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Emergencies in Adult Nursing

Edited by Philip Downing

Publisher:
Oxford University Press
Print Publication Date:
Jun 2009
Print ISBN-13:
9780199226573
Published to Oxford Medicine:
Aug 2010
DOI:
10.1093/med/9780199226573.001.0001

Disclaimer

Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding.

Diabetes

Chapter:
Diabetes
DOI:
10.1093/med/9780199226573.003.0014

Differential diagnosis

Diabetes True emergencies

  • • Diabetic ketoacidosis

  • • Hypoglycaemia

Diabetes mellitus

Diabetes mellitus is a chronic metabolic disorder in which the blood glucose becomes too high as a result of cells being unable to access it due to a lack of insulin.

Glucose is normally absorbed from the duodenum after eating. It is also stored in the liver in the form of glycogen. Insulin is released by the pancreas in response to raising levels of blood glucose. It enables the glucose to enter cells where it is further metabolized. Insulin also enables glucose not required immediately by the body to be stored in the liver for future use.

Glucose is the main source of energy for cells and the normal range within the blood stream is between 4–8mmol/L. The brain is most susceptible to acute changes to blood glucose levels.

There are two main types of diabetes—type 1 and type 2.

Type 1

  • • Insulin-dependent diabetes mellitus (IDDM)

  • • Younger onset, <40 years old

  • • Patient unable to produce insulin

  • • Treatment: insulin injections

Type 2

  • • Non-insulin-dependent diabetes mellitus (NIDDM)

  • • More common, up to 95% of all cases

  • • Strong link to obesity

  • • Older age of onset

  • • Insulin is produced but not in sufficient quantities

  • • Treatment depends on the extent and stage of the problem and may follow a range of treatment including:

    • • lifestyle changes such as regular exercise, weight loss, dietary changes

    • • oral medication

    • • insulin injections

Diabetes Diabetic ketoacidosis

DKA is a life-threatening complication of diabetes resulting from a severe deficiency of insulin. In young adults, it may be the first indication that the patient has diabetes. In people with established type 1 diabetes it may occur if their demand for insulin is increased by:

  • • Infection

  • • Trauma

  • • Surgery

  • • MI

DKA can occur in patients with type 2 diabetes but is less common.

Due to lack of insulin, cells utilize fat as a source of energy. This process produces ketones which alter the blood pH making it acidaemic. Ketones are excreted in urine but increasing blood ketone levels will lead to coma and death if untreated.

Key signs and symptoms

  • • Polydipsia, excessive thirst

  • • Polyuria

  • • Dehydration

  • • Glycosuria

  • • Fatigue

  • • N&V

  • • Odour of acetone on breath

  • • Abdominal pain

  • • Confusion and drowsiness

Key history and assessment

  • • History of vomiting, drowsiness, and increased confusion over 2–3 days

  • • History of polyuria and polydipsia

  • • Concurrent infection

  • • Poorly controlled or poorly managed diabetes

Key observations and findings

  • • Raised blood glucose level >15mmol/L

  • • Kussmaul's breathing: deep sighing characteristic

  • • Ketones on breath and in the urine

  • • Electrolyte imbalance (hyperkalaemia) may be noted on ABG

Key investigations

  • • ABGs

  • • U&Es

  • • FBC

  • • ECG

  • • Cardiac enzymes

  • • CXR if chest infection suspected

  • • Blood, urine, and sputum for culture if indicated

Key actions and observations

  • • Maintain airway if necessary

  • • Rehydration with isotonic IV fluids

  • • Monitor blood glucose levels

  • • Monitor urinary output, catheterize if necessary

  • • Insulin infusion according to local guidelines

  • • Regular vital signs monitoring

  • • ECG monitoring

  • • NG tube if conscious level is impaired

  • • Refer to in patient medical team

Diabetes Hypoglycaemia

Hypoglycaemia is the most common emergency presentation in diabetics and is most commonly seen in patients with type 1 diabetes. It occurs when blood glucose levels fall too low, normally as a result of:

  • • Too much insulin

  • • Missed meal resulting in insufficient glucose

  • • Too much oral medication

  • • High utilization of glucose due to exercise

Blood glucose must always be measured in patients presenting with:

  • • Seizures

  • • Abnormal behaviour

  • • Apparent alcohol intoxication

Key signs and symptoms

  • • Sweating

  • • Pallor

  • • Hunger

  • • Irritability and confusion

  • • Atypical behaviour

  • • Lethargy

  • • Loss of coordination

  • • Tremor

  • • Visual disturbance

  • • Unconsciousness

  • • Seizures: glucose must be checked in patients presenting with a seizure

Key history and assessment

  • • Known IDDM

  • • History of missed meals

  • • History of recent illness e.g. diarrhoea and vomiting

Key observations and findings

  • • Reduced conscious level: record GCS

  • • Low blood glucose level: <3.5mmol/L

Key investigations

  • • Check blood glucose

Key actions and treatment

  • • Maintain airway and ensure adequate breathing if necessary

  • • If conscious: give fast acting glucose drink or gel

  • • If unconscious:

    • • 50mL 50% glucose IV—into a large vein as this solution is an irritant

    • • glucagon 1mg by IM injection

    • • may require an IV glucose infusion

  • • Check blood glucose after 15–20min

  • • If the cause has been identified, and patient can be accompanied home, may be able to discharge

  • • May require referral to:

    • • inpatient team

    • • outpatient follow-up appointment

    • • diabetic specialist nurse

    • • Primary Care

  • • May require admission if:

    • • Blood glucose difficult to control

    • • Concurrent illness

    • • Patient on oral hypoglycaemics—as hypoglycaemia will recur