Comprehensive Overview of Diabetes Management and Medical Emergencies: EMT Intermediate Refresher

1. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

2. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

3. Diabetes Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment MEDICAL EMERGENCIES

4. definition • Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both

5. description • Hyperglycemia further results in acute & chronic complications of the disease, leading to significant morbidity and mortality

6. description • American Diabetes Association (one of the following must be met): • Symptoms of diabetes & a causal plasma glucose >200mg/dL • Fasting plasma glucose >126mg/dL • Two-hour plasma glucose >200mg/dL during a 75g, 2-hr oral glucose tolerance test

7. description • Prediabetes • Impaired fasting glucose • 100-125mg/dL • Impaired glucose tolerance • 140-199mg/dL

8. epidemiology • 7% of the US population has diabetes • 5-10% Type 1 • 90-95% Type 2

9. epidemiology • T2DM prevalence among youth is rising • Old figure = 1 to 2% of diabetic children had T2DM • New figure = 8 to 45% of diabetic children have T2DM

10. types • The National Diabetes Data Group defines 4 major types of diabetes mellitus (DM) • Type 1 DM • Type 2 DM • Gestational Diabetes • Impaired Glucose Tolerance (Impaired fasting glucose)

11. New versus Old Names • Type 1 DM (aka: juvenile onset, insulin dependent diabetes mellitus) • Type 2 DM (aka: adult onset, noninsulin dependent diabetes mellitus)

12. pathophysiology • Type 1 Diabetes Mellitus • Abrupt failure of production of insulin • Parental insulin required to sustain life • Autoantibodies implicated in the cell-mediated autoimmune destruction of beta cells of the pancreas

13. Diabetic ketoacidosis (DKA) - initial onset hyperglycemia Polyuria Polydipsia Polyphagia Ketosis Osmotic diuresis Eventual coma - hypovolemia Type 1 DM

14. treatment • Type 1 Diabetes Mellitus • Insulin • SC injections • Pumps • Oral hypoglycemics • Insulin sensitizers with primary action in the liver • Metformin • Insulin sensitizers with primary action in peripheral tissues • Pioglitazone, rosiglitarzone • Insulin secretagogues • Repaglinide,, nateglinide • Carbohydrate absorption slowing agents • Acarbose, miglitol

15. complications • Type 1 Diabetes Mellitus • Complications • Hypoglycemia • Hyperglycemia • Retinopathy, neuropathy, nephropathy, CAD, CVA, “silent MI”

16. Pathophysiology Usually middle-aged or older, overweight Insulin deficiency (insulin secretory deficit) Impaired insulin function related to poor insulin production Failure of insulin to reach the site of action or, failure of end-organ response to insulin Type 2 DM

17. Initial onset Hyperosmalar Hyperglycemic Nonketotic Coma (HHNC) Polyuria Polydipsia Polyphagia Osmotic diuresis Eventual coma - hypovolemia Type 2 DM

18. Type 2 DM Treatment • Lower glucose levels on a consistent basis to normal or near normal • Lifestyle changes & metformin • Other oral antidiabetic agents • Insulin

19. Gestational Diabetes • Glucose intolerance of variable degree with onset or 1st recognition during pregnancy

20. Gestational Diabetes • Complications • Miscarriages • Birth defects • Growth acceleration & fetal obesity

21. Hypoglycemia ALOC Lethargy Confusion Combativeness Agitation Seizures Focal neurologic deficits Unresponsiveness Hypglycemia Anxiety Nervousness Irritability N/V Palpitations Tremor Sweating Bradycardia Salivation s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives

22. DKA • Diabetic ketoacidosis occurs primarily in patients with type 1 diabetes. • The incidence is roughly 2 episodes per 100 patient years of diabetes, with about 3% of patients with type 1 diabetes initially presenting with diabetic ketoacidosis. • It can occur in patients with type 2 diabetes as well; however, this is less common.

23. DKA • The most common scenarios for DKA are • underlying or concomitant infection (40%) • missed insulin treatments (25%) • newly diagnosed, previously unknown diabetes (15%) • Other associated causes make up roughly 20% in the various series.

24. HHNC • The incidence of hyperosmolar hyperglycemic state (HHS) is <1 case per 1000 person/year • making it significantly less common than DKA. As the prevalence of type 2 diabetes mellitus increases, the incidence of HHS will likely increase as well.

25. Physical Exam Findings, Diagnostic Findings, S/S, pertinent positives

26. Treatment • Hyperglycemia - DKA • Hyperosmalar Hyperglycemia Nonketotic Coma • Adults - All IVs macrodrip set (10-15 drops/ml) • Pediatrics All IVs measured-vol solution administration (Volutrol) • 0-6 yrs All IOs bolus with 60ml syringe, not Volutrol

27. Treatment • Hyperglycemia - DKA • Hyperosmalar Hyperglycemia Nonketotic Coma • Saline Lock or TKO: may generally use interchangeably if fluid or medication not currently required but may be in future (exceptions are noted in specific PROTOCOLS). • Saline locks avoid IV line entanglement during complex extrications, however TKO allows for immediate administration of fluids as needed

28. Treatment: DKA & HHNC • Maintenance fluids:stable pts with no contraindications to fluid (pulmonary edema): • Adults: 120ml/hr (macrodrip 1 drop q 2-3 sec) • Pediatrics: 2 ml/kg/hr or reference Broselow tape • Fluid challenge: • Adults (SBP80-100 or HR>100): 500ml bolus (recheck VS after bolus) • Pediatrics: bolus only - no challenge indicated

29. DKA & HHNC: Treatment • Fluid bolus: • Adults (SBP<80): 1-L bolus wide open under pressure • Repeat SBP <80: repeat bolus once, then contact base • Pediatrics: shock, indicated by protocol: 20ml/kg/bolus • If improvement: repeat bolus once then contact base

30. DKA & HHNC: Treatment • Pediatric Shock: SBP<(70+2x age in years) per PROTOCOL: PediatricParameters • In the case of fluid challenge or bolus: Contact base as soon as possible. If communication failure, continue per guidelines to a maximum of 3-L in adults and 60ml/kg in pediatrics

31. DKA & HHNC: Treatment Fluid Challenge or Bolus Procedure • Check vitals & lung exam after each fluid challenge/bolus • As vitals change refer back to the table above for fluid guidelines (I.e., initial SPB=80, give 1-L bolus; recheck SBP=90, give 500ml bolus; recheck) • If signs of pulmonary edema (crackles, respiratory distress, increased respiratory rate) develop during IV fluid administration, decrease to TKO & contact base for fluid orders

32. DKA & HHNC: Treatment • Notes • If PROTOCOL orders IV fluid, refer to this PROCEDURE for gauge, IV number, & fluid rate. If IV fluid orders differ from this it will be indicated in the specific protocol. • If it is likely that pt will not be transported, contact base prior to IV attempts

33. Treatment • Hypoglycemia • See ALOC protocol- Adult & Peds • Hyperglycemia • Support ABCs • Airway mtg | vomiting/aspiration prevention • Large bore IV • Fluids

34. Differential diagnosis • In the field: • Alcohol • Epilepsy • Insulin • Overdose • Uremia • Trauma • Infection • Psychosis • Stroke

35. Perspective • Pathophysiology • Epidemiology • Physical Exam Findings • Diagnostic Findings • Signs and Symptoms • Differential considerations • Treatment

36. Questions? • References • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.