Hyperglycemic Crises, ACLS

1. Diabetic ketoacidosis (DKA) =

2. Hyperosmolar hyperglycemic state (HHS) =

1. uncontrolled hyperglyc + MA + inc ketones

2. sev hyperglyc + hyperosmolality + dehydration w/o significant ketoacidosis

Medications that can cause hyperglycemic crises → 7

1. SGLT2i

2. glucocorticoids

3. antipsychotics

4. CPIs

5. sympathomimetics

6. thiazides

7. pentamidine

CLINICAL PRESENTATION

DKA vs HHS

1. Onset

2. Cognitive state

3. Main s/s

4. other s/s

5. Respiration

1. DKA hrs-days → HHS days-weeks

2. DKA alert → HHS change in cog

3. BOTH polyuria, polydipsia, -weight, dehydration

4. DKA NV + abd pain → HHS co-presenting w other acute illness

5. DKA kussmaul resp

DKA is most common in ______

T1DM

HHS is most common in _____

T2DM

DKA/HHS TREATMENT → 5

1. fluids

2. insulin

3. K+

4. phos

5. bicarb

FLUIDS

1. fluid =

2. ________ during the first _____

3. Add dextrose-containing fluids (eg. 5% or 10% dextrose) when blood glucose ______ mg/dL

1. balanced crystalloid (LR or plasmalyte)

2. 500-1000 mL, 2-4h

3. <250

INSULIN

1. Goals: correct hyperglycemia by ______ mg/dL/h

2. Goals: blood glucose

3. IV insulin: ______ infusion

4. Hyperglycemia is corrected _______ than ketoacidosis →

1. 50-75

2. DKA 150-200; HHS 200-250

3. 0.1U/kg/h

4. faster → -inf rate to 0.05U/kg/h when BG <250

SPECIAL CASE - EUGLYCEMIC DKA (EDKA)

1. Associated with ______

2. Glucose _____ in presence of MA diagnosis criteria

3. Start …

1. SGLT2i

2. <200

3. dextrose fluid concomitantly w insulin inf

POTASSIUM

1. Goals: K+ _____ mEq/L

2. Initiate replacement once K+ is ____ → ______ mEq KCl per liter of IV fluid

3. If K+ _____ → DO NOT initiate insulin therapy (risk of sev hypokalemia)

4. Monitor serum K+ _____

1. 4-5

2. <5 → 20-30

3. <3.5

4. q 2-4h

PHOSPHATE

1. phosphate decreases with _____ therapy

2. overcorrection can cause severe _____

3. Repletion may be indicated in patients with … (3)

4. Consider _____ of potassium phos

1. insulin

2. hypocalc

3. muscle weakness, cardiac/resp dysfx, phos <1

4. 20-30 mmol

BICARBONATE

1. Consider bicarbonate in patients with pH ____

2. Dosing → … until pH>^

1. <7

2. 100 mEq sodium bicarb in 400 mL sterile water q2h

TRANSITIONING TO SQ INSULIN

when hyperglycemic crisis is resolved

1. Restart home dose or _________

2. Give SQ insulin _____ prior to DC continuous infusion

1. 0.5-0.8 U/kg/day

2. 2h

Which is the most appropriate fluid to administer?

a. Albumin

b. Lactated Ringer’s

c. Normal saline

B

Which is the most appropriate medication to administer at this time?

a. IV bicarbonate

b. IV insulin

c. SQ insulin

d. IV potassium chloride

D

(correct K+ to 3.5 before we start insulin)

T or F:

Intensive insulin therapy is beneficial in critically ill patients.

F

(not beneficial, increases the risk of severe hypoglycemia)

TARGET GLUCOSE RANGES → 3

1. 140-180 → most ICU pts, MICU, SICU, NSICU, etc

2. 110-140 → cardiac surg, only if hypoglycemia is avoided (avoid BG </=70)

3. >180 → elderly, end of life care

RISK FACTORS FOR HYPOGLYCEMIA

1. _____ therapy

2. Interruption of ______

3. _________ of hypoglycemia

4. Reduction in ______ doses

5. ________

6. ________

1. insulin

2. nutrition

3. inappropriate mgmt

4. corticosteroid

5. renal fail

6. liver disease

GLYCEMIC CONTROL OF CRITICALLY ILL PATIENTS

1. Initiate insulin therapy when BG ______ mg/dL

2. Decrease insulin therapy if BG ______ mg/dL

3. Avoid ________ in glycemic control

1. >/= 180

2. <100

3. large fluctuations

C

INSULIN ROUTES OF ADMIN

When to use …

1. SQ →

2. IV →

1. clinically stable, low insulin req

2. T1DM, DKA, changing clinical status, uncontrolled on SQ

IV TO SQ INSULIN

1. Calculate _______

2. Use ______ of total daily insulin req

3. Basal only →

4. Basal bolus →

5. Overlap SQ basal insulin & insulin infusion for AT LEAST _____

6. Start ___________ w initiation of SQ regimen

7. Consider restarting infusion if BG remains _____ mg/dL

1. 24h insulin req

2. 50-75%

3. insulin NPH in 2 div doses or glargine/detemir qd

4. 50% basal + 50% bolus (div doses)

5. 2h

6. sliding scale insulin

7. >300

Which SQ insulin regimen is most appropriate?

a) Detemir 60 units SQ daily

b) Glargine 40 units SQ daily

c) NPH 40 units SQ BID

d) Regular 40 units SQ daily

B

(6h = 16U → 16 x 4 = 64 → 50-75% = 32-48U as SQ

NPH BID or glargine/determir qd)

SYMPTOMATIC HYPOGLYCEMIA TX

1. PO intake →

2. No PO intake → IV access

3. No PO intake → no IV access

1. 15g simple carbs → recheck in 15min → if BG<70, repeat cycle

2. 25-50 mL dex 50% IV → recheck in 15min → may repeat 2x → if still <70, start D5W or D10W → recheck in 15min

3. glucagon 1 mg SQ/IM → recheck in 15min

D

BRADYCARDIA

1. HR ____ bpm

2. s/s (unstable) → 5

3. Treatment →

4. MOA →

5. ^max cumulative dose of _____

6. ^INEFFECTIVE in _____ and ______

7. If unresponsive → 3

1. <60

2. hypotension, chest pain, dyspnea, AMS, syncope

3. atropine 1 mg q 3-5min

4. +SA node firing

5. 3 mg

6. heart transplant, complete heart block

7. EP inf 2-10 mcg/min; DA inf 5-20 mcg/kg/min; transcutaneous pacing

SINUS TACHYCARDIA

1. HR ____ bpm

2. s/s → 5

1. >100

2. hypotension, AMS, shock, ischemic chest discomfort, acute HF

SUPRAVENTRICULAR TACHYCARDIA

1. HR ____ bpm

2. ______ are 1st line → (4)

3. ______ are 2nd line (^not successful) → dosing

4. ^ MOA

1. >150

2. vagal maneuvers → coughing, bearing down, carotid massage, modified valsalva

3. adenosine → 6 mg IV rapid push initial → 12 mg rapid IV push repeat

4. -conduction thru SA/AV nodes

Adenosine ADEs → 5

1. flushing

2. dyspnea

3. chest pain

4. bradycardia

5. hypotension

ADENOSINE ADMINISTRATION

1. Administer via IV push over ____

2. Immediately administer _____ and _______

3. Use of ______ or ______ is recommended to facilitate faster admin

4. Administer via ______ as proximal to trunk

5. →

1. 1-2s

2. 20 mL flush, elevate extremity

3. T connector, stopcock

4. peripheral IV

5. if central → -dose 50%

TORSADES DE POINTES

Tachycardia in setting of QTc prolongation

1. Treatment →

2. MOA → (3)

1. magnesium 1-2g IV/IO → push if pt no pulse; inf over 15min if pulse

2. slow SA node impulse formation, +conduction time, stabilize cardiac memb

QTC PROLONGING DRUG CLASSES → 6

1. Antiarrhythmics

2. serotonergics

3. antimicrobials

4. antipsychotics

5. diphenhydramine

6. methadone

C

C

GOALS OF ACLS

1. Primary →

2. Secondary →

3. Ultimate →

1. high quality CPR + rapid defib

2. med admin

3. ROSC (return of spontaneous circulation)

CPR

1. compress atleast ____ deep

2. goal rate _____ bpm

3. basic airway:

4. advanced airway (laryngeal mask, laryngeal tube, endotracheal tube):

1. 2 in

2. 100-120

3. 30 comp q 2 breaths

4. 1 breath q 6s

SHOCKABLE rhythms =

1. VF → no QRS, disorganized, no pulse

2. pVT → no P, organized, no pulse

SHOCKABLE RHYTHM TX (VT, pVT) → 5

1. CPR

2. defib → resume CPR immediately after shock

3. EP 1 mg IV/IO after 2nd shock → repeat q 3-5min

4. amiodarone or lidocaine after 3rd shock

5. continue until ROSC

EPINEPHRINE

1. MOA →

2. Dosing →

3. Continuous infusion at _____ for shock after ROSC

4. Indicated in shockable or non-shockable rhythm?

1. alpha/beta agonist

2. 1 mg IV/IO q 3-5min

3. 2-10 mcg/min

4. both

AMIODARONE

1. MOA →

2. Dosing →

3. →

4. ADEs → 3

1. Class III AA, K+ blocker

2. VF/pVT → 300 mg IV push followed by 150 mg IV push

3. tachycardia+pulse → 150 mg IV inf over 10min followed by cont inf

4. hypotension, bradycardia, +QTc

LIDOCAINE

1. MOA →

2. Dosing →

3. Max dose →
   Could consider infusion after ROSC

1. Class IB AA, Na+ blocker

2. 1-1.5 mg/kg IV bolus followed by 0.5-0.75 mg/kg q 5-10min

3. 3 mg/kg

REVERSIBLE CAUSES of cardiac arrest

1. H’s → 6

2. T’s → 5

1. hypovolemia, hypoxia, H+ (acidosis), hypo/hyperK, hypothermia, hypoglycemia

2. tension pneumothorax, tamponade (cardiac), toxins, thrombosis, trauma

NON-shockable rhythms

1. PEA → electrical present, no pulse

2. asystole → no electrical, no pulse

NON-SHOCKABLE RHYTHM (PEA, asystole) TX

1. high quality CPR

2. EP 1 mg IV/IO q 3-5min

3. continue until rhythm shockable/ROSC

D

C

OTHER MEDICATIONS IN ACLS

Calcium Chloride

1. MOA →

2. Indications →

3. Dosing →
   No benefit in cardiac arrest

4. Ensure ________ btwn calcium & sodium bicarb admin

1. stabilize cardiac memb, +inotropy

2. hypoCa, hyperK, CCB/BB tox, massive transfusion protocol

3. 1g IV push

4. line is flushed

OTHER MEDICATIONS IN ACLS

Dextrose

1. Indications →

2. Dosing →
   No benefit in cardiac arrest

1. hypoglycemia

2. 25-50g IV push

OTHER MEDICATIONS IN ACLS

Naloxone

1. MOA →

2. Indications →

3. Dosing →

4. May be administered via … (5)

1. opioid antag

2. opioid overdose or resp arrest

3. 0.4-2 mg, repeat as indicated

4. IV, IO, IM, intranasal, ET tube

OTHER MEDICATIONS IN ACLS

Sodium Bicarbonate

1. MOA →

2. Indications →

3. Dosing →

4. ________ is not recommended

1. buffers pH, move K+ into cell

2. MA, hyperK, certain overdoses, prolonged resus efforts

3. 50 mEq IV/IO

4. routine admin

Any medication administered IV can be given ____

IO

What drugs can be administered ET?

1. naloxone

2. atropine

3. vasopressin

4. EP

5. lidocaine

Doses of drugs administered via ET is __________ (EXCEPT ______)

2-2.5x IV route, vasopressin

VASOPRESSIN

1. MOA →

2. Indications →

3. Dosing →

1. ADH analog

2. vasodilatory shock RF to fluid resus+catechol, IHCA w EP+steroids

3. 20-40U IV/IO

TARGETED TEMP MANAGEMENT

1. Intentional cooling of a patient to a goal of ____________

2. Consider for any patient who is _____ and ______ to verbal commands after ROSC
   Thought to improve neurologic fx and survival after cardiac arrest

1. 32-37.5C for atleast 24h

2. comatose, unresponsive