Transcript diabetes mellitius - Hatzalah of Miami-Dade

DIABETES MELLITIUS
Cells and Molecules
Clinical Application
Presented 9/6/02
By
M. Grant Ervin MD,MHPE,FACEP
Objectives
• Correlate clinical presentation of patient
with DKA with occurrences on cellular
level
• Describe mechanisms by which glucagon
and insulin regulate glycolysis
• Discuss therapeutic measures used to treat
the patient in DKA and the cellular impact
A 45 year old male is brought
into the ED c/o increased thirst,
dizziness, weakness for the past
week. He denies any medical
problems, medications, allergies.
BP – 100/60, RR-24, HR – 120,
Temp.99.9 F
What are the abnormalities?
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Thirst
Weakness
Low blood pressure
Fast heart rate
Fast respiratory rate
Simultaneous Diagnostic,
Therapeutic, and Rescuscitative
Measures
Pulse Ox
EKG
IV line, blood for I-stat, extra tubes to be
determined
Cardiac monitor, BP monitor
Physical Exam significant dry mucus
membranes and abnormal vital signs as
stated
Causes of Elevated Anion Gap
Metabolic Acidosis
• Carbon
monoxide/cyanide
exposure
• Alcohol
• Touluene
• Methanol
• uremia
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DKA
Paraldehyde ingestion
Isoniazid/Iron
Lactic acidosis
Ehtylene glycol
salicylates
Cellular Correlations
• Elevated glucose levels secondary to
decreased insulin, liver has diminished
enymatic capacity to remove glucose
• Decreased glucokinase activity
• Loss of insulin’s action on key enzymes of
glycogenesis and the glycolytic pathway
• Liver stuck in gluconeogenesis fueled by
substrate from body protein degradation
Cellular Correlations (con.)
• Muscle fails to take up glucose with decreased
insulin
• Adipose tissue is stimulated to lipolysis due to low
insulin/glucagon ration
• Leads to increased blood levels fatty acids
• Accelerated ketone body production
• Metabolic acidosis
• Increase respiratory rate is trying to correct
acidosis
Overall metabolism is stuck in
every tissue continuing its
catabolic state producing
more fuel despite increase
glucose. Insulin/ glucagon
ration is unbalanced
Therapeutic Measures
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Fluids
Insulin
Correct electrolyte deficiencies
Look for precipitating causes
Summary
• In Insulin Dependent and Non-Insulin
Dependent Diabetes the insulin/ glucagon
ratio is vital in intracellular glucose control
• Therapeutic measures are directly tied to
what is occurring on a cellular level