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Diabetic Ketoacidosis -Type 1 DM -+ve ketones + art. pH < 7.30 + bicarb. - <15 MEDICAL EMERGENCY
Pathogenesis Insulin deficiency excess breakdown adipose stores Inc. fatty acids oxidised ketone bodies (rate of production>rate of degradation)
Precipitating factors -Acute infection -Poor control -Prepubertal girls – monthly intervals -Failure of compliance
Epidemiology Commonest causes of DKA…. -Infections (30%) -Non-compliance with treatment (20%) -Newly diagnosed diabetes (25%)
GP Investigations -BM + serum glucose -Urine dipstick - ?ketones -Bloods – Na+ (low usually) K+ (high on blood test, total body K+ invariably low) Urea (raised)
Clinical features Acute onset Vomiting Abdominal pain Headache Thirst Polyuria Hyperventilation Drowsy/coma
Clinical features cont… Gradual onset Nocturia (nocturnal enuresis in children) Weight loss Lethargy
Clinical features cont… Severly ill – can be in shock, oliguric/anuric NOTE – Breath may smell of ketones
Detecting dehydration in children Useful indicators – -Capillary refill time -Abnormal skin turgor -Respiratory pattern (Kussmaul breathing – deep sighing)
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)
Prognosis MORTALITY – Developed countries – 2-5% Developing countries – 6-24% Under 28 years old – susceptible to cerebral oedema during treatment (0.7-1.0%)
HONK (Hyperosmolar non-ketotic hyperglycaemia)
DIAGNOSIS -Very HIGH blood glucose - > 30mmol/l -Only trace/1+ ketones in urine -Very HIGH plasma Osmolarity 2(Na + K) + Urea + Glucose
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)
Precipitating Factors Infection High Carbohydrate intake Thiazide diuretics Steriods Propranolol
Clinical Features Consider HONK in… -ELDERLY -Hyglycaemia -Dehydration with excessive thirst -Marked drowsiness
Clinical features cont… Other features… 1.Convulsions 2.Coma 3.Focal CNS signs HONK predisposes to thrombosis Hyperventilation is NOT a feature of HONK
Emergency Care Part 1: Managing Diabetic Ketoacidosis (DKA)
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