Category: Endocrine

Hypothermia

Remove COLD, Add WARM, Don’t SHAKE

  • 32-35ºC [Mild] – Shivering, Tachycardia, Tachypnoeic, Vasoconstriction
  • 30-32ºC [Moderate] – Shivering stops, Pale/Cyanosed, Hypotensive, Confused, Lethargic
  • <30ºC [Severe] – Low GCS, Bradycardia/pnoeic, Hypotensive, Arrhythmias, Cardiac Arrest

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Diabetic Hyperglycaemia (Kids)

Diabetic children sometimes attend ED with hyperglycaemia, but not in DKA (what should we do?)

Paeds have produced some advice to follow:

  1. Ketones over 0.6?
    • <0.6: Encourage fluids & food, may need an insulin correction
    • >0.6: ask Question 2
  2. Are there clinical features of DKA?
    • NO: Encourage fluids & food, decide Insulin correction, will need to be monitored
    • YES: Will need Paeds admission

Hypoglycaemia – Adult

Hypoglycaemia (Blood glucose under 4.0 mmol/l) is potentially fatal and should be treated. it may be defined as “mild” self-treated, or “severe” treated by a third party i.e. you.

Hypoglycaemia is a common side-effect of insulin and sulfonylureas (they start with gli-) as they both work by lowering glucose concentration in the blood. Other diabetic medications work by preventing glucose rise, thus posing a lesser risk.

 

Signs & Symps

  • Autonomic: Sweating, Palpitations, Shaking, Hunger
  • Neuroglycopenic: Confusion, Drowsy, Odd behaviour, Incoordination, Speech difficulty
  • General: Nausea, Headache

Risk Factors

  • Medical: 
    • Diabetic: Strict control, Long term Insulin, Lipohypertrophy at injection sites,Impaired awareness of hypoglycaemia
    • Organ dysfunction: Severe hepatic dysfunction, Renal impairment, Cognitive dysfunction/dementia, Endocrine (Addisons, hypothyroid, hypopituitary)
    • GIT: Gastroenteritis, impaired absorption, Bariatric surgery
    • Medication: Concurrent use of medicines with hypoglycaemic agents e.g. warfarin, quinine, salicylates, fibrates, sulphonamides (including cotrimoxazole), monoamine oxidase inhibitors, NSAIDs, probenecid, somatostatin analogues, SSRIs.
    • Sepsis
    • Terminal illness
  • Lifestyle:
    • Reduced/Irregular intake: Poor diet, Irregular lifestyle, Alcohol
    • Increased use: Exercise (relative to usual), Early pregnancy, Breast feeding
    • Poor control: Increasing age, No or inadequate blood glucose monitoring, Alcohol

Treatment

Conscious & Orientated

  1. 15-20g fast acting glucose
    • 4-5 jelly babies
    • 3-4 heaped teaspoons of sugar dissolved in water (milk delays absorption)
    • 150-200ml fresh fruit juice
  2. Rpt Blood Glucose 10-15min
    • if blood glucose remains <4.0mmol/l step one may be repeated up to 3 times in total
  3. Blood Glucose remains <4.0mmol/l
    • 150-200ml 10% Glucose IV
    • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
  4. Blood Glucose >4.0mmol/l – Give long acting Carbs
    • 2 Biscuits
    • 1 Slice bread/toast
    • 200-300ml milk (not soya)
    • Meal
  5. Don’t omit insulin injections
  6. Diabetic review: most patients can be followed up by diabetic nurses but some may need admission.
  7. Patient Advice Sheet

Conscious but agitated, confused, unable to cooperate

  • If patient CAN cooperate – follow guide above
  • If patient CAN’T cooperate
    • 1.5 -2 tubes 40% glucose gel (Glucogel) squeezed into the mouth between the teeth and gums (can be substituted for step 1 above)
    • 1mg Glucogon IM (if starved or sulfonylureas may not work well)
    • Follow subsequent steps as above

Unconscious, seizures, very aggressive

Start at step 3 above (while managing ABC), the choice of whether to use IV glucose or IM glycogen will be determined by practicality of achieving IV/IO access.

Although you will need to follow the remaining steps the patient will almost certainly require admission.

 

Reference

Patient Advice Sheet – Hypo’s

Joint British Diabetic Society – The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitus 3rd edition

 

 

Hypokalaemia

Hypokalaemia (low potassium), is a common problem. It is found in 14% of outpatients and 20% of inpatients, however only 4-5% of those are of clinical significance.

Severity

  • Severe: <2.5 mEq/l OR Symptomatic – Look for Hypomagnesaemia
  • Moderate: 2.5-2.9 mEq/l (No or Minor symptoms)
  • Mild: 3.0-3.4 mEq/l  (Usually asymptomatic)

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Hyponatraemia

Hyponatraema is a common finding, especially within our elderly population. However, its significance is is not a simple numbers game, and needs senior input. Prior to treatment the following need to be considered and balanced.

  1. Symptoms Severity – these are not exclusive to hyponatraemia and may be due to other disease processes (esp. if the low sodium is long-term)
  2. Sodium Level – the sodium concentration doesn’t always correlate to the clinical picture, and is dependant on speed of change, and co-morbidities
  3. Rate of Drop – the faster sodium levels drop the more symptomatic the patient often is (i.e. with long term hyponatraema the patient may be profoundly hyponatraemic but asymptomatic)
  4. Co-morbidities – Increasing sodium too quickly risks osmotic demyelination. How well will the patient cope with treatment?

Emergency treatment (hypertonic saline) is generally indicated in those with Severe Symptoms ONLY

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