糖尿病急症-灾难医学会.pptVIP

Diabetic 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 Diabetes mellitus 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 beta cells. Type II: caused by other illnesses or medications 如何思考臨床問題? 你要問什麼? Diabetic Emergency Types of diabetes mellitus History: occur, clinical course, therapy Duration of diabetes Diabetes care Clinical manifestation Others 病例討論個案 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 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? 病例一: history PE 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? 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 病例一: 分析並處置 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ㄧ眼就看出來了!) 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!) 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? 病例一: Diabetic ketoacidosis (DKA) DKA is typically characterized by hyperglycemia over 300 mg/dL, low bicarbonate (15 mEq/L), and acidosis (pH 7.30) with ketonemia and ketonuria. Counterregulatory hormones, such as glucagon, growth hormone, and catecholamines, enhance triglyceride breakdown into free fatty acids and gluconeogenesis 病例一: Diabetic ketoacidosis 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 病例一: Diabetic ketoacidosis Clinical manifestations; Thirst, polyuria, polydipsia, nocturia Generalized weakness, malaise/lethargy Nausea/vomiting Decreased perspiration Anorexia or increased ap