User:Bron766/My Portfolio/BSL

Here are some big teaching points that need activities designed around them:
 * Hypoglycemic patients can be confused, irritable and resistant to taking oral glucose. Recognise this as a symptom and find a way to treat it.
 * Insulin overdose:
 * How to manage insulin overdose (including deliberate) - case study, another case study
 * Fatal mistakes: Drawing up the wrong dose of insulin by using the wrong type of syringe (or incorrect concentration calculation)
 * Analyse what went wrong in several fatal overdoses: 10x dose here, 10x dose here, 10x dose here, ?illiterate and wrong syringe here, wrong syringe here, 100x dose here
 * Note differences in scale on tuberculin 1mL syringe and insulin syringe below:
 * [[Image:Three types of syringes.jpg|x250px]][[Image:Comparing_insulin_and_tuberculin_syringes.jpg|x250px]]
 * Real world challenge: can you think of a better way to stop people making these mistakes again?

Other ideas:
 * Managing DKA - the enemies are ketones, the aim is to replace the missing insulin. Theory, protocols, pitfalls.
 * Managing perioperative/fasting diabetics - including continuing basal insulin...
 * Glossary of insulins?
 * Medications affecting blood glucose
 * BSL chart analysis, which insulin to adjust
 * Giving insulin and dextrose for hyperkalemia is high risk for errors


 * reference=

Normal blood sugar
The most important blood sugar seems to be glucose. Extension Q: Are we missing something by concentrating only on glucose? What is the importance of the other blood sugars, like fructose, galactose, sorbitol, xylose or maltose?
 * What is the normal range?
 * How do you measure blood glucose?
 * technique, contaminants (skin or IV line)
 * Extension: arterial or venous, does it differ?

Low blood glucose
1. Identify when there is a problem with low blood glucose

Actions to take
 * Who can you call for help if you identify someone with hypoglycemia?



2. Treat symptomatically 3. Find and treat cause
 * Oral glucose
 * IV glucose
 * Glucagon
 * Excess insulin or sensitivity to insulin (Basic principle: body excess is due to increased input, decreased output or shift between body compartments).
 * Exogenous = common (insulin or oral hypoglycemics)
 * Endogenous = rare (insulinoma, other tumours eg retroperitoneal sarcoma... Salicylates?)
 * Also note the ongoing debate re: reactive / postprandial hypoglycemia... Whipple's triad may be useful to distinguish these types.
 * Lack of opposing hormones
 * Low cortisol or GH (Addison's etc, hypopituitarism)
 * Glucagon/catecholamines too
 * Lack of glucose
 * Lack of input
 * Failure to metabolise carbohydrates to replenish blood glucose (eg acute alcohol ingestion, lack of glycogen stores in liver disease, metabolic failure in hereditary Galactosemia/fructose intolerance/glycogen storage diseases)

4. Anticipate future problems, prevent recurrence and manage complications
 * Potassium
 * Absorption/metabolism/excretion profiles of insulins vs glucose vs complex carbohydrates
 * Planning diabetic adjustment of insulin on sick days...
 * Complications of recurrent hypoglycemia
 * Choosing the wrong syringe type, leading to overdose
 * Manage intentional overdoses

High blood glucose
1. Identify when there is a problem with high blood glucose
 * Symptomatic hyperglycemia and its symptoms, signs and effects
 * Asymptomatic hyperglycemia (and evidence for treating it due to long term effects)
 * Read about the ongoing debate regarding tight vs loose control in hospital...
 * DKA and HONK

2. Treat symptomatically 3. Find and treat cause (Basic principle as above: body excess is due to increased input, decreased output or shift between body compartments). 4. Anticipate future problems, prevent recurrence and manage complications
 * Insulin
 * Rehydration
 * Oral hypoglycemics...
 * Excess input of glucose (obesity)
 * Excess of opposing hormones
 * High cortisol or GH(Cushings's etc, hyperpituitarism, acromegaly),
 * Consider glucagon/catecholamines too (phaeo, shock, seizures...)
 * Lack of insulin or sensitivity to insulin (diabetes mellitus)
 * Learn how to diagnose diabetes mellitus type 1, 2, prediabetes, gestational etc.
 * OGTT here?
 * Consider renal threshold here?
 * Potassium
 * Complications of a lack of insulin: DKA.
 * Micro and macrovascular complications of diabetes
 * Comorbidities: associated autoimmune diseases e.g. pancreas and thyroid (and similarities in presentation of thyrotoxicosis and diabetes, though hypothyroid may be hypothyroidism), also celiac disease
 * Anticipate changing insulin requirements with changes in feeding/fasting, medications (especially steroids) or during recovery from sepsis