Diabetes mellitus o o 200 mgdl 140 mgdl

Diabetes mellitus 糖尿病(高血糖症) o o 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 140 mg/dl或以上 分型: Type I and Type II Type I: inability of the pancreas to secrete insulin because of autoimmune destruction of the beta cells. Type II: caused by other illnesses or medications Chiu-Mei Lin 2005 -10 -07 2

Diabetic Emergency o o o Types of diabetes mellitus History: occur, clinical course, therapy Duration of diabetes Diabetes care Clinical manifestation Others Chiu-Mei Lin 2005 -10 -07 4

病例一: history &PE o o 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? Chiu-Mei Lin 2005 -10 -07 7

病例一: 分析並處置 o o o “馬爺”口訣: 乾瘦渴喘吐—測血糖 F/S: high (爆錶!) Arterial gas: PH: 7. 102, PCO 2: 16 mm. Hg, PO 2: 98 mm. Hg, HCO 3: 8. 4 Na: 128, K: 5. 7, urine ketone: 3+ 病人是什麼問題? 如何處置呢? Chiu-Mei Lin 2005 -10 -07 10

病例一: Diabetic ketoacidosis (DKA) o o DKA is typically characterized by hyperglycemia over 300 mg/d. L, low bicarbonate (<15 m. Eq/L), and acidosis (p. H <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 11

病例一: Diabetic ketoacidosis o o 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 Chiu-Mei Lin 2005 -10 -07 12

病例一: Diabetic ketoacidosis o Clinical manifestations; ü ü ü 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 Chiu-Mei Lin 2005 -10 -07 13

病例一: Diabetic ketoacidosis o 誘發因素: ü ü ü underlying or concomitant infection (40%), missed insulin 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 Chiu-Mei Lin 2005 -10 -07 14

病例一: Diabetic ketoacidosis o Management: ü ü ü ABC stable Hydration Insulin 計算Na, K 的缺少和假象 Acidosis correct Monitor: ABG, sugar, Na, K, urine output Chiu-Mei Lin 2005 -10 -07 15

DKA management o o o Hydration: 1 -2 L normal saline /half saline challenge Monitor urine output NPO initially Chiu-Mei Lin 2005 -10 -07 16

DKA management o Insulin injection: ü ü ü Continuous infusion: 0. 1 u/kg/hr F/S sugar >600, injection insulin? 爭議 F/S sugar 多少時要注意? Chiu-Mei Lin 2005 -10 -07 17

Na 的計算 o Sodium: The osmotic effect of hyperglycemia moves extravascular water to the intravascular space. For each 100 mg/d. L of glucose over 100 mg/d. L, the serum sodium is lowered by approximately 1. 6 m. Eq/L. When glucose levels fall, the serum sodium will rise by a corresponding amount Chiu-Mei Lin 2005 -10 -07 18

K 的計算 o 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 Chiu-Mei Lin 2005 -10 -07 19

Na. HCO 3 的補充 o o PH <7. 0 -7. 1 HCO 3 < 10 meq/ml Basis excess: negative, 補充一半 Monitor Chiu-Mei Lin 2005 -10 -07 20

病例二: o o 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 mm. Hg, PR: 92/min, RR: 24/min, BT: 39, GCS: E 1 M 4 V 2, no trauma history Triage: I 接下來，你會如何做? Chiu-Mei Lin 2005 -10 -07 21

病例二: history and PE o o o 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 Chiu-Mei Lin 2005 -10 -07 22

病例二: 檢查 (Lab data) o o 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? Chiu-Mei Lin 2005 -10 -07 23

病例二: 檢查 (Lab data) o o o Sugar control Chest X-ray ECG Serum WBC Brain CT? DM foot? Chiu-Mei Lin 2005 -10 -07 24

病例二: Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK) o o o Definition: 一般sugar >250 mg/d. L, blood 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? Chiu-Mei Lin 2005 -10 -07 25

病例二: HHNK o Calculated blood osm. : 2(Na+K)+sugar/18+BUN/2. 8 有何意義? Chiu-Mei Lin 2005 -10 -07 26

病例二: HHNK o Patient present with Conscious change ü ü ü 口訣: “ TIPS AEIOU” 口訣: MODS 口訣: sugar-O 2 -opioate-thiamine (Tx: DONE-dextrose, O 2, naloxone, thiamine) Chiu-Mei Lin 2005 -10 -07 27

病例二: HHNK o Clinical manifestation ü ü Precipitating factors: vomiting with dehydration, AMI, infection… Neurologic deficits: drowsiness, delirium, coma, seizure, hemiparesis… tachycardia, tachypnea, hyponatremia, hyperkalemia… Hyperglycemia >600 mg/d. L Chiu-Mei Lin 2005 -10 -07 28

病例二: HHNK o o Precipitating factors correct: infection, AMI… Management: ü ü ü ABC 穩定 Hydration: 0. 5 -1 L Insulin infusion? Underlying disease treat Urine output monitor O 2, if necessary Chiu-Mei Lin 2005 -10 -07 29

Thank you for your attention! 30

Question and comment? 31