0071643192.pdf

ENDOCRINE, METABOLIC, FLUID, AND

ELECTROLYTE DISORDERS

Sepsis should be considered in

all patients with a low blood

sugar.

Sulfonylureas (glipizide,

glyburide) increase insulin

release. Octreotide inhibits

insulin release.

Do not discharge patients with

an overdose of a long-acting

hypoglycemic agent until they

have been observed beyond

the duration of the drug.

DIFFERENTIAL

A patient presenting with seizures or altered mental status without a known

reason deserves an immediate bedside glucose. Administering glucose to a hypo-

glycemic patient should quickly resolve their symptoms. If not, further investiga-

tion is required.

■ Alcohol: Inhibition of gluconeogenosis and depletion of glycogen stores

■ Salicylate: Primary hypoglycemia and seizures in children are common

■ β-Blockers: Potentiate hypoglycemic effects of medications in diabetics

■ Haloperidol

■ Phenothiazines

■ Disopyramide: In malnourished elderly patients without glycogen stores

■ MAO inhibitors

■ Cimetidine

TREATMENT

■ IV glucose is the mainstay of treatment.

■ IM glucagons can also be used when IV access is not available, but may not

be effective on elderly or alcoholic patients who do not have adequate glyco-

gen stores. Octreotide, which inhibits insulin release, may also be used, par-

ticularly for recurrent hypoglycemia following sulfonylurea overdose.

■ IV dextrose is fast and effective but not a large or long-lasting source of car-

bohydrate. An amp of D50 provides only 25 g or 100 calories.

■ A complex meal consisting of protein, fat, and complex carbohydrates is

preferable to simple sugars such as fruit juice or candy bars.

Hyperglycemia

Hyperglycemia is a common ED complaint. DKA and hyperglycemic hyperos-

molar nonketotic coma are life threatening emergencies and must be considered

in all ED patients with an elevated blood sugar. Patients with isolated hyper-

glycemia with a blood sugar less than 400 can generally go home without ED

treatment but with a consideration of changes in medications and close follow up.

An elderly nursing home resident with a history of DM presents with altered

mental status. She appears ill and dehydrated. Her bedside blood glucose is

950. What is her most likely diagnosis?
     This patient has a hyperglycemic hyperosmolar nonketotic coma.

Diabetic Ketoacidosis

The diagnosis of DKA requires the presence of hyperglycemia(may be mild),

ketosis, and an anion gap metabolic acidosis. Serum HCO 3 −may be normal

due to the presence of both an anion gap acidosis and metabolic alkalosis due

to vomiting and dehydration. Do not ignore an increased anion gap. Multiple

factors induce diabetic patients into DKA, including:

■ Relative insulin insufficiency →inability of glucose to enter cells →

hyperglycemia →cellular starvation →stress hormone upregulation →

increased gluconeogenesis, glycogenolysis, and lipolysis →further elevated

hyperglycemia →increased free fatty acids →ketone formation (β-

hydroxybutyrate and acetoacetate).

■ High extracellular sugar levels create an osmotic diuresis. Patients with

DKA are usually severely dehydrated, acidotic, and electrolyte depleted.