krisis hiperglikemia
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Penanganan Krisis Hiperglikemia pada bidang Emergency MedicineTRANSCRIPT
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KRISISHIPERGLIKEMI
PENYUSUN:
BENEDICTUS YUDHA B.
ENISA NUR AMALIA
PEMBIMBING: DR. SURYANTO, SP.EM
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DIABETES MELITUS
Kriteria Diagnoa
1. Gejala klasik DM + GDA 200 mg/dL
ATAU
2. Gejala klasik DM
+
GDP 126 mg/dL dengan puasa 8 jam
ATAU
3. 2 jam PP TTG 200 mg/dL
TTG dengan !e!an "# g gluk$sa
PAPDI, !""#
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KOMPLIKASIAKUT
%&'('()'P*&GL'%
*M'
%AD
))(
HIPOGLIKEMI
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KRISIS HIPERGLIKEMI
$. Dia%eti& Ketoa&i'oi
!. H()ero*o+ar ()erg+(&e*i& tate
DKA %an(a-
tera'i )a'a/ia */'a 012 ta/n
Morta+ita)a'a -rii
i)erg+i-e*iter/ta*a
tera'i -arena)en(a-it)en&et/
(ang*en(ertai.
HHS %an(a-tera'i )a'a
/ia t/a 3 12ta/n
Onet DKA
'a+a* a*ingga arie'ang-anHHS ariingga*ingg/
U)to'ate, !"$2
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!45 )en'eritaDKA a'a+a)aien DM ti)e
$.
Prognoi %/r/-)a'a )aien
/ia t/a (ang*enga+a*i
-o*a,i)oteni, 'an
)en(a-it)en(erta (ang
)ara.
Morta+ita )a'aHHS 3 DKA
A%%a et a+, !""#
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6AKTOR PENCETUS
• In7e-i 8!"9 ;"9< = Par/ 'an tra-t/ /rinari/
• C>A
• M(o&ar'ia+ in7ar&tion
• Pan&reatiti
• Pe*%erian in/+in (ang ti'a- a'e-/at 'an %erenti -on/*iin/+in.
•
Dr/g 8teroi', (*)ato*i*eti&, tia?i'e<
ADA, !""#
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DIABETIC KETOACIDOSIS
• Tria DKA :
$. Ketone*ia 8-etoi<
!. Hi)erg+i-e*ia5. A&i'e*ia
• Biaan(a DKA 'iin'i-ai-an, %a-an /nt/- *en'iagnoi)en'erita DM ti)e $, na*/n ter'a)at )ening-atan -a/ )a'a
DM ti)e ! (ang ter%/-ti ter'a)at -eton 8-etoi< 'ie%/t /gaketosis-prone diabetes mellitus.
ADA, !""#
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HYPEROSMOLAR HYPERGLYCEMIC STATE
Di'a)at-an :
@ Hi)oo+e*ia@ Hi)erg+i-e*ia 831""*g4'L< anpa 'iertai i)er-etone*iaigni-an 80 5 **o+4L< ata/ ai'oi 8)H3,5, %i-ar%onat 3$2**o+4L<
@ Hi)ero*o+a+ita 3 5!" *O*4-g
ADA, !""#
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PATOGENESIS
ADA, !""#
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DIAGNOSIS
$. ANAMNESIS
!. PEMERIKSAAN 6ISIK
5. PEMERIKSAAN PENUNANG
ADA, !""#
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Anamnesis 'i'a)at-an :
$. Po+i/ria
!. Po+i'i)i
5. eigt +o
;. Dei'rai
2. Tan'atan'a in7e-i4 7a-tor )en&et/
1. Per/%aan -ea'aran
. RiFa(at )engo%atan
. RiFa(at -e+/arga
Peme,iksaan -isik 'i'a)at-an :
#. T/rgor -/+it *en/r/n
$". Re)irai -/*a/+ 8DKA<
$$. Ta-i-ar'ia
$!. Hi)oteni
$5. Per/%aan -ea'aran 8+etargi ingga -o*a<
$;. Tan'a ne/ro+ogi 7o-a+ 'an -eang )a'a HHS
$2. M/a+, */nta, 'i7/e a%'o*ina+ )ain %an(a- 'ite*/-an )a'a )aien DKA 832"9<.ADA, !""#
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Peme,iksaan Penunjang• Ka'ar g/+a 'ara
• Keton er/* 'an -eton /rine• E+e-tro+it er/*, o*o+a+ita, anion ga)
• BGA
• B+oo' /rea nitrogen4&reatinine
• Urina+(i
• Dara +eng-a)
• EKG
• K/+t/r %a-teri /rine, 'ara, ata/ tenggoro-.
• 6oto tora
ADA, !""#
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KRITERIA DIAGNOSA
DKA HHS
Mi+' Mo'erate Seere
P+a*a g+/&oe8*g4'+<
Arteria+ )H
Ser/* %i&ar%onate
8*E4+<
Urine -etone
Ser/* -eton
EJe&tie er/*o*o+a+it(
8*o*4-g<
Anion ga)
A+teration in enoriaan' *enta+
3 !2"
.!2.5"
$2$
8<
8<
>aria%+e
3 $"
A+ert
3 !2"
."".!;
$" to $2
8<
8<
>aria%+e
3 $!A+ert4'roF(
3 !2"
0 .""
0 $"
8<
8<
>aria%+e
3$!St/)or4&o*a
3 1""
3 .5"
3 $
S*a++
S*a++
35!"
>aria%+eSt/)or4&o*a
Ani$n gap a+ l + )3 m*4/l.
sm$lali5 2a+ glu$se 18
ADA, !""#
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DI66ERENTIAL DIAGNOSIS
Tintina++i EM t E', !"$$
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MANAEMEN KAD DAN HHS
ADA, !""#
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MONITORING
• G/+a 'ara )eri7er 8tia) a*<
• E+e-tro+it er/* 'an %i-ar%onat 8! a* )erta*a<
• Pro'/-i Urin
• Te-anan 'ara 4 Na'i
• Kea'aran
ADA, !""#
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PEMELIHARAAN
• Pertaan-an g+/-oa er/* $2"!"" *g4'L ingga -ontro+ *eta%o+i-ter&a)ai
• Ce- e+e-tro+t, BUN, PH 'ara, -reatinin, 'an g+/-oa etia) !; a*
ingga )aien ta%i+• Sete+a reo+/i DKA ata/ HHS 'an -eti-a )aien /'a *a*)/ /nt/-
*a-an, */+ai+a regi*en in/+in */+ti'oe SC
• Unt/- *eng/%a 'ari I> -e SC, teta) +an/t-an in7/ in/+in $! a*ete+a in/+in SC /nt/- *e*ati-an +ee+ in/+in )+a*a /'a a'e-/at
• Pa'a )aien (ang %e+/* )erna *en'a)at-an tera)i in/+in , 'i*/+ai
'ari ".2 U4-g ingga ". U4-gBB4ari 'an tent/-an 'oi in/+in e/ai-e)er+/an
• Teta) &ari 7a-tor )en&et/
ADA, !""#
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KRITERIA RESOLUSI DKA
$. G+/-oa 'ara 0 !"" *g4'L
!. )H 3 .5 /nit
5. Bi-ar%onat 3 $." **o+4L
Tintina++i EM t E', !"$$
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KOMPLIKASI KAD
Tintina++i EM t E', !"$$
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KOMPLIKASI HHS
• Hi)og+i-e*ia
• Hi)o-a+e*ia
• P/+*onar( e'e*a
GraJeo, !"$$
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LAPORAN KASUS
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IDENTITAS
• Na*a : N(. S
• eni Ke+a*in : anita
• Uia : ! ta/n
• No. Regiter : $$!2
• A+a*at : Singoari, Ma+ang
Datang -e IGD RSSA )a'a tangga+ !1 Ag/t/ !"$2 )/-/+ $.5"IB
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PRIMARY SUR>EY
A : Paten, /ara na7a ta*%aan 8snoring, gargling, stridor < 8<.
B : E-)ani 'a'a i*etri, RR 55 4*enit, reg/+ar, &e)at 'an 'a+a*, retra-i
'in'ing 'a'a 8<.
C : TD: $51415 **Hg, Na'i : $!$4*enit, -/at, reg/+ar, a-ra+ angat 'an
-ering, CRT 0 ! 'eti-
D : GCS 5!;, ree- &aa(a 4, )/)i+ %/+at io-or 5** 4 5**
E : S// a-i+a 5#"
C
Pasien masuk ,iage P 1
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INITIAL TREATMENT
•
A : • B : O! ia NRBM $" +)*
• C : I> +ine NaC+ ",#9 !" &&4-gBB4 a*
• D :
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ANAMNESIS 8HETEROANAMNESIS<
• Ke+/an /ta*a: Ti'a- a'ar
Paien 'i%aFa -e IGD 'engan -e+/an ti'a- a'ar ea- $! a* SMRS. AFa+n(a )aien ti'/r teta)i /+it 'i%ang/n-an, /+it
'iaa- -o*/ni-ai.
Paien an(a %er%aring 'i te*)at ti'/r ea- 2 ari *r-arena ti'a- %ia a-tiita 'an +e*a. Paien /ga *e*i+i-i +/-a'i%agian )antat, +/-a e)erti +e&et, -/+it ter-e+/)a, nana 8<.Paien /ga *e*i+i-i +/-a 'i -a-i -anan ea- $ *ingg/ SMRS,
aFa+n(a e)erti *e+e)/, %eng-a-, n(eri 8< 'an e+an/tn(a 2ari -e*/'ian */n&/+ +/-a -eita*an 'i -a-i t%, nana 8<,-e+/ar &airan 'ara 'an %er%a/.
Paien /ga 'i-e+/-an 'e*a* ea- 2 ari SMRS, 'e*a*tinggi 'iertai *enggigi+. Bat/- 8<, */a+ */nta 8< $ -a+i.
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• RiFa(at Pen(a-it Da/+/
Paien *e*i+i-i riFa(at DM ea- ta/n !"", ti'a- ter-ontro+.
Paien *e*i+i-i riFa(at i)erteni (ang ti'a- ter-ontro+ 8$"4$$"<.
an/ari !"$2 )aien 'iraFat 'i RSUD LaFang -arena */a+ */nta 'an g/+a'ara ren'a.
• RiFa(at Pen(a-it Ke+/arga
DM 8< HT 8<
• RiFa(at Pengo%atanUnt/- )en(a-it DM )aien %iaa -on/*ig+i%en&+a*i'e $2 *g.
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(*DA&7 (U&*7
Kea'aan /*/*: ta*)a- a-it %eratGCS 5!;
B 1" -g Heigt $1" &*BMI !5.; -g4*!
BP Q $5115 **Hg
PR Q $!$4*enit, reg/+ar, -/at RR Q 55 4*enit, reg/+ar,&e)at 'an 'a+a*
Ta : 5#"C
Hea' Con/&tia ane*i& 8<S&+era i&teri& 8<
P/)i+ io-or 545**
Ne&- >P R " &* H!", 5""
)oition Lnn. En+arge*ent 8<
ToraCor I&t/ inii%+e )a+)a%+e at ICS > MCL S , RHM SL D, LHM i&t/ . S$ S! reg/+ar, */r*/r 8<, ga++o) 8<
P/+*o Si*etri Ste* 7re*it/ DQS Sonor % % R
% %
% %
A%'o*en 6+at, oe, BoFe+ So/n' N, +ier )an &*. Tra/%e )a&e ti*)ani, Si7ting '/++ne
Etre*itie E'e*a A-ra+ angat -ering
U+-/ )e'i 'etra 1; &*, )/ 8<, 'aar ten'on.CRT0! 'eti-
P/ngg/ng U+-/, Ø 5 cm
PEMERIKSAAN 6ISIK
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La% >a+/e La% >a+/e
Le/-oit !".;"" ;.5""$".5""4VL GDS ;"$ 0!"" *g4'+
He*og+o%in $$,1" $$,;$2,$ g4'L Ka+i/* ," ,1$$," *g4'L
Tro*%oit 55!.""" $;!.""";!;."""4VL
Po)or 5,! !,;,2 *g4'L
MC> ;,; " #5 7L Natri/* $21 $51$;2 **o+4L
MCH !2,$" ! 5$ )g Ka+i/* 5,$ 5,22," **o+4L
MCHC !#," 5! 51 g4'L K+ori'a $52 #$"1 **o+4L
DiJ &o/nt "4",$4#,;4;,142,#
";4"$42$14!2554!2
O*o+arita 555,; !"!#2 *O*4KgH!O
Ure/* !2," $1,1;,2 *g4'L Anion ga) ,2 $1 **o+
Kreatinin 5,"# 0 $,! *g4'L Aa* +a-tat !,2 >ena: ",2!,!Arteri: ",2$,1
PEMERIKSAAN LABORATORIUM
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La! alue
)H ,!2 ,52,;2
)CO! !,2 52;2 **Hg
)O! $;!,$ "$"" **Hg
HCO5 $!,2 !$! **o+4L
BE $2," 85< 85<
Sat O! #,9 3#2
Kei*)/+an :
BLOOD GAS ANALYSIS
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URINALISIS
Re/+t Re/+t
SG $."!2 $"W
PH 2,2 E)ite+ia !,1
Le/&o&(te 5 C(+in'er
Nitrite H(a+ine
Protein ! Gran/+ar
G+/&oe ;" W
Er(tro&(te $ Eritroit !;#,
Denit( Ker/ E/*or- Poiti7 Keton /rine Di*or-
Uro%i+inogen Le/-o&(te 2!2,2
Bi+ir/%in Cr(ta+
Ba&teria 12$,5
W$"5
arna
K/ning
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6OTO THORAW
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EKG
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HYPERKALEMIA
ECG &ange in H()er-a+e*ia:
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PENATALAKSANAAN
• O! $" +)* ia NRBM
• I>6D NaC+ ",#9 !" &&4-gBB4 a*
• Dri) KCL !2 *e
• In in/+in 2 i/ i
• Dri) in/+in 2 i/4a*
• In. Ci)rooa&in !"" *g i
•
In. O*e)ra?o+e ;" *g i• In. Meto&+o)ra*i'e $" *g i
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DIAGNOSIS KERA
$. Krii Hi)erg+i-e*ia 't KAD
!. Se)i 't /+-/ )e'i initra
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PEMBAHASAN
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DKA HHS
Mi+' Mo'erate Seere
P+a*a g+/&oe8*g4'+<
Arteria+ )H
Ser/* %i&ar%onate
8*E4+<Urine -etone
Ser/* -eton
EJe&tie er/*o*o+a+it(
8*o*4-g<
Anion ga)
A+teration in enoriaan' *enta+
3 !2"
.!2.5"
$2$
8<
8<
>aria%+e
3 $"
A+ert
3 !2"
."".!;
$" to $2
8<
8<
>aria%+e
3 $!A+ert4'roF(
3 !2"
0 .""
0 $"
8<
8<
>aria%+e
3$!St/)or4&o*a
3 1""
3 .5"
3 $
S*a++
S*a++
35!"
>aria%+eSt/)or4&o*a
8ADA, !""#<
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KESIMPULAN
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KESIMPULAN
DKA *er/)a-an -o*)+i-ai a-/t (ang ering 'ite*/-an)a'a DM ti)e $.
Ko*)+i-ai ini /ga 'ie%a%-an o+e %e%era)a 7a-tor)en&et/ (ang ter%an(a- a'a+a -arena in7e-i 'an
)engg/naan in/+in (ang ti'a- a'e-/at.
Ana*nea, )e*eri-aan i-, 'an )e*eri-aan)en/nang (ang %ai- 'a)at *enega--an 'iagnoa
'engan te)at )a'a DKA 'an DKA 'a)at egera 'itangani'engan tera)i &airan (ang agrei7 /nt/- tata+a-ana
aFa+ )a'a triae.
DKA 'an HHS 'a)at 'i%e'a-an *e+a+/i )e*eri-aan
)en/nang 'engan *ei+at ai+ BGA, Ser/* e+e-tro+it8o*o+a+ita<, 'an /rina+ii 8-eton<.
Ko*)+i-ai (ang *en(e%a%-an *orta+ita 'ie%%a-ano+e 7a-tor )en&et/n(a, e)erti in7e-i 'an *(o&ar'
in7ar&t. Se+ain it/ )a'a /ia t/a, *e*i+i-i )en(a-it gina+ata/ ant/ng, 'an -o*a *ening-at-an *or%i'ita
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TERIMA KASIH
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AGNER GRADING SYSTEM 6OR DIABETIC
6OOT IN6ECTION
" Inta&t S-in
$ /)er&ia+ /+&er o7 -in or /%&/taneo/ ti/e! /+&er eten' into ten'on, %one, or &a)/+e
5 'ee) /+&er Fit oteo*(e+iti or a%&e
; Gangrene o7 toe or 7ore7oot
2 Mi'7oot or in'7oot gangrene