This document discusses the management of hyperglycemic emergencies including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It presents two case studies, one of an 18-year-old male with DKA and one of a 54-year-old male with HHS. It covers the definitions, pathophysiology, clinical features, diagnostic tests, and management including correction of dehydration and hyperglycemia, electrolyte replacement, and treatment of any precipitating infections for these conditions. Complications are also briefly mentioned.

1. HYPERGLYCEMIC
EMERGENCIES
DR SOURAB HIREMATH
MD INTERNAL MEDICINE
Emergency Medicine
Sugars are High
They reach the
sky
Breath smells of
grapes
I m under the
drapes
My breathing is
fast
I hop I will last
Insulin and saline
They are the life
line

2. PRE TEST
• DKA and HHS both have same level of elevated glucose levels in body
• DKA patients have Cheyne stokes type of breathing
• Among ketones most important to cause major symptoms is acetoacetate

3. • Treating hyperglycaemia by insulin is more important than correction of
hydration by fluids
• No need for potassium replacement in DKA on insulin infusion if K+ levels are
within normal limit
• Rapid reduction of sugars of atleast 150 mg /dl per hour should be done

4. STORY OF MAHESH AND SURESH
Case of Mahesh Case of Suresh
18 year old boy complains of severe abdominal
pain vomiting , loose stools and fever since 3
days
Associated with weight loss of around 10 kg in
five months
h/o polyuria , polydipsia present
Past : nothing significant
Family : no h/o DM , HTN
Personal : Nothing contributory
54 year old male brought to casualty with h/o LOC
since 1 hour with 1 episode of GTCS .
No fever , vomiting.
Past : K/C/O of diabetes since 10 years stopped
drugs since 1 month
Family : H/o DM in sibling
Personal : Nothing significant

5. O/E of mahesh O/e of Suresh
DROWSY
PR : 110/ min
BP : 80/ 60 mm of Hg
RR : 28 / min
Spo2 : 96 % on room air
Severely dehydrated
Drowsy
PR : 120/min
Bp : 100/60 mm of Hg
RR : 24/min
Spo2 : 94 % on room air
Severely dehydrated

6. O/E OF MAHESH

7. O/E OF SURESH
• Drowsy
• Dehydrated
• No ketotic odour
• No focal neurological deficits
• Other systemic examination is normal

8. Mahesh Suresh
GRBS : 480 mg/dl
RBS : 450 mg/dl
Sr HCO3 : 12 meq/dl
GRBS : High
RBS : 980mg/dl
Sr HCO3 : 24 meq/dl

9. DIAGNOSIS
• Case 1 : DIABETIC KETO ACIDOSIS
• Case 2 : Hyperosmolar Hyperglycemic state

10. DEFINITION
• DKA : State of absolute or relative insulin deficiency characterised By
Diabetes : >300mg/dl
Ketosis : positive ketones in serum and urine
Acidosis : ph <7.30 / HCO <15 meq/L
• HHS : High plasma osmolality
Sugars usually > 1000 mg /dl

11. PRECIPITATING FACTORS

12. PATHOPHYSIOLOGY

13. CLINICAL FEATURES
• Symptoms
Classical hyperglycemic symptoms : 3 Ps
Gastrointestinal Symptoms : Nausea , vomiting , diarrhea , abdominal pain
CNS : Altered sensorium Convulsions
Intercurrent infection : fever , dysuria , cough
Rapid weight loss

14. EXAMINATION
• Signs of dehydration
• Odour of breath
• Signs of acidosis
• Signs of intercurrent illness

15. DIAGNOSTIC TESTS
• CBC
• Renal function tests
• Arterial blood gas analysis
• Osmolarity : 2*Na + glucose /18 + BUN /2.8

16. URINE

17. GLUCOSE

18. OTHER TESTS
• Sodium : hyponatremia : 100 mg dl : 1.6 meq/L
• Potassium
• Phosphorus
• ECG
• Chest xray

20. MANAGEMENT
Correction of dehydration Correction of Hyperglycaemia
Electrolytes Treatment of precipitating factors
DKA/HHS

21. CORRECTION OF DEHYDRATION

22. FLUID WHEN SUGARS < 200 ?????????????????
NS/RL is replaced By 5% Dextrose

23. CORRECTION OF HYPERGLYCEMIA

24. TYPE OF INSULIN USED
Use only short acting insulin

25. DOSE
0.1 Units /Kg body weight /hour
Intravenous Infusion

26. OPTIMAL DECLINE OF SUGAR
50-75 mg / dl per hour
Avoid rapid reduction

27. ELECTROLYTE CORRECTION

28. OTHERS
• Bicarbonate correction
• Phosphate replacement

29. TREATMENT OF INFECTION
•Appropriate empirical antibiotics

30. COMPLICATIONS
• Cerebral edema
• Hypokalemia
• CVT
• MI
• Hypoglycemia
• Acute pulmonary edema

31. THANK YOU