1. Diabetic Emergencies

2. Diabetic Ketoacidosis -Type 1 DM -+ve ketones + art. pH < 7.30 + bicarb. - <15 MEDICAL EMERGENCY

3. Pathogenesis Insulin deficiency  excess breakdown adipose stores  Inc. fatty acids  oxidised  ketone bodies (rate of production>rate of degradation)

4. Precipitating factors -Acute infection -Poor control -Prepubertal girls – monthly intervals -Failure of compliance

5. Epidemiology Commonest causes of DKA…. -Infections (30%) -Non-compliance with treatment (20%) -Newly diagnosed diabetes (25%)

6. GP Investigations -BM + serum glucose -Urine dipstick - ?ketones -Bloods – Na+ (low usually) K+ (high on blood test, total body K+ invariably low) Urea (raised)

7. Clinical features Acute onset Vomiting Abdominal pain Headache Thirst Polyuria Hyperventilation Drowsy/coma

8. Clinical features cont… Gradual onset Nocturia (nocturnal enuresis in children) Weight loss Lethargy

9. Clinical features cont… Severly ill – can be in shock, oliguric/anuric NOTE – Breath may smell of ketones

10. Detecting dehydration in children Useful indicators – -Capillary refill time -Abnormal skin turgor -Respiratory pattern (Kussmaul breathing – deep sighing)

11. Management in GP 1.Make diagnosis 2.Fluid replacement (if poss.) 3.Oxygen 4.Consider NG (to stop aspiration/gastric dilatation) 5.Insulin (give 10u iv whilst pump is being set up)

12. Prognosis MORTALITY – Developed countries – 2-5% Developing countries – 6-24% Under 28 years old – susceptible to cerebral oedema during treatment (0.7-1.0%)

13. HONK (Hyperosmolar non-ketotic hyperglycaemia)

14. DIAGNOSIS -Very HIGH blood glucose - > 30mmol/l -Only trace/1+ ketones in urine -Very HIGH plasma Osmolarity 2(Na + K) + Urea + Glucose

15. Accounts for 10-15% diabetic decompensation NOTE – serum Na+ may be low – due to redistribution of fluid into the extracellular fluid (secondary to high glucose level)

16. Precipitating Factors Infection High Carbohydrate intake Thiazide diuretics Steriods Propranolol

17. Clinical Features Consider HONK in… -ELDERLY -Hyglycaemia -Dehydration with excessive thirst -Marked drowsiness

18. Clinical features cont… Other features… 1.Convulsions 2.Coma 3.Focal CNS signs HONK predisposes to thrombosis Hyperventilation is NOT a feature of HONK