DiabeticEmergency糖尿病急症PPT课件

1、1Diabetic 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 2005-10-072Diabetes mellitus 糖尿病(高血糖症)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140mg/dl或以上o 分型: Type I and Type IIo Type I: inability of the pancreas to secrete insulin because of autoimmune destruction of the be

2、ta cells. o 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 2005-10-074Diabetic Emergencyo Types of diabetes mellituso History: occur, clinical course, therapyo Duration of diabeteso Diabetes careo Clinical manifestationo Others 5 病例討論個案Chiu-Mei Lin 2005-10-076病例一:o 2

3、2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o Vital signs: BP:110/68 mmHg, PR: 120/min, RR: 22/min, BT:36.8o Triage: IIo 接下來，你會怎麼做?Chiu-Mei Lin 2005-10-077病例一: history &PEo Past history: denied diabetes, hypertension, or other systemic disordero Present illness: progressively dyspnea for 2 days, nausea

4、 and vomiting, epigastragia, poor appetiteo P.E.: 上腹微微壓痛o 接下來，你會怎麼想?Chiu-Mei Lin 2005-10-078病例一: 分析並處置o 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 Chiu-Mei Lin 2005-10-079病例一: 分析並處置o 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:我眼就看出來了!)Chiu-M

5、ei Lin 2005-10-0710病例一: 分析並處置o “馬爺”口訣: 乾瘦渴喘吐測血糖o F/S: high (爆錶!)o 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?Chiu-Mei Lin 2005-10-0711病例一: Diabetic ketoacidosis (DKA)o DKA is typically characterized by hyperglycemia over 300 mg/dL

6、, low bicarbonate (15 mEq/L), and acidosis (pH 600, injection insulin?爭議 F/S sugar 多少時要注意?Chiu-Mei Lin 2005-10-0718Na 的計算o Sodium: The osmotic effect of hyperglycemia moves extravascular water to the intravascular space. For each 100 mg/dL of glucose over 100 mg/dL, the serum sodium is lowered by ap

7、proximately 1.6 mEq/L. When glucose levels fall, the serum sodium will rise by a corresponding amount Chiu-Mei Lin 2005-10-0719K 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

8、levels Chiu-Mei Lin 2005-10-0720NaHCO3 的補充o PH 7.0-7.1o HCO3 100/HPFo 你還想知道什麼?Chiu-Mei Lin 2005-10-0724病例二: 檢查 (Lab data)o Sugar controlo Chest X-rayo ECGo Serum WBCo Brain CT?o DM foot?Chiu-Mei Lin 2005-10-0725病例二: Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK)o Definition: 一般sugar 250 mg/dL, bl

9、ood Osm.320o 你知道blood Osm.如何算嗎?o 你知道coma的病人，如何快速找到原因嗎?Chiu-Mei Lin 2005-10-0726病例二: HHNKo Calculated blood osm.: 2(Na+K)+sugar/18+BUN/2.8 有何意義?Chiu-Mei Lin 2005-10-0727病例二: HHNKo Patient present with Conscious change 口訣: “ TIPS AEIOU” 口訣: MODS 口訣: sugar-O2-opioate-thiamine (Tx: DONE-dextrose, O2, na

10、loxone, thiamine)Chiu-Mei Lin 2005-10-0728病例二: HHNKo 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 2005-10-0729病例二: HHNKo Precipitating factors correct: infection, AMIo Management