糖尿病急症.ppt

1,DiabeticEmergency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-MeiLin2005-10-07,2,Diabetesmellitus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200mg/dl以上即可。第二種是二次空腹血糖在140mg/dl或以上分型:TypeIandTypeIITypeI:inabilityofthepancreastosecreteinsulinbecauseofautoimmunedestructionofthebetacells.TypeII:causedbyotherillnessesormedications,3,如何思考臨床問題?你要問什麼?,Chiu-MeiLin2005-10-07,4,DiabeticEmergency,TypesofdiabetesmellitusHistory:occur,clinicalcourse,therapyDurationofdiabetesDiabetescareClinicalmanifestationOthers,5,病例討論個案,Chiu-MeiLin2005-10-07,6,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Vitalsigns:BP:110/68mmHg,PR:120/min,RR:22/min,BT:36.8Triage:II接下來，你會怎麼做?,Chiu-MeiLin2005-10-07,7,病例一:history&PE,Pasthistory:denieddiabetes,hypertension,orothersystemicdisorderPresentillness:progressivelydyspneafor2days,nauseaandvomiting,epigastragia,poorappetiteP.E.:上腹微微壓痛接下來，你會怎麼想?,Chiu-MeiLin2005-10-07,8,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,Chiu-MeiLin2005-10-07,9,病例一:分析並處置,上腹微微疼痛合併噁心想吐UlcerPancreatitisAMIPneumoniaCholecystitisGBstones(傷腦筋)(笨蛋護士小姐說:我眼就看出來了!),Chiu-MeiLin2005-10-07,10,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!)Arterialgas:PH:7.102,PCO2:16mmHg,PO2:98mmHg,HCO3:8.4Na:128,K:5.7,urineketone:3+病人是什麼問題?如何處置呢?,Chiu-MeiLin2005-10-07,11,病例一:Diabeticketoacidosis(DKA),DKAistypicallycharacterizedbyhyperglycemiaover300mg/dL,lowbicarbonate(15mEq/L),andacidosis(pH600,injectioninsulin?爭議F/Ssugar多少時要注意?,Chiu-MeiLin2005-10-07,18,Na的計算,Sodium:Theosmoticeffectofhyperglycemiamovesextravascularwatertotheintravascularspace.Foreach100mg/dLofglucoseover100mg/dL,theserumsodiumisloweredbyapproximately1.6mEq/L.Whenglucoselevelsfall,theserumsodiumwillrisebyacorrespondingamount,Chiu-MeiLin2005-10-07,19,K的計算,Potassium:Thisneedstobecheckedfrequently,asvaluesdropveryrapidlywithtreatment.AnECGmaybeusedtoassessthecardiaceffectsofextremesinpotassiumlevels,Chiu-MeiLin2005-10-07,20,NaHCO3的補充,PH250mg/dL,bloodOsm.320你知道bloodOsm.如何算嗎?你知道coma的病人，如何快速找到原因嗎?,Chiu-MeiLin2005-10-07,26,病例二:HHNK,Calculatedbloodosm.:2(Na+K)+sugar/18+BUN/2.8有何意義?,Chiu-MeiLin2005-10-07,27,病例二:HHNK,PatientpresentwithConsciouschange口訣:“TIPSAEIOU”口訣:MODS口訣:sugar-O2-opioate-thiamine(Tx:DONE-dextrose,O2,naloxone,thiamine),Chiu-MeiLin2005-10-07,28,病例二:HHNK,ClinicalmanifestationPrecipitatingfactors:vomitingwithdehydration,AMI,infectionNeurologicdeficits:drowsiness,delirium,coma,seizure,hemiparesistachycardia,tachypnea,hyponatremia,hyperkalemiaHyperglycemia600mg/dL,Chiu-MeiLin2005-10-07,29,病例二:HHNK,Precipitatingfactorscorrect:infection,AMIManagement:ABC穩定Hydrat