Project: Ghana Emergency Medicine Collaborative Document Title: Diabetic Emergencies Author(s): Andrew Wong (University of Michigan/St. Joseph Mercy Hospital), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected]with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
This is a lecture by Dr. Andrew Wong from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Project: Ghana Emergency Medicine Collaborative Document Title: Diabetic Emergencies Author(s): Andrew Wong (University of Michigan/St. Joseph Mercy Hospital), MD 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
1
Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ
Public Domain – Expired: Works that are no longer protected due to an expired copyright term.
Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)
Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.
Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
{ Content the copyright holder, author, or law permits you to use, share and adapt. }
{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }
{ Content Open.Michigan has used under a Fair Use determination. }
2
3
Objectives � Pathophysiology of diabetes
� Signs, symptoms, diagnosis and management of acute complications of diabetes: � Hypoglycemia � Diabetic ketoacidosis � Hyperglycemic hyperosmolar nonketotic coma
4
Case 1 � 23yo F with history of DM Type I presents to the ED for difficulty
breathing.
� 7 days ago, she began having vaginal spotting, and dysuria
� She lost her glucometer earlier this week and was unable to measure blood sugars
� Today, she began to have nausea and vomiting and complained of abdominal pain.
� Mother also noticed that she was having a hard time breathing
� Found glucometer today and it read “high”
5
Case 1 � PMH: Type I DM
� PSH: None
� Medications: Cannot recall—uses both short acting and long-‐acting insulin
� Allergies: None
� SH: Sexually active; denies any illicit drug, alcohol or tobacco use. Senior in high school
6
Case 1 � Physical Exam:
� VS: T37 BP100/70 HR120 RR38 O2sat100%ra � General: ill-‐looking thin female who appears to have labored
respirations � HEENT: PERRL, EOMI, MM dry, OP clear � Neck: soft, supple with no lymphadenopathy � Lungs: CTAB, no w/r/r � CV: tachycardic but regular rhythm, no m/r/r � Abdomen: +BS. Diffusely tender with area of maximal tenderness
in the LLQ. No lesions found. No adnexal masses palpated � Pelvic: White creamy exhudate with +CMT and left adnexal
tenderness � Extremities: cool to touch. 2+ radial, DP and posterior tibial pulses
cap refill 3 seconds. � Skin: No rash, +skin tenting
7
Normal Physiology � Glucose rise triggers pancreatic beta cells to release insulin
� Insulin lowers serum glucose levels � Stimulate glucose uptake and storage, facilitate use by fat and
muscle � Inhibit glycogen breakdown in liver � Degraded in 3-‐10 min in liver and kidney � Inhibits hepatic gluconeogenesis and glycogenolysis � Stimulate glycogen (stored form of glucose) storage
� Fasting state stimulates pancreatic alpha cells to release glucagon � Glucagon increases levels of glucose in blood
� Stimulate liver to break down glycogen and release glucose � Kidney release glucose in prolonged starvation � Increases ketone production to enhance gluconeogenesis
8
Background � Diabetes
� Most common endocrine disease
� Spectrum of disorders characterized by hyperglycemia and disturbances in carbohydrate and lipid metabolism
� Four types of Diabetes � Type I: Immune-‐mediated or idiopathic failure to produce insulin
� Type II: Hyperinsulinemic state due to resistance to insulin
� Gestational Diabetes Mellitis: during pregnancy; similar to DMII
� Impaired Glucose Tolerance: increased risk of developing DMII
9
Epidemiology � Prevalence of DM in US is 6.6%
� 5-‐10% have Type I
� 90-‐95% have Type II
� Groups at risk for DM � More in whites than nonwhites � Native Americans
� Age of onset � Peak age of onset of Type I DM is 10-‐14years � Onset of Type II DM tend to be older; younger people
getting disease due to obesity
10
Clinical Features Clinical Features Type I Diabetes Type II Diabetes
Body habitus Lean Obese
Age Younger than 40yo Middle-‐aged or older
Insulin levels Absent or low Normal to high
Onset Abrupt Gradual
� Initial presentation of Type I DM usually DKA
� Type II DM is being Dx in younger people
� Diagnosis:
� Any random plasma glucose >200mg/dL (11.1 mmol/dL) with symptoms of diabetes
� Fluids mainstay of therapy; pts usually down 3-‐5L � Adult: 1-‐2L over 1-‐3 hrs; Child: 20 mL/kg over 1 hour � Follow with fluid resuscitation to maintain UOP of 1-‐2mL/kg/hr
� Insulin � Infusion of 0.1 units/kg/hr up to 5-‐10 units/kg/hr � Bolus of insulin prior to drip optional in adults; contraindicated in
children � Check glucose every 1 hour � Switch IV fluids to contain dextrose to prevent hypoglycemia when