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Which Of The Following Signs And Symptoms Are Most Characteristic Of Hyperglycemic Ketoacidosis?

Diagnosis And Management Of Type 2 Diabetes, 10th Edition, Ch 14, Pt1

Diagnosis And Management Of Type 2 Diabetes, 10th Edition, Ch 14, Pt1

Acute Complications: Metabolic – DKA Steve V. Edelman, MD Robert R. Henry, MD The most common acute complications of diabetes are metabolic problems (DKA, HHNS, hypoglycemia) and infection. In addition, the quality of life of patients with chronic and severe hypoglycemia is adversely affected. Characteristic symptoms of tiredness and lethargy can become severe and lead to increased falls in the elderly, decreased school performance in children, and decreased work performance in adults…. METABOLIC Diabetic Ketoacidosis (DKA) This acute metabolic complication typically results from a profound insulin deficiency (absolute or relative) associated with uncontrolled Type 1 diabetes mellitus and less commonly in severely decompensated Type 2 diabetes. Individuals with Type 2 diabetes may develop DKA under certain conditions: Poor nutrition that contributes to dehydration and catabolism of fat to provide necessary calories Severe physiologic stress (e.g., infection, myocardial infarction) that leads to increased levels of counterregulatory hormones (e.g., epinephrine, cortisol, and glucagon), which stimulate lipolysis, elevate free fatty acids, and stimulate hepatic ketogenesis Chronic poor metabolic control that leads to decreased insulin secretion and decreased glucose uptake (glucose toxicity) Dehydration that leads to decreased excretion of ketones in urine and a buildup of ketone bodies in the blood. Key characteristics include: Hyperglycemia (300 to 800 mg/dL although usually Ketosis: serum ketones usually 10 to 20 mM and acidosis (pH 6.8-7.3, HCO3 <15mEq/L) Dehydration caused by: Nausea Vomiting Inadequate oral intake Electrolyte depletion (e.g., potassium, magnesium, etc). Precipitating factors vary from individual to individual and may include the following (approx Continue reading >>

Chapters 24 & 25

Chapters 24 & 25

Sort According to the National Institutes of Health, what percentage of the U.S. population suffers from diabetes? A) 5% B) 8% C) 10% D) 7% D When blood calcium levels are high, the thyroid gland releases ___________, which causes the reabsorption of calcium by the bones. A) Parathyroid hormone (PTH) B) Calcitonin C) Thyrotropin-releasing hormone (TRH) D) Thyroxine (T4) B Which hormones are released from the posterior pituitary gland? A) Antidiuretic hormone (ADH) and oxytocin B) Follicle-stimulating hormone (FSH) and oxytocin C) Growth hormone (GH) and luteinizing hormone (LH) D) Antidiuretic hormone (ADH) and prolactin A Thyroid storm is a form of thyrotoxicosis and is a true medical emergency. Patients with this condition commonly exhibit the following signs and symptoms: A) Bradycardia, hypotension, hypothermia, palpitations, and delirium B) Tachypnea, tachycardia, hyperthermia, palpitations, and delirium C) Tachycardia, delirium, hypothermia, palpitations, and delirium D) Tachycardia, hypothermia, palpitations, and delirium B When blood calcium levels are low, the hormone ___________ causes the bones to release calcium into the blood and the kidneys to reabsorb calcium. A) Calcitonin B) Parathyroid hormone (PTH) C) Thyroxine (T4) D) Thyrotropin-releasing hormone (TRH) B Which of the following pituitary hormones plays a major role in the reabsorption of water into the bloodstream and the absence of this hormone can cause the development of diabetes insipidus? A) Antidiuretic hormone (ADH) B) Follicle-stimulating hormone (FSH) C) Oxytocin D) Luteinizing hormone (LH) A Patients who suffer from chronic alcoholism or liver problems can also suffer from what vitamin deficiency? A) Vitamin B6 (pyridoxine) B) Vitamin B3 (niacin) C) Vitamin B2 (riboflavin) D) Vitamin B1 (th Continue reading >>

Diabetic Ketoacidosis In A Pediatric Intensive Care Unit

Diabetic Ketoacidosis In A Pediatric Intensive Care Unit

Objective: To describe the characteristics of children aged 0-14 years diagnosed with diabetic ketoacidosis and compare the following outcomes between children with prior diagnosis of type 1 diabetes mellitus and children without prior diagnosis of type 1 diabetes mellitus length of hospital stay, severity on admission, insulin dosage, time of continuous insulin use, volume of fluids infused during treatment, and complications. Methods: A retrospective descriptive study with review of medical records of patients admitted to the pediatric intensive care unit of a referral hospital from June 2013 to July 2015. The following data regarding 52 admissions were analyzed: age, sex, weight, body surface area, signs, symptoms and severity on admission, blood gas, blood glucose, glycated hemoglobin, serum osmolarity, and index of mortality. The insulin dosage, time of continuous insulin use, volume administered in the expansion phase and in the first 24 h, length of stay, and complications such as electrolyte disturbances, hypoglycemia, cerebral edema, and death were compared between the two groups. Results: Patients without a previous diagnosis of DM1 were younger at admission, with mean age of 8.4 years (p < 0.01), reported more nausea or vomiting, polydipsia and polyuria, and showed more weight loss (p < 0.01). This study also observed a higher prevalence of hypokalemia (p < 0.01) and longer hospital stay in this group. Conclusions: No differences in severity between groups were observed. The study showed that children without prior diagnosis of type 1 diabetes mellitus were younger at admission, had more hypokalemia during the course of treatment, and had greater length of hospital stay. KEYWORDS Diabetic ketoacidosis; Children; Cerebral edema; Mortality; Diabetes mellitus Continue reading >>

What Are The 3 P's Of Diabetes?

What Are The 3 P's Of Diabetes?

The 3 classic symptoms of diabetes mellitus are polyuria, polydipsia and polyphagia -- also known as the 3 P's. Polyuria, polydipsia and polyphagia are defined as an increase in urination, thirst and hunger, respectively. The presence of the 3 P’s is a good indication that your blood sugar may be too high. With type 1 diabetes (T1DM), these symptoms typically develop relatively quickly and are more obvious, often leading to diagnosis of the condition. With type 2 diabetes (T2DM), the 3 P's are often more subtle and develop more gradually. As a result, people with type 2 diabetes may overlook these symptoms, leading to a delay in diagnosis. Video of the Day The 3 P’s of diabetes are typically among the first symptoms to occur in T1DM, but they can occur with other conditions. Polyuria, or excessive urine production, can be identified by needing to urinate during the night, frequent bathroom trips or accidents in potty-trained children. Polydipsia, a consequence of polyuria, is characterized by excessive thirst. An increase in fluid intake due to polydipsia can also contribute to increased urination. Polyphagia is the term for excessive or increased hunger. It occurs with diabetes because blood sugar is fails to enter body tissues normally, leaving them short of fuel to produce energy. To compensate, fat and muscle are broken down and used for energy resulting in weight loss, lack of energy and fatigue, which are most often seen with T1DM. Signs of long-term high blood sugar, such as blurred vision and tingling or numbness in hands and feet, are more common at diagnosis with T2DM. High Blood Sugar and the 3 P's The 3 P's of diabetes all stem from high blood sugar levels. Blood sugar is normally filtered by the kidneys but then reabsorbed into the blood. When blood sug Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic Ketoacidosis Definition Diabetic ketoacidosis is a dangerous complication of diabetes mellitus in which the chemical balance of the body becomes far too acidic. Description Diabetic ketoacidosis (DKA) always results from a severe insulin deficiency. Insulin is the hormone secreted by the body to lower the blood sugar levels when they become too high. Diabetes mellitus is the disease resulting from the inability of the body to produce or respond properly to insulin, required by the body to convert glucose to energy. In childhood diabetes, DKA complications represent the leading cause of death, mostly due to the accumulation of abnormally large amounts of fluid in the brain (cerebral edema). DKA combines three major features: hyperglycemia, meaning excessively high blood sugar kevels; hyperketonemia, meaning an overproduction of ketones by the body; and acidosis, meaning that the blood has become too acidic. Insulin deficiency is responsible for all three conditions: the body glucose goes largely unused since most cells are unable to transport glucose into the cell without the presence of insulin; this condition makes the body use stored fat as an alternative source instead of the unavailable glucose for energy, a process that produces acidic ketones, which build up because they require insulin to be broken down. The presence of excess ketones in the bloodstream in turn causes the blood to become more acidic than the body tissues, which creates a toxic condition. Causes and symptoms DKA is most commonly seen in individuals with type I diabetes, under 19 years of age and is usually caused by the interruption of their insulin treatment or by acute infection or trauma. A small number of people with type II diabetes also experience ketoacidosis, but this is rare give Continue reading >>

Diabetic Ketoacidosis Clinical Presentation

Diabetic Ketoacidosis Clinical Presentation

History Insidious increased thirst (ie, polydipsia) and urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA). Malaise, generalized weakness, and fatigability also can present as symptoms of DKA. Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. A history of rapid weight loss is a symptom in patients who are newly diagnosed with type 1 diabetes. Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe. Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and arthralgia. Acute chest pain or palpitation may occur in association with myocardial infarction. Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients. A study by Crossen et al indicated that in children with type 1 diabetes, those who have had a recent emergency department visit and have undergone a long period without visiting an endocrinologist are more likely to develop DKA. The study included 5263 pediatric patients with type 1 diabetes. [15] Continue reading >>

What Are The 3 P’s Of Diabetes & Their Characteristics?

What Are The 3 P’s Of Diabetes & Their Characteristics?

Diabetes is a dreaded and serious illness affecting large number of people worldwide. In diabetes, there is increased blood glucose level, which can lead to several health complications and may prove to be fatal at times. The most common symptoms to identify this condition are the 3 P's of diabetes, namely polyuria, polydipsia and polyphagia, which is increase in urination, thirst and hunger or appetite, respectively. Diagnosing the condition at an early stage can save lives and also reduce the burden of the patients suffering from diabetes. Diagnosing can help in early treatment and hence the advancement of complications and diseases can be prevented. Presence of these 3 P's of diabetes is an early indication that the person is having higher blood sugar level and diabetes. However, in type 1 diabetes, all these three symptoms usually develop quickly and are obvious, making the diagnosis easier. But, in type 2 diabetes these 3 Ps are always subtle and it develops slowly, which makes it difficult to diagnose. Patients with type 2 diabetes often overlook the symptoms and hence they delay their diagnosis which may worsen the condition. Well, all the 3 P's of diabetes usually shoot from high blood glucose levels. The glucose in blood is usually filtered by the kidneys and it is then absorbed back into the blood. If the blood glucose level is higher, the kidneys can't function efficiently to reabsorb all the sugar and hence it ends up in urine. Polyuria - If there is high content of sugar in urine, excessive water from body is lost through urination and hence polyuria develops. Polydipsia - The loss of excessive body water causes dehydration and this increases thirst, thus polydipsia develops. Polyphagia - When there is lack of insulin production in body, which occurs in dia Continue reading >>

Diabetic Ketoacidosis In Type 1 And Type 2 Diabetes Mellitusclinical And Biochemical Differences

Diabetic Ketoacidosis In Type 1 And Type 2 Diabetes Mellitusclinical And Biochemical Differences

Background Diabetic ketoacidosis (DKA), once thought to typify type 1 diabetes mellitus, has been reported to affect individuals with type 2 diabetes mellitus. An analysis and overview of the different clinical and biochemical characteristics of DKA that might be predicted between patients with type 1 and type 2 diabetes is needed. Methods We reviewed 176 admissions of patients with moderate-to-severe DKA. Patients were classified as having type 1 or type 2 diabetes based on treatment history and/or autoantibody status. Groups were compared for differences in symptoms, precipitants, vital statistics, biochemical profiles at presentation, and response to therapy. Results Of 138 patients admitted for moderate-to-severe DKA, 30 had type 2 diabetes. A greater proportion of the type 2 diabetes group was Latino American or African American (P<.001). Thirty-five admissions (19.9%) were for newly diagnosed diabetes. A total of 85% of all admissions involved discontinuation of medication use, 69.2% in the type 2 group. Infections were present in 21.6% of the type 1 and 48.4% of the type 2 diabetes admissions. A total of 21% of patients with type 1 diabetes and 70% with type 2 diabetes had a body mass index greater than 27. Although the type 1 diabetes group was more acidotic (arterial pH, 7.21 ± 0.12 vs 7.27 ± 0.08; P<.001), type 2 diabetes patients required longer treatment periods (36.0 ± 11.6 vs 28.9 ± 8.9 hours, P = .01) to achieve ketone-free urine. Complications from therapy were uncommon. Conclusions A significant proportion of DKA occurs in patients with type 2 diabetes. The time-tested therapy for DKA of intravenous insulin with concomitant glucose as the plasma level decreases, sufficient fluid and electrolyte replacement, and attention to associated problems remai Continue reading >>

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

INTRODUCTION Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state [HHNK]) are two of the most serious acute complications of diabetes. DKA is characterized by ketoacidosis and hyperglycemia, while HHS usually has more severe hyperglycemia but no ketoacidosis (table 1). Each represents an extreme in the spectrum of hyperglycemia. The precipitating factors, clinical features, evaluation, and diagnosis of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, and treatment of these disorders are discussed separately. DKA in children is also reviewed separately. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) Continue reading >>

Hyperglycemic Crises In Diabetes

Hyperglycemic Crises In Diabetes

Ketoacidosis and hyperosmolar hyperglycemia are the two most serious acute metabolic complications of diabetes, even if managed properly. These disorders can occur in both type 1 and type 2 diabetes. The mortality rate in patients with diabetic ketoacidosis (DKA) is <5% in experienced centers, whereas the mortality rate of patients with hyperosmolar hyperglycemic state (HHS) still remains high at ∼15%. The prognosis of both conditions is substantially worsened at the extremes of age and in the presence of coma and hypotension (1–10). This position statement will outline precipitating factors and recommendations for the diagnosis, treatment, and prevention of DKA and HHS. It is based on a previous technical review (11), which should be consulted for further information. PATHOGENESIS Although the pathogenesis of DKA is better understood than that of HHS, the basic underlying mechanism for both disorders is a reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones, such as glucagon, catecholamines, cortisol, and growth hormone. These hormonal alterations in DKA and HHS lead to increased hepatic and renal glucose production and impaired glucose utilization in peripheral tissues, which result in hyperglycemia and parallel changes in osmolality of the extracellular space (12,13). The combination of insulin deficiency and increased counterregulatory hormones in DKA also leads to the release of free fatty acids into the circulation from adipose tissue (lipolysis) and to unrestrained hepatic fatty acid oxidation to ketone bodies (β-hydroxybutyrate [β-OHB] and acetoacetate), with resulting ketonemia and metabolic acidosis. On the other hand, HHS may be caused by plasma insulin concentrations that are in Continue reading >>

Hyperglycemia And What To Do About It

Hyperglycemia And What To Do About It

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail [email protected] Both hypoglycemia and hyperglycemia are true medical emergencies. As we discussed last month, hypoglycemia often has a rapid onset and can impact any patient whose body is not provided an adequate glucose supply. While anyone can experience hypoglycemia, it is most common in patients who have been diagnosed with diabetes and whose natural insulin does not function normally. Patients with diabetes also risk developing hyperglycemia, a complex and dangerous metabolic derangement that can be fatal without proper care. The American Diabetes Association says that in 2011 there were a staggering 25 million patients with diabetes and 79 million with pre-diabetes across the United States. This month’s CE article explores the consequences of hyperglycemia on the body and the life-threatening emergencies it can cause. Diabetic Disease Progression Recall that insulin secretion is stimulated by eating. Insulin secretion is not stimulated between meals, and a decline in the body’s blood glucose levels inhibits the pancreatic islets’ insulin secretion and stimulates the secretion of glucagon, which allows glucose levels to remain in a normal range. Figure 1 demonstrates the relationship between blood glucose levels and the pancreas. With the exception of very few organs, such as the brain and the kidneys, the body’s tissues require insulin for glucose to pass through the cell walls. For patients with diabetes mellitus (DM), either thei Continue reading >>

Diabetes Mellitus

Diabetes Mellitus

Diabetes mellitus, disorder of carbohydrate metabolism characterized by impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar (glucose) in the blood. Diabetes is a major cause of morbidity and mortality, though these outcomes are not due to the immediate effects of the disorder. They are instead related to the diseases that develop as a result of chronic diabetes mellitus. These include diseases of large blood vessels (macrovascular disease, including coronary heart disease and peripheral arterial disease) and small blood vessels (microvascular disease, including retinal and renal vascular disease), as well as diseases of the nerves. Causes and types Insulin is a hormone secreted by beta cells, which are located within clusters of cells in the pancreas called the islets of Langerhans. Insulin’s role in the body is to trigger cells to take up glucose so that the cells can use this energy-yielding sugar. Patients with diabetes may have dysfunctional beta cells, resulting in decreased insulin secretion, or their muscle and adipose cells may be resistant to the effects of insulin, resulting in a decreased ability of these cells to take up and metabolize glucose. In both cases, the levels of glucose in the blood increase, causing hyperglycemia (high blood sugar). As glucose accumulates in the blood, excess levels of this sugar are excreted in the urine. Because of greater amounts of glucose in the urine, more water is excreted with it, causing an increase in urinary volume and frequency of urination as well as thirst. (The name diabetes mellitus refers to these symptoms: diabetes, from the Greek diabainein, meaning “to pass through,” describes the copious urination, and mellitus, from the Latin meaning “sweetened wi Continue reading >>

Clinical And Biochemical Characteristics Of Diabetes Ketoacidosis In A Tertiary Hospital In Riyadh

Clinical And Biochemical Characteristics Of Diabetes Ketoacidosis In A Tertiary Hospital In Riyadh

Go to: Introduction Diabetes is considered the fifth leading cause of death, and it is a leading cause of morbidity and mortality in the developed world, as well as in many developing countries. Diabetes prevalence (in adults) is reported to be 24% in Saudi Arabia,1 which is higher than that reported in the developed countries. According to the International Diabetes Federation, the diabetes rate in Saudi Arabia in 2015 was 17.6%.2 Diabetic ketoacidosis (DKA) is one of the life-threatening acute complications of diabetes mellitus (DM) that mainly occurs in type 1 diabetes patients, as well as in some patients with type 2 diabetes. It tends to present under stressful conditions or in association with illnesses that feature metabolic decompensation. DKA is characterized by hyperglycemia, ketoacidosis, and ketonuria.3 DKA affects both children and adults and requires immediate attention. The true annual incidence rate for DKA is difficult to establish, but population-based studies have reported ranges from 4.6 to 8 cases per 1,000 patients with diabetes.4,5 DKA rates may be between 5% and 7% in individuals aged <18 years.6 The global incidence of DKA is influenced by various factors and is reflective of the prevalence of diabetes in that population.7,8 Mortality due to DKA is <5% according to the American Diabetes Association (ADA).8,9 Most cases of DKA arise due to missed insulin doses, either as a result of negligence or poor socioeconomic status.10 Other precipitators of DKA include infections, cerebrovascular accidents, alcohol/drug abuse, pancreatitis, myocardial infarction, and trauma. Simple lifestyle modifications, such as educating the patients about not missing any insulin doses—especially during illness—and providing the patients with an adequate insulin reg Continue reading >>

Quick And Dirty Guide To Diabetic Emergencies

Quick And Dirty Guide To Diabetic Emergencies

Diabetes Mellitus Diabetes Mellitus is a systemic disease of the endocrine system resulting from the insufficiency/dysfunction of the pancreas. It is a complex disorder of fat, carbohydrates, and protein metabolism. Diabetes mellitus is potentially lethal, putting the patient at risk for several types of medical emergencies. It is characterized by a lack of insulin, or a persons inability to use insulin. In order to properly manage the numerous calls for diabetics, it is important for EMS professionals to have a basic knowledge of diabetes (DM) before dealing with the associated emergencies that may arise as a result of the disease. Diabetes is the seventh leading cause of death in the US, as well as, it is estimated that 5 + million US citizens become diabetic annually and don't realize they have the disease until an emergency arises. To truly understand the signs and symptoms of the various related conditions, we must first, comprehend some basic pathophysiology. The primary energy fuel for cells is glucose. Glucose is a simple sugar that accounts for approximately 95 percent of the sugar in the bloodstream after gastrointestinal absorption. Thus, it is the blood glucose level that EMS and other health care practitioners are most interested in determining. The key function of insulin (A hormone secreted by the beta cells in the pancreas) is to move glucose from the blood into the cells, where it can be used for energy. However, insulin does not directly carry glucose into the cell, it triggers a receptor on the plasma membrane to open a channel allowing a protein helper (through the process of facilitated diffusion), to carry the glucose molecule into the cell. As long as any insulin is available in the blood, is active, is effective, and is able to stimulate the rece Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic ketoacidosis is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. Hyperglycemia causes an osmotic diuresis with significant fluid and electrolyte loss. DKA occurs mostly in type 1 diabetes mellitus (DM). It causes nausea, vomiting, and abdominal pain and can progress to cerebral edema, coma, and death. DKA is diagnosed by detection of hyperketonemia and anion gap metabolic acidosis in the presence of hyperglycemia. Treatment involves volume expansion, insulin replacement, and prevention of hypokalemia. Diabetic ketoacidosis (DKA) is most common among patients with type 1 diabetes mellitus and develops when insulin levels are insufficient to meet the body’s basic metabolic requirements. DKA is the first manifestation of type 1 DM in a minority of patients. Insulin deficiency can be absolute (eg, during lapses in the administration of exogenous insulin) or relative (eg, when usual insulin doses do not meet metabolic needs during physiologic stress). Common physiologic stresses that can trigger DKA include Some drugs implicated in causing DKA include DKA is less common in type 2 diabetes mellitus, but it may occur in situations of unusual physiologic stress. Ketosis-prone type 2 diabetes is a variant of type 2 diabetes, which is sometimes seen in obese individuals, often of African (including African-American or Afro-Caribbean) origin. People with ketosis-prone diabetes (also referred to as Flatbush diabetes) can have significant impairment of beta cell function with hyperglycemia, and are therefore more likely to develop DKA in the setting of significant hyperglycemia. SGLT-2 inhibitors have been implicated in causing DKA in both type 1 and type 2 DM. Continue reading >>

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