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67 Cards in this Set
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A serum glucose level of less than 50-60 mg/dl
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Hypoglycemia
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Associated with sepsis
liver disease alcohol intoxication starvation and certain toxic ingestions. |
Hypoglycemia
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Should be considered in the differential diagnosis in any patient with altered mental status or
focal neurologic signs. |
Hypoglycemia
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At least one study in the past showed that approximately 50 percent of patients treated for what problem in an urban ED were acutely intoxicated with ethanol or
were chronic alcohol abusers. |
Hypoglycemia
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What is the condition that causes these:
Inhibition of gluconeogenesis systemic hypoperfusion resulting in increased peripheral glucose use and metabolic acidosis decreasing gluconeogenesis Also hepatic dysfunction |
Hypoglycemia
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Inadequate food intake
increased physical exertion incorrect medication dosing or drug interactions in the diabetic can cause what? |
Hypoglycemia
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Male gender
adolescent and very elderly age groups African American heritage polypharmacy (more than five agents) and recent hospitalization Risk factors & or Causes what condition? |
Risk factors for hypoglycemia
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Nature of hypoglycemia in chronic alcohol abusers
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Alcohol inhibits hepatic gluconeogenesis
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How long a fast is sufficient for severely malnourished alcoholics to become hypoglycemic.
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12 hours
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A decline in serum sugar in the brain this causes alterations in consciousness
lethargy confusion combativeness agitation unresponsiveness seizures and focal neurologic deficits what is this called? |
Neuroglycopenia
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Release of the counterregulatory hormones
primarily the catecholamines Anxiety nervousness irritability nausea vomiting palpitations and tremor follow. |
Hyperepinephrinemia
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Stimulation of the cholinergic nervous system also occurs and may result in manifestations such as sweating
changes in pupillary size bradycardia and salivation. |
Hypoglycemia
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Neuroglycopenia signs and symptoms tell you what about the onset of hypoglycemia?
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Slow onset
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Anxiety
diaphoresis tremor and other hyperepinephrinemia findings tell you what about the onset of hypoglycemia? |
Quick onset
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1 g/kg body weight dextrose as what?
Followed by the infusion of what? at a rate to maintain serum glucose above 100 mg/dl Repeat bedside glucose determination q 30 min. For 2 hrs. Also 100 mg thiamine. |
IV tx of hypoglycemia
D50W D10W |
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Oral replacement for hypoglycemia consists of how many grams of carbs?
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300 g of carbohydrate should be given PO
as sodas juices sandwiches or snacks. |
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Can be used in diabetics or
in those in whom intravenous access is not readily obtainable Response is generally slower when compared with intravenous dextrose |
Glucagon
1 mg IM or IV |
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A synthetic analogue of Somatostatin
inhibits the release of insulin and has been used in the treatment of sulfonylurea-induced hypoglycemia. |
Octreotide
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Omission of daily insulin injections and a variety of stressful events
such as infection stroke MI trauma pregnancy hyperthyroidism pancreatitis pulmonary embolism surgery and steroid use |
Factors known to precipitate DKA
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Are a much more common precipitant for DKA than previously thought
especially in the younger population. |
Errors in insulin usage
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Primary metabolic derangements in DKA (3)
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Hyperglycemia
volume depletion and acidosis. |
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Causes an increased osmotic load with movement of intracellular water into the vascular compartment.
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Hyperglycemia
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In DKA
vomiting exacerbates the ? Loss and contributes to rapidly progressive volume loss weakness and weight loss Mental confusion or coma may be apparent at the time of presentation. |
K+
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Almost all patients with DKA present with a blood glucose level greater than
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300 mg/dl
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Elevated serum ketone levels lead to what?
this may be the only clue because vomiting and diuresis may mask this problem. |
Wide-anion-gap metabolic acidosis
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In DKA
the measured serum potassium level is normal or elevated despite total body depletion in most patients because of two important factors: |
Extracellular shift of potassium secondary to acidemia and increased intravascular osmolarity.
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The presence of hyperglycemia tends to artificially
lower? or raise? the serum sodium levels? |
Lower
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Often present in DKA because of hemoconcentration and stress.
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Leukocytosis
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A blood glucose level greater than 250 mg/dl
a bicarbonate level of less than 15 meq/L and an arterial ph of less than 7.3 with moderate ketonemia constitutes |
DKA
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Identify the treatment goals for DKA.
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Volume repletion
correction of electrolyte and acid-base imbalances recognition and treatment of precipitating causes |
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The average adult DKA patient has a water deficit of ?
and a sodium deficit of ?? |
100 ml/kg (5–10 L)
7 to 10 meq/kg. |
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The most frequently recommended fluid for initial volume repletion
even though the extracellular fluid of the patient is hypertonic initially. |
NS
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For fluid replacement in DKA
the first 2 L are administered rapidly over 0 to 2 h the next 2 L over 2 to 6 h and then 2 L more over how long? |
6-12h
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In giving fluids in DKA
the patient's blood glucose level needs to be monitored carefully and D5 is added to the rehydration solution when the glucose level is |
250 to 300 mg/dl
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It is generally accepted that the "ideal way" to administer insulin is by continuous intravenous infusion of small doses
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Regular insulin through an infusion pump.
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Insulin should continue until ??
has cleared and the anion gap has normalized Resolution of hyperglycemia often earlier than the ? it may be necessary to administer glucose from the beginning of insulin therapy or shortly after its institution. |
Ketonemia
anion gap |
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Usual total body K + deficit in DKA
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3 to 5 meq/kg
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What percent of total-body potassium is intravascular?
The initial serum concentration is usually normal or high because of the intracellular exchange of potassium for ?? during acidosis the total-body fluid deficit and the diminished renal function. |
2
hydrogen ions |
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Goals of potassium replacement: to maintain a normal extracellular potassium concentration during the acute phases of therapy and to replace the intracellular deficit over a period of
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Days
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The most life-threatening electrolyte derangement during the treatment of DKA.
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Severe hypokalemia
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The most common findings are tachycardia
tachypnea and diffuse mild to moderate abdominal tenderness most often associated with acute cessation of alcohol consumption after chronic alcohol abuse. |
Alcoholic Ketoacidosis
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Common concurrent illnesses are pancreatitis
gastritis or upper gastrointestinal bleeding seizures alcohol withdrawal pneumonia sepsis and hepatitis Glucose level less than 300 mg/dl Wide-anion-gap metabolic acidosis without alternate explanation |
AKA
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The fluid of choice is D5NS
Glucose stimulates insulin production which stops lipolysis and halts the further formation of ketones Insulin is of no proven benefit and can be dangerous |
AKA
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Occurs in patients with poorly controlled or
undiagnosed type 2 diabetes mellitus a similar disease process as DKA but ketones aren't nearly as high. |
Hyperosmolar hyperglycemic nonketotic syndrome
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Usually elderly
c/o weakness anorexia fatigue cough dyspnea or abdominal pain poorly controlled type 2 diabetes that has been precipitated by an acute illness Pneumonia and urinary tract infection account for 30 to 50 percent of cases. |
HHNS
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In general
any patient with hyperglycemia an impaired means of communication and limited access to free water intake is at major risk for |
HHNS
Hyperosmolar Hyperglycemic Nonketotic State |
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Replacement of intravascular fluid losses alone can account for reductions in serum glucose of 35 to 70 mg/h on average
or up to ?? percent of the necessary reduction |
80
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Life-threatening hypermetabolic state due to hyperthyroidism
occurring as a result of either unrecognized or poorly treated state. |
Thyroid storm
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May be precipitated by infection
trauma DKA MI CVA PE surgery iodine administration or palpation of the thyroid glands |
Thyroid storm
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The classic mark of this disease is fever
sinus or supraventricular tachycardia out of proportion to the fever changes in normal mental status (e.g. confusion delirium coma) and gastrointestinal symptoms. |
Thyroid storm
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Mortality rates for thyroid storm
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10-75%
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Nonspecific lab findings include: leukocytosis
hyperglycemia increased transaminases and bilirubin Labs: not helpful. Not usually available to ER PA. |
Thyroid storm
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What is used to tx the severe adrenergic sx of thyroid storm?
What Rx has the advantage of blocking T4 conversion to T3 |
B Blockers
Propanolol |
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Decrease synthesis or
conversion of additional thyroid hormone make sure to use before using iodine to reduce the secretion of preformed thyroid hormone |
Propylthiouracil (PTU)
or Methimazole (MMI) |
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Rare clinical state in which an individual with long-standing preexisting hypothyroidism presents with life-threatening decompensation.
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Myxedema coma
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Decline in metabolic function
usually gradual and insidious in onset decline in O2 consumption heat generation and redistribution of blood flow centrally change in end-organ responsiveness to catecholamines & decline in cardiac performance Is what condition/Dz? |
Myxedema
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Severe decompensated metabolic state
altered mental status hypothermia bradycardia hypoventilation cardiovascular collapse |
Myxedema
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What might precipitate myxedema?
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Infection
cold exposure drugs etc |
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In treating myxedema
routine administration of glucocorticoid is recommended to avoid the potential of precipitating |
Adrenal crisis in patients with unrecognized adrenal insufficiency
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Most common cause of tertiary adrenal insufficiency
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Chronic administration of exogenous glucocorticoids
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Postpartum necrosis of the pituitary
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Sheehan syndrome
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When the body undergoes a significant stress and the adrenals are unable to respond by increasing cortisol secretion
may present with pts who are chronic AI or in who the adrenals or hypothalamic-pituitary-adrenal (HPA) axis fails abruptly |
Adrenal crisis
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Hemorrhage of the adrenals
is a possible complication of anticoagulant therapy DIC or sepsis This could this cause an/a ? |
Adrenal crisis
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The presence of unexplained hyponatremia and hyperkalemia in the setting of hypotension unresponsive to catecholamine and fluid administration is strong evidence of
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Adrenal crisis
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Hypotension abdominal or
flank pain may be a result of head trauma or hemorrhage of a certain gland |
Adrenal crisis
pituitary |
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The treatment of AC
whether primary or secondary requires only the use of |
Glucocorticoids.
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Any patient in whom AC is suspected should receive
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100mg hydrocortisone intravenously
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