Linda Burns Diabetes Specialist Nurse Diabetic Emergencies Linda Burns Diabetes Specialist Nurse Linda Burns Diabetes Specialist Nurse

Diabetic Emergencies Hypoglycaemia Hyperglycaemia Diabetes and Illness – ‘sick day’ Diabetic Ketoacidosis HONK/HHS Linda Burns Diabetes Specialist Nurse

Hypoglycaemia What is Hypoglycaemia – BG levels below 4mmol/l. ‘Four is the Floor’ Symptoms can be felt at higher levels if control is poor Worth confirmation using BG meter if at all possible Linda Burns Diabetes Specialist Nurse

Hypoglycaemia Linda Burns Diabetes Specialist Nurse

How does Hypoglycaemia affect people? Cognitive functions deteriorate at blood glucose <3.0 mmol/l Complex tasks are consistently impaired memory and attention concentration/abstract thought rapid decision making hand-eye coordination Accuracy is preserved at expense of speed Inter-individual differences are common Linda Burns Diabetes Specialist Nurse

Hypoglycaemia Signs and Symptoms Adrenergic symptoms Sweating Shaking / tremor Palpitations Hunger Tingling lips and tongue Slurred speech Behavioural changes Confusion Aggression Lack of co-ordination Drowsy Coma Linda Burns Diabetes Specialist Nurse

Causes of Hypoglycaemia Too much insulin/ Sulphonylurea Inadequate food consumption Increased physical activity Alcohol Linda Burns Diabetes Specialist Nurse

Treatment of Hypoglycaemia 15-20g of simple CHO 100ml of lucozade or 150-200ml of coke/fruit juice or 5 glucose tablets Follow with 10-20g more complex CHO eg bread/crisps/cereal bar Repeat after 10mins if BG still<3.5 Linda Burns Diabetes Specialist Nurse

Severe Hypoglycaemia 10% of insulin treated individuals have a 3rd party hypo each year Treat with Glucagon-usually effective within 10mins Follow with 20g of simple CHO +40g complex CHO Linda Burns Diabetes Specialist Nurse

Management of Hypoglycaemia Explore cause: e.g. exercise/alcohol/lack of CHO/ poor knowledge Define future strategies to minimise Advise driving guidelines Linda Burns Diabetes Specialist Nurse

Hypoglycaemic Unawareness Inability to recognise symptoms Autonomic neuropathy Affects 25% of adults with Type 1 diabetes Associated with strict glycaemic control Prevalence rises with duration of diabetes Risk of severe hypoglycaemia is greater Associated with significant morbidity Range of severity; potentially reversible Linda Burns Diabetes Specialist Nurse

Management of Hypoglycaemic Unawareness Aim for less strict control i.e. ‘Do not treat to target’ Self BG Monitoring is essential Education Refer to specialist Linda Burns Diabetes Specialist Nurse

HYPO BOX: TREATMENT OF HYPOGLYCAEMIA Hypoglycaemia is a blood glucose of 4 mmol/L or less. Wherever possible, check blood glucose level prior to treatment. If patient asymptomatic, repeat test. MILD Patient conscious and able to swallow Trembling, sweating, hungry, tingling, headache, anxiety, palpitations, nausea, forgetfulness MODERATE Patient conscious and able to swallow, but in need of assistance Difficulty concentrating, confusion, weakness, giddiness, drowsiness, unsteady, headache, dizziness, difficulty focusing and speaking SEVERE Patient unconscious and unable to swallow. Unconscious, fitting STEP 1 Administer 10g – 20g fast acting glucose* 3-5 x GlucoTabs (4g glucose per tablet) or 1 x 59ml bottle of Glucojuice Administer 1-2 tubes of GlucoGel*/** (10g glucose per tube) Ensure gag reflex is present. Check airways. Place patient in recovery position Intramuscular injection of Glucagon 1mg. (Children weighing less than 25kg – 500 micrograms)* STEP 2 Wait 15 minutes and recheck glucose levels, and record. If reading is still below 4 mmol/L, or if no physical improvement, repeat STEP 1 Once patient is conscious, give sips of Glucose Liquid Blast or Lucozade Recheck glucose level every 15 minutes to ensure increase to at least 4 mmol/L ALWAYS FOLLOW UP WITH A SLOWLY DIGESTED/ STARCHY CARBOHYDRATE Check glucose level. Once it is at 4 mmol/L or over and patient is recovered, eat a minimum of 15g slowly digested/starchy carbohydrate. Eg: 1 x slice/sandwich of low GI bread (ideally multigrain or granary); two digestive biscuits, glass of milk, banana, small carton of fruit juice. Recheck glucose levels after 15 minutes. NOTE: Insulin should NEVER be omitted following an episode of hypoglycaemia. * British National Formulary, 2007 ** Type 1 Diabetes: Diagnosis and Management of Type 1 Diabetes in children, young people and adults. NICE Clinical Guideline No. 15, July 2004. Linda Burns Diabetes Specialist Nurse

Hyperglycaemia Blood glucose > 17mmol/l Fatigue Polyuria Polydipsia Blurred vision Increased risk of complications Type 1 – Ketones/ risk of DKA Type 2 – risk of HONK/HHS Linda Burns Diabetes Specialist Nurse

What should the ketone test results be? Under 0.6 mmol/L - a normal blood ketone value 0.6 to 1.5 mmol/L - indicates that more ketones are being produced than normal, test again later to see if the value has lowered 1.6 to 3.0 mmol/L - a high level of ketones and could present a risk of ketoacidosis. It is advisable to contact your healthcare team for advice. Above 3.0 mmol/L - a dangerous level of ketones which will require immediate medical care. Linda Burns Diabetes Specialist Nurse

Linda Burns Diabetes Specialist Nurse

Causes of Hyperglycaemia Illness (e.g. infection) Over eating CHO food Stress Drugs (e.g. Steroids) Insufficient treatment Injection sites/ technique Frozen or damaged insulin Linda Burns Diabetes Specialist Nurse

Management of Hyperglycaemia Explore cause – optimise treatments/dietary advice/treat illness Education Refer to specialist Aim for appropriate balance in some patients Linda Burns Diabetes Specialist Nurse

Ketoacidosis/Honk/HHS Diabetic Ketoacidosis is a serious, acute complication of Diabetes. It carries significant risk of death and/or morbidity especially with delayed treatment. Linda Burns Diabetes Specialist Nurse

Aetiology of Ketoacidosis Secondary to insulin deficiency, and the action of counter-regulatory hormones, blood glucose increases leading to severe hyperglycaemia and glycosuria. Glycosuria causes an osmotic diuresis, leading to dehydration and electrolyte imbalance. In the absence of insulin activity the body fails to utilize glucose as fuel and uses fats instead. This leads to metabolic acidosis Linda Burns Diabetes Specialist Nurse

Signs/Symptoms of DKA High BG levels Osmotic symptoms Dry/flushed skin Fatigue/Lethargy/Conscious level Hyperventilation Abdominal pain Nausea/Vomitting Smell on breath ( ketones) Large ketones in blood/urine Linda Burns Diabetes Specialist Nurse

Patients at Risk Type 1 diabetes (incl undiagnosed) Young children – symptoms often similar to childhood illnesses Pregnant women – high ketones can affect the unborn baby Pump users – no background insulin if pump fails Adolescents – body image, chaotic lifestyle, substance abuse, emotions, growth hormones Substance abusers Linda Burns Diabetes Specialist Nurse

Treatment of DKA Urgent referral to acute services Hospital admission DKA protocol http://www.diabetologists- abcd.org.uk/JBDS/JBDS_IP_DKA_Adults_Revised.pdf High dependency care pcDSN ... Recent improvement in morbidity figures thought to be due to HBGM, education and accessibility of expertise Linda Burns Diabetes Specialist Nurse

Risk Reduction Referral to Secondary Care Diabetes Team Education Diabetes Specialist Nurse Psychological services Combined services – adolescent/antenatal/pump/renal Linda Burns Diabetes Specialist Nurse

HONK/HHS No precise definition - list of characteristics Differs from DKA – Can develop over time Older age Type 2 Can be due to physical/psychological stress (Infection, CVA,MI,trauma,bereavement, increased CHO) Mortality rate as high as 15% - higher than DKA BG levels >33mmols/L. Without ketones or acidosis Hyperosmolality > 320mmol/kg Hypovolaemia Coma (sometimes seizures) Linda Burns Diabetes Specialist Nurse

Treatment of HONK/HHS Urgent referral to acute services I.V. Fluid replacement – replace Na I.V. Insulin – not always! Caution in rapid rehydration – Heart failure HHS Protocol http://www.diabetologists- abcd.org.uk/JBDS/JBDS_IP_HHS_Adults.pdf Linda Burns Diabetes Specialist Nurse

Diabetes and Illness Risk of illness in poorly controlled Diabetes Flu Jab Education/Self management skills Annual/Regular review Linda Burns Diabetes Specialist Nurse

Sick Day Rules Never omit insulin Check BG 2 Hourly If vomiting – anti emetic – GP/NHS24 Replace CHO in liquid form 200mls fluid hourly Type 1 check for ketones if BG >16mmol/l Type 1 use fast acting insulin Linda Burns Diabetes Specialist Nurse