Diabetic emergencies
Introduction
• there are 3 major emergencies associated with diabetes
• this includes hypoglycaemia and extreme hyperglycemia causing diabetic ketoacidosis (DKA) or hyperosmolar non-
ketotic state (HONK)
Hypoglycemia
• it can be defined as when blood glucose level falls below 3.6 mmol/L
• severe hypoglycemia is when the blood glucose level is <2.2 mmol/L
• this can lead to fits, alteration of consciousness, self-injury, etc
• hypoglycemia can occur both with insulin treatment and taking oral hypoglycemic agents, esp. the long-acting
sulphonylureas such as glibenclamide
• it is most common in those with kidney function impairment and elderly diabetics
• omitted or inadequate amount of food
• excessive alcohol
• physical over-activity
Signs and symptoms of hypoglycemia
• these signs and symptoms are caused by the release of counter-regulatory hormones predominantly glucagon,
noradrenaline and adrenaline
• Autonomic
• sweating
• trembling
• tachycardia
• palpitations
• pallor
• Neuroglycopenic
• visual disturbances
• drowsiness
• loss of concentration
• faintness
• confusion
• coma
• Other
• headache
• hunger
• perioral tingling/numbness
Diagnosis and investigations of hypoglycemia
• random blood glucose
• liver function test
• blood urea and electrolytes
Management objectives
• to restore the blood glucose levels to their normal level
• to retain the level of blood glucose level to its normal range till the patient can eat normally
• to identify and address the cause of hypoglycemia
Non-pharmacological management
• this approach can only be used if the patient can swallow safely without the risk of aspiration
• in mild hypoglycemia, pure sources of glucose such as 2-3 teaspoon of granulated sugar or 3 cubes of sugar or soft
drinks containing sugar, a tablespoonful of honey or fruit drink or milk can be useful
• this should be followed up with a meal or snack
• in moderate hypoglycemia, it can be managed as above
• if there is no improvement, it must be treated as severe hypoglycemia
Pharmacological management
• for patients who are at high risk of aspiration because of decreased level of consciousness, parenteral will be
considered
• for severe hypoglycemia, first-line treatment
• in adults
• IV dextrose 50%(25-50 mL over 1-3 mins through a large vein)
• then IV dextrose 5-10% 500 mL 4 hourly until the patient can eat normally
• in children
• IV 10% dextrose 4 mL/kg over 1-3 mins through a large vein then IV dextrose 5% according to total daily
fluid requirement until the blood normalizes
• for second line treatment,
• glucagon SC, IM or IV 1 mg stat
• in children
• 8-18 yrs (body weight > 25 kg); 1 mg stat, (body weight < 25 kg); 500 mcg stat, 1 month - 8 yrs; 500 mcg
stat, in neonate 20 mcg/kg stat
Diabetic ketoacidosis (DKA)
• it is a common cause of death among diabetes patients, esp. in Ghana
• occurs because of the absence of insulin causing extreme hyperglycaemia
• in DKA, there is high blood glucose > 18 mmol/L
• which is unavailable for the body tissue to utilize as energy
• the body in turn breaks down fat as an alternative source of energy-releasing toxic chemicals such as ketones
• metabolic acidosis causes stimulation of the medullary center giving rise to Kussmaul respiration (deep and rapid
breathing)
• the patient's breath may have a fruity odour of the ketones
• precipitating factors for DKA in type 1 diabetes are usually the omission of insulin dose or interruption of anti-
hyperglycemic therapy, trauma, acute infection, and myocardial infarction,
• although this condition normally occurs in type 1 diabetes, it may also occur in patients with type 2 diabetes
Symptoms of DKA
• polyuria
• polydipsia
• nausea
• vomiting
• alteration in sensorium or collapse
• abdominal pain
Signs of DKA
• low blood pressure
• dehydration
• deep and fast breathing
• fast and weak pulse
• confusion
• unconsciousness
Diagnosis of DKA
• the diagnosis requires the demonstration of metabolic acidosis with the presence of ketones and hyperglycemia
• the biochemical diagnosis of ketoacidosis is normally conducted at the bedside and then confirmed at the laboratory
• urinalysis usually shows glucosuria (usually > 3+) and ketones (usually 2+)
• a random blood glucose(usually > 18 mmol/L)
Other investigations for DKA
• blood urea electrolytes(usually low potassium, however, if in renal failure, urea and potassium may be high)
• blood culture
• urine culture
• chest X-ray
• arterial blood gases
• electrocardiogram
Management objectives of DKA
• to replace deficient insulin
• to replace the electrolyte losses, esp. potassium
• to replace fluid losses
Important
Read on the sliding scale
Pharmacological management of DKA
Hyperosmolar non-ketotic state(HONK)
• this is normally associated with patients with type 2 diabetes mellitus
• it is like DKA in many aspects however there are some major differences
• in HONK, there is no significant ketone production and therefore no severe acidosis
• factors that precipitate HONK are poor adherence to medication regimen, medications that cause diuresis or impair
glucose tolerance (e.g. glucocorticoids), infection, myocardial infarction, etc
• the management of HONK is like that of DKA
Role of the pharmacist
• counsel patients on their medications and the need for adherence
• explaining side effects and providing information on potential drug interactions
• education of patients about their disease and help patients or caregivers to identify hypoglycemic and hyperglycemic
signs
Important
Read more on the role of the pharmacists in the management of diabetic emergencies
Case study on hypoglycemia
References
