Endocrine Emergencies: Diabetes Mellitus - Hypoglycemia

1. 21 Endocrine Emergencies: Diabetes Mellitus - Hypoglycemia

2. Introduction • Diabetes mellitus (DM) is a condition in which the body no longer metabolizes glucose correctly. • This inability can lead to seriously high or low levels of blood sugar. • The Advanced EMT must quickly identify the problem and support lost function to reduce morbidity and mortality.

3. Epidemiology (cont’d) • Type 1 diabetes mellitus • Autoimmune disease process • Characteristic to younger patients • Requires supplemental insulin • Prone to hypoglycemia and diabetic ketoacidosis (DKA)

4. Epidemiology (cont’d) • Type 2 diabetes mellitus • Impaired insulin production • Impaired insulin effects • Commonly an adult onset • Associated with a higher BMI • Controlled through diet and oral pills • Prone to hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

5. Pathophysiology • Role of hormones in glucose regulation • Insulin and glucagon • Cellular metabolism of glucose

6. Glucose movement into the cell with insulin and the inability of glucose to get into the cell without insulin.

8. Pathophysiology (cont’d) • Hypoglycemia • Precipitating causes • Patients become symptomatic when BGL falls to 40-50 mg/dL • Brain most sensitive to low levels of glucose • Body then releases additional hormones aimed at trying to raise glucose back up

9. Assessment Findings • General considerations • Findings can be broadly categorized • Hyperadrenergic – increases sympathetic tone • Neuroglucopenic – brain dysfunction from lack of glucose

10. Signs and Symptoms of Hypoglycemia

11. Assessment Findings (cont’d) • Other notable assessment characteristics • Hypoglycemia may occur suddenly. • Hypoglycemia may present like a stroke. • Once referred to as “insulin shock” as many presentation findings mirrored hypovolemic shock.

12. Emergency Medical Care • Keep airway patent; be alert for vomiting. • Place patient in lateral recumbent position. • Administer oxygen based on ventilatory needs. • Keep SpO2 >95%.

13. Emergency Medical Care (cont’d) • Administer oral glucose if criteria is met • Administer 50% dextrose if criteria is met

14. Hyperglycemia Review the frequency with which hyperglycemic emergencies occur. Discuss the etiologies of hyperglycemia. Discuss physiology and pathophysiology of hyperglycemic episodes. DKA and HHNS Review appropriate treatment strategies.

15. Introduction Hyperglycemic episodes are at the opposite end of diabetic emergencies. DKA or HHNS must be considered in all patients with altered consciousness. History of onset and monitored BGL levels are the best way to differentiate hyperglycemic episodes from other problems.

16. Epidemiology DKA is more common in Type 1 DM. HHNS is more common in Type 2 DM. HHNS occurs with higher frequency than DKA does, and is more prevalent in females. Mortality rates can be 10-20% in hyperglycemic emergencies.

17. Pathophysiology Diabetic ketoacidosis (DKA) A relative of absolute insulin deficiency. BGL rises greater than 300 mg/dL. The brain has plenty of glucose, but the body cannot use it without insulin. Progression produces: Metabolic acidosis Osmotic diuresis Electrolyte disturbance

18. Assessment Findings Diabetic ketoacidosis Slow change in mental status History and findings consistent with severe dehydration Nausea and vomiting, abdominal pain Fatigue, weakness, lethargy, confusion Kussmaul respirations

19. Kussmaul respirations

20. Pathophysiology (cont’d) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Severe elevations in BGL (>600 mg/dL) Some insulin still present Not enough or not effective Changes in physiology Osmotic diuresis Electrolyte disturbance No ketogenesis

21. Assessment Findings HHNS Slow progression of symptoms Dehydration findings Polyuria early, oliguria late Changes in mental status Possible seizure activity Findings of volume depletion

22. Signs and Symptoms of Diabetic Emergency Conditions

23. Signs and Symptoms of Diabetic Emergency Conditions

24. Treatment Considerations General considerations Focus of hypoglycemia is the administration of glucose. Focus of DKA and HHNS is rehydration of the patient.

25. Emergency Medical Care Establish and maintain a patent airway. Establish and maintain adequate ventilation. Establish and maintain adequate oxygenation. Assess blood glucose level. Initiate intravenous therapy.

26. Case Study You are called one afternoon to evaluate an elderly female patient at home. Upon arrival PD is on scene and has forced entry into the home based on the neighbor saying that the elderly occupant has not been seen for days. You find the patient lying on the couch, dried vomit on the face, with loud sonorous respirations.

27. Case Study (cont’d) Scene Size-Up Standard precautions taken. Scene is safe, no entry or egress problems. One patient, elderly female, looks unresponsive on the couch. NOI is unknown mental status change. No signs of struggle or trauma.

28. Case Study (cont’d) What are some concerns you have based on the scene size-up? What are possible conditions you suspect at this time?

29. Case Study (cont’d) Primary Assessment Findings Patient does not respond to painful stimuli. Sonorous respirations. Breathing is tachypneic with alveolar breath sounds. Peripheral perfusion absent; skin dry, carotid pulse present. No indication of significant trauma.

30. Case Study (cont’d) Is this patient a high or low priority? Why? What are the life threats to this patient? What emergency care should you provide based on the primary assessment findings?

31. Case Study (cont’d) Medical History Unknown Medications Unknown Allergies Unknown

32. Case Study (cont’d) Pertinent Secondary Assessment Findings Pupils midsize and midposition. Airway now maintained with OPA. Breathing still adequate, rate fast. Carotid pulse present, peripheral perfusion absent. Skin cool and dry, tongue furrowed, membranes pale.

33. Case Study (cont’d) Pertinent Secondary Assessment Findings (continued) B/P 84/64, heart rate 128, respirations 30/min. Finger prick test of BGL reveals 860 mg/dL. Pulse oximeter intermittently reading 94%.

34. Case Study (cont’d) Pertinent Secondary Assessment Findings (continued) No other findings contributory to presentation. Dried urine stains on patient's clothing and couch.

35. Case Study (cont’d) With this information, has your field impression changed at all? What would be the next steps in management you would provide to the patient?

36. Case Study (cont’d) Care provided: Patient placed in lateral recumbent position. High-flow oxygen administered via NRB mask. OPA kept in place, airway remained patent.

37. Case Study (cont’d) Care provided: Intravenous therapy and fluid resuscitation. Patient packaged and prepared for transport to hospital.

38. Case Study (cont’d) In a patient with this field impression, discuss why the following findings were present: Decrease in mental status Tachycardia Dry skin and furrowed tongue Low blood pressure High glucose level

39. Summary Hyperglycemia can be recognized by its onset and elements of dehydration. Although the Advanced EMT's treatment of this problem is supportive in nature, immediate initiation of intravenous therapy can allow for rehydration to begin during transport to the hospital.

40. Summary • Diabetic patients are a fairly common type of patient seen by the Advanced EMT. • Based on the type of diabetes they have, the resulting emergency may cause high or low levels of glucose to develop.

41. Summary (cont’d) • The Advanced EMT's goal is to recognize the type of diabetic reaction and provide appropriate care.