1、1,Diabetic Emergency 糖尿病急癥,新光吳火獅紀(jì)念醫(yī)院 急診醫(yī)學(xué)科 林秋梅 醫(yī)師,Chiu-Mei Lin 2005-10-07,2,Diabetes mellitus 糖尿病(高血糖癥),定義:第一種是凡病人出現(xiàn)明顯之癥狀如多尿、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 insulin because of autoimmune destruction of the

2、 beta cells. Type II: caused by other illnesses or medications,3,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,5,病例討論個案,Chiu-Mei Lin 2005-10-07,6,病例一:,

3、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(shù)星期來消瘦許多 Vital signs: BP:110/68 mmHg, PR: 120/min, RR: 22/min, BT:36.8 Triage: II 接下來，你會怎麼做?,Chiu-Mei Lin 2005-10-07,7,病例一: history Thirst, polyuria, polydipsia, nocturia Generalized weakness, malaise/lethargy Nausea/vomiting Decreased perspiration Anorexia or increased

4、 appetite Confusion Fever Dysuria Chills Chest pain Abdominal pain Shortness of breath,Chiu-Mei Lin 2005-10-07,14,病例一: Diabetic ketoacidosis,誘發(fā)因素: underlying or concomitant infection (40%), missed insulin treatments (25%), and newly diagnosed, previously unknown diabetes (15%). Other associated caus

5、es make up roughly 20% in the various series. AMI CVA Trauma Pregnancy Others,Chiu-Mei Lin 2005-10-07,15,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,Chiu-Mei Lin 2005-10-07,16,DKA management,Hydration: 1

6、-2 L normal saline /half saline challenge Monitor urine output NPO initially,Chiu-Mei Lin 2005-10-07,17,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?,Chiu-Mei Lin 2005-10-07,18,Na 的計算,Sodium: The osmotic effect of hyperglycem

7、ia 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,Chiu-Mei Lin 2005-10-07,19,K 的計算,Potassium: This needs to be c

8、hecked 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 2005-10-07,20,NaHCO3 的補充,PH 7.0-7.1 HCO3 10 meq/ml Basis excess: negative, 補充一半 Monitor,Chiu-Mei Lin 2005-10-07,21,病例二:,65歲老太太，糖尿病10年。今天早上被發(fā)現(xiàn)意識

9、不清而送急診。 診察病人，發(fā)現(xiàn)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?,Chiu-Mei Lin 2005-10-07,22,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 sp

10、ecial,Chiu-Mei Lin 2005-10-07,23,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?,Chiu-Mei Lin 2005-10-07,24,病例二: 檢查 (Lab data),Sugar control Chest X-ray ECG Serum WBC Brain CT? DM foot?,Chiu-Mei Lin 2005-10-07,25,病例二: Hyperglycemic Hyperosmolar Nonke

11、totic Coma (HHNK),Definition: 一般sugar 250 mg/dL, 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 2005-10-07,26,病例二: HHNK,Calculated blood osm.: 2(Na+K)+sugar/18+BUN/2.8 有何意義?,Chiu-Mei Lin 2005-10-07,27,病例二: HHNK,Patient present with Conscious change 口訣: “ TIPS AEIOU” 口訣: MODS 口訣:

12、 sugar-O2-opioate-thiamine (Tx: DONE-dextrose, O2, naloxone, thiamine),Chiu-Mei Lin 2005-10-07,28,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,Chiu-Mei Lin 2005-10-07,29,病例二: HHNK,Precipitating factors correc