO NEXT?

29. THE URINE DIPSTIX
SHOWS NO KETONES.
WHAT IS YOU DIAGNOSIS?

30. NOW TELL ME YOUR TREATMENT
PLAN FOR THIS PATIENT
(or write it down)
AND DON’T FORGET TO DO THE ABG!!!!

31. LAST ONE
A 67 YEAR OLD FEMALE PATIENT IS
BROUGHT IN WITH A GCS 0F 9/15, A
HISTORY OF A SEVERE UTI AND AN HGT
OF HI
WHAT ARE YOUR TWO POSSIBLE
DIAGNOSIS?
WHAT DO YOU DO NEXT?

32. THE URINE HAS NO
KETONES.
WHAT IS YOUR DIAGNOSIS?

33. AGAIN, DESCRIBE YOUR
TREATMENT PLAN BASED ON
WHAT YOU HAVE LEARNED

34. IT IS IMPOSSIBLE TO COVER ALL THE
INTRICACIES OF MANAGING SUCH
PATIENTS IN A SHORT TEACHING
PRESENTATION SUCH AS THIS
BUT I HOPE YOU WILL FIND IT MUCH
EASIER TO APPROACH HYPERGLYCAEMIA
IN THE FUTURE ,AND WILL LEARN THE
SUBTLETIES AS YOU SPEND MORE YEARS
IN THE FIELD
THANK YOU