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45 Cards in this Set

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what is characterized by hypoglycemia, what is it assoc with, what sx does it show, how might these be masked

HYPOglycemia: SNS stim (tachy, diaphoresis, anxiety)

altered mental status

maked by B blockers!
how is DKA characterizeed
1. hyperglycemia
2. ketonemia
3 acidmenia

bc of lack of insulin and increased glucagon, GH, catecholamines, cortisol

can lead to chock and death
how is hyoerosmolar hyperglycemic state characterized
lack of insulin --> HYPERglycemia

mortality due to: MI or CVA

can HYPOventilate
what are the 3 metabolic complications assocaited with DM
1. HYPOglycemia
2. DKA
3. Hyperosmolar hyperglycemic state
what does EtOH do to DM
predisposes to HYPOglycemia
what is the initial treatment to pt with DM and altered mental status

Airway- rarely required in DM but assess always

Breathing- give O2 to any pt with altered mental status

Circulation- HYPOtension --> IMMEDIATE administration with isotonic crystalloid. always do 2 IV lines

**also do accu check, dextrose and monitor
how often is airway mgmt required in the pt w/DM w/metabolic complications
not often!
based on cardiac monitoring what are hte signs of requiring K supplements
T or small U- consider early supplementation

Tall peaked T- consistent with hyperkalemia, and supplementation is withheld until the level of K is known
how often do you see polyuria, polydipsia adn polyphagia in DKA
tell me what DM pts get dextrose

*if accucheck shows HYPERglycemia it can be withheld until you get true values (sometimes accucheck is wrong).

*typically you can do more harm from being HYPO than HYPER so they sometimes risk it and give dextrose even with a high sccucheck
tell me about the heart monitor and DM altered mental status
assess rhythem

asses T waves for K levels (DKA- K is normal or high but falls FAST with tx, to prevent hypokalemia K is supplemented)

Normal/Small T & U wave- consider early K supplementation

Tall Peaked T- indicated hyperkalemia, hold off on supplementation
what happens to K in DM with DKA
its normal to high but drops as we start to treat, use EKG to determine when to start supplementing K

**supplement with U waves
*tall peaked T means HYPERkalemia, dont supplement
tell me about altered mental status and naloxone
given to all pts

*cover against an occult opoid intoxication
what are the areas of focus in a Hx in a pt with DM w/altered mental status
1. Activity
2. Meds- changes, dose, how often etc
3. food
4. B BLOCKERS, mask initial sx of tachy, diaphoretic, anxious
5. thirsty, hungry, pee lots
6. usual mental status
7. GI complaints
8. stress, trauma, infections
9, known complicationsof DM
what is DKA misdx as often
ABG and altered mental status
pH assess degree of acidosis
shoudl we do UA for DKA
you bet!

glucose, ketones, infection, dehydration
whats the coma scale
monitor pt, look for deterioration/improvement
whats a flow sheet
in pt w/DKA

serial recording of vitals, urine outflow, fluid intake, mental status, lab values

do as a flow sheet so ppl can follow
besides just monitoring rhythem, ischemia and electrolytes, why is EKG important in DM
DM have silent MI more often
where do you focus on your PE with DM w/altered mental status

1. GEN: dehydrated --> hypovolumic shock. fruity breath
2. Vitals: tachy, tachy penia (fast deep breath-kussmals)
3. consciousness: varies
4. HEENT: look for trauma, malignant otitis externa, meningitis, fundoscopic exam
5. Heart: dehydration, be sure there is perfusion
6. Lungs: kussmals, cxr for consolidations or aspirations
7. abd: hypokalemia will decrease bowel soudns. SIGNIFICANT pain w/o peritoneal signs of guarding and rebound
8. Ext: cap refill, turgor
9. neuro: intracranial pathology
whats kussmals
rapid deep breathing with DKA

will smell fruity, tachypenic
define DKA
Glucose >300 (typically btwn 500-800)
Ketones: >1.2
Acid: <7.3 pH or <15 Bicarb

**acidosis can be PROFOUND
why get CBC in DM w/AMS
WBC usually always increased (even w/o infection)

white count related to severity of DKA

Hgb, HCt increased bc of dehydration
what electrolytes are important in DM w/AMS
Na low- can be fake low
K normal then drops w/tx
what happenes to Na in DKA
renal fx and DKA, how are the results changed
BUN increased bc of dehydration
Creatanine increased bc of ketones
what does it mean if someone with true DKA has normal measured ketones
you make 3 ketones: acetone, acetoacetate, b hydroxy butyrate

B hydroxybutyrate is normally the highes but is not measured by nitroprusside rxn
what can ppt cerebral edema in DKA
rapid decrease in serum osmolarity

2(Na) + glucose/18 + Bun/2.8

285-385 is normal
how do you calc serum OSM
2 (Na) + glucose/18 + Bun/2.8

normal is 285-385
why do you see hyaline causes in UA in DKA
bc of dehydration

WBC- infection (high in blood always)
what are the main goials of DKA tx
1. restore volume
2. normalize glucose
3. correct acidemia
4. correct/maintain electrolytes
5. restore normal serum OSM (285-385)
how is hypoglycemia controlled

what if its caused by oral hypoglycemic agents
pt awake: oral glucose followed by protein meal

unconscious: IV glucose or IM glucagon

oral hypoglycemic agents --> ADMIT
what is the MOST important part of therapy in DKA

how is it initially managed for stable and unstable pt
fluids, will increase circulating volume AND dilute the sugar. it WONT clear ketones, need insulin for that

6L deficit! WOW

Stable: 1L over 30 min, 2 L over 1-2 hrs

UNstable: 2L NaCLgiven rapid and watch
how much does glucose fall in DKA when you restore fluids
how do you lower glucose in DKA
slow 100mg/dl/hr

give with insulin

**when you get to like 250-300 glucose start adding dextrose
in DKA what is necessary to clear ketones

**insulin is not given initially, hten given, then cut in half and continued until acidosis adn acedemia are resolved
what is a persons hypoglycemia is cause by increased amt of oral hypoglycemic agents
ADMIT them
do you give bicarb to correct for acidemia in DKA
nope, you can but itsrisky

better to just use inculin to clear acids adn ketones
whats the infusion rate of K
varies every hour!

be sure there are no spiked T's
as we treat DKA what do we want to monitor closely every hourr
what fluid is given in HHS
normal saline until stable then 0.45 NaCl

**want to lower at about 100mg/dl/hr
**fluids will drop glucose about 25-30%
who is more sensitive to insulin DKA or HHC
HHS, when you give it use less than in DKA
when do you give K for HHS
as soon as you get urine output
what complicates HSH
lots! its like the deal that HHS is complicated by other health complications and DKA usually wont have other associations