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Diabetic Emergency 糖尿病急症

新光吳火獅紀念醫院 急診醫學科林秋梅 醫師

Chiu-Mei Lin 2005-10-07 2

Diabetes mellitus 糖尿病 ( 高血糖症 ) 定義 :第一種是凡病人出現明顯之症狀　　　　　

　如多尿、多渴、多吃、體重減輕、疲倦等加上任意血糖值在 200 mg/dl 以上即可。第二種是二次空腹血糖在 140mg/dl 或以上

分型 : Type I and Type II Type I: inability of the pancreas to secrete insuli

n because of autoimmune destruction of the beta cells.

Type II: caused by other illnesses or medications

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如何思考臨床問題 ? 你要問什麼 ?

Chiu-Mei Lin 2005-10-07 4

Diabetic Emergency

Types of diabetes mellitus History: occur, clinical course, therapy Duration of diabetes Diabetes care Clinical manifestation Others

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病例討論個案

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病例一 : 22 歲男性警察， 2日來感到容易疲倦，喘，

上腹疼痛，噁心想吐，數星期來消瘦許多 Vital signs: BP:110/68 mmHg, PR: 120/m

in, RR: 22/min, BT:36.8 Triage: II 接下來，你會怎麼做 ?

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病例一 : history &PE

Past history: denied diabetes, hypertension, or other systemic disorder

Present illness: progressively dyspnea for 2 days, nausea and vomiting, epigastragia, poor appetite

P.E.: 上腹微微壓痛 接下來，你會怎麼想 ?

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病例一 : 分析並處置 喘 :有何原因 ? 如何診斷和排除 ?證據何

在 ? 心臟 肺臟 腦部受創或出血壓迫 血液循環 腎臟 內分泌合併電解質異常 其他

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病例一 : 分析並處置 上腹微微疼痛合併噁心想吐

Ulcer Pancreatitis AMI Pneumonia Cholecystitis GB stones … ( 傷腦筋 ) ( 笨蛋—護士小姐說 : 我ㄧ眼就看

出來了 !)

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病例一 : 分析並處置 “馬爺”口訣 : 乾瘦渴喘吐—測血糖 F/S: high ( 爆錶 !) Arterial gas: PH: 7.102, PCO2: 16 mmHg, PO2:

98 mmHg, HCO3: 8.4

Na: 128, K: 5.7, urine ketone: 3+

病人是什麼問題 ?

如何處置呢 ?

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病例一 : Diabetic ketoacidosis (DKA)

DKA is typically characterized by hyperglycemia over 300 mg/dL, low bicarbonate (<15 mEq/L), and acidosis (pH <7.30) with ketonemia and ketonuria.

Counterregulatory hormones, such as glucagon, growth hormone, and catecholamines, enhance triglyceride breakdown into free fatty acids and gluconeogenesis

Chiu-Mei Lin 2005-10-07 12

病例一 : Diabetic ketoacidosis

beta-oxidation of free fatty acids deplete extracellular and cellular acid buffers

hyperglycemia-induced osmotic diuresis depletes sodium, potassium, phosphates, and water as well as ketones and glucose

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病例一 : Diabetic ketoacidosis Clinical manifestations;

Thirst, polyuria, polydipsia, nocturia Generalized weakness, malaise/lethargy Nausea/vomiting Decreased perspiration Anorexia or increased appetite Confusion Fever Dysuria Chills Chest pain Abdominal pain Shortness of breath

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病例一 : Diabetic ketoacidosis

誘發因素 : underlying or concomitant infection (40%), missed in

sulin treatments (25%), and newly diagnosed, previously unknown diabetes (15%). Other associated causes make up roughly 20% in the various series.

AMI CVA Trauma Pregnancy Others

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病例一 : Diabetic ketoacidosis

Management:

ABC stable Hydration Insulin 計算 Na, K 的缺少和假象 Acidosis correct Monitor: ABG, sugar, Na, K, urine output

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DKA management

Hydration: 1-2 L normal saline /half saline challenge

Monitor urine output NPO initially

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DKA management

Insulin injection: Continuous infusion: 0.1 u/kg/hr F/S sugar >600, injection insulin? 爭議 F/S sugar 多少時要注意 ?

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Na 的計算 Sodium: The osmotic effect of hyperglyce

mia moves extravascular water to the intravascular space. For each 100 mg/dL of glucose over 100 mg/dL, the serum sodium is lowered by approximately 1.6 mEq/L. When glucose levels fall, the serum sodium will rise by a corresponding amount

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K 的計算 Potassium: This needs to be checked

frequently, as values drop very rapidly with treatment. An ECG may be used to assess the cardiac effects of extremes in potassium levels

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NaHCO3 的補充 PH <7.0-7.1 HCO3 < 10 meq/ml Basis excess: negative, 補充一半 Monitor

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病例二 : 65 歲老太太，糖尿病 10 年。今天早上被發

現意識不清而送急診。 診察病人，發現 BP: 140/72 mmHg, PR: 92

/min, RR: 24/min, BT: 39, GCS: E1M4V2, no trauma history

Triage: I 接下來，你會如何做 ?

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病例二 : history and PE

DM history with oral hyperglycemic agents for 10 years

Malaise for 3 days Fever was noted this morning SOB without cough P.E.: nothing special

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病例二 : 檢查 (Lab data) Finger sting: high BUN: 42, Cr: 1.7, Na: 120, K: 5.2 U/A: WBC >100/HPF 你還想知道什麼 ?

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病例二 : 檢查 (Lab data) Sugar control Chest X-ray ECG Serum WBC Brain CT? DM foot?

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病例二 : Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK) Definition: 一般 sugar >250 mg/dL, bloo

d Osm.>320 你知道 blood Osm. 如何算嗎 ? 你知道 coma 的病人，如何快速找到原因嗎 ?

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病例二 : HHNK Calculated blood osm.: 2(Na+K)+sugar/1

8+BUN/2.8 有何意義 ?

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病例二 : HHNK Patient present with Conscious change

口訣 : “ TIPS AEIOU” 口訣 : MODS 口訣 : sugar-O2-opioate-thiamine (Tx: DON

E-dextrose, O2, naloxone, thiamine)

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病例二 : HHNK Clinical manifestation

Precipitating factors: vomiting with dehydration, AMI, infection…

Neurologic deficits: drowsiness, delirium, coma, seizure, hemiparesis…

tachycardia, tachypnea, hyponatremia, hyperkalemia…

Hyperglycemia >600 mg/dL

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病例二 : HHNK Precipitating factors correct: infection, A

MI… Management:

ABC 穩定 Hydration: 0.5-1 L Insulin infusion? Underlying disease treat Urine output monitor O2, if necessary

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Thank you for your attention!

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