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21. Endocrine Emergencies: Diabetes Mellitus - Hypoglycemia. 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.

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21

Endocrine Emergencies: Diabetes Mellitus - Hypoglycemia


Introduction
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.


Epidemiology cont d
Epidemiology (cont’d)

  • Type 1 diabetes mellitus

    • Autoimmune disease process

    • Characteristic to younger patients

    • Requires supplemental insulin

    • Prone to hypoglycemia and diabetic ketoacidosis (DKA)


Epidemiology cont d1
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)


Pathophysiology
Pathophysiology

  • Role of hormones in glucose regulation

    • Insulin and glucagon

    • Cellular metabolism of glucose


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


Pathophysiology cont d
Pathophysiology (cont’d) inability of glucose to get into the cell without insulin.

  • 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


Assessment findings
Assessment Findings inability of glucose to get into the cell without insulin.

  • General considerations

    • Findings can be broadly categorized

      • Hyperadrenergic – increases sympathetic tone

      • Neuroglucopenic – brain dysfunction from lack of glucose


Signs and symptoms of hypoglycemia
Signs and Symptoms of Hypoglycemia inability of glucose to get into the cell without insulin.


Assessment findings cont d
Assessment Findings (cont’d) inability of glucose to get into the cell without insulin.

  • 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.


Emergency medical care
Emergency Medical Care inability of glucose to get into the cell without insulin.

  • Keep airway patent; be alert for vomiting.

  • Place patient in lateral recumbent position.

  • Administer oxygen based on ventilatory needs.

    • Keep SpO2 >95%.


Emergency medical care cont d
Emergency Medical Care (cont’d) inability of glucose to get into the cell without insulin.

  • Administer oral glucose if criteria is met

  • Administer 50% dextrose if criteria is met


Hyperglycemia
Hyperglycemia inability of glucose to get into the cell without insulin.

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.


Introduction1
Introduction inability of glucose to get into the cell without insulin.

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.


Epidemiology
Epidemiology inability of glucose to get into the cell without insulin.

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.


Pathophysiology1
Pathophysiology inability of glucose to get into the cell without insulin.

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


Assessment findings1
Assessment Findings inability of glucose to get into the cell without insulin.

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


Kussmaul respirations
Kussmaul respirations inability of glucose to get into the cell without insulin.


Pathophysiology cont d1
Pathophysiology (cont’d) inability of glucose to get into the cell without insulin.

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


Assessment findings2
Assessment Findings inability of glucose to get into the cell without insulin.

HHNS

Slow progression of symptoms

Dehydration findings

Polyuria early, oliguria late

Changes in mental status

Possible seizure activity

Findings of volume depletion


Signs and symptoms of diabetic emergency conditions
Signs and Symptoms of Diabetic Emergency Conditions inability of glucose to get into the cell without insulin.


Signs and symptoms of diabetic emergency conditions1
Signs and Symptoms of Diabetic Emergency Conditions inability of glucose to get into the cell without insulin.


Treatment considerations
Treatment Considerations inability of glucose to get into the cell without insulin.

General considerations

Focus of hypoglycemia is the administration of glucose.

Focus of DKA and HHNS is rehydration of the patient.


Emergency medical care1
Emergency Medical Care inability of glucose to get into the cell without insulin.

Establish and maintain a patent airway.

Establish and maintain adequate ventilation.

Establish and maintain adequate oxygenation.

Assess blood glucose level.

Initiate intravenous therapy.


Case study
Case Study inability of glucose to get into the cell without insulin.

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.


Case study cont d
Case Study (cont’d) inability of glucose to get into the cell without insulin.

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.


Case study cont d1
Case Study (cont’d) inability of glucose to get into the cell without insulin.

What are some concerns you have based on the scene size-up?

What are possible conditions you suspect at this time?


Case study cont d2
Case Study (cont’d) inability of glucose to get into the cell without insulin.

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.


Case study cont d3
Case Study (cont’d) inability of glucose to get into the cell without insulin.

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?


Case study cont d4
Case Study (cont’d) inability of glucose to get into the cell without insulin.

Medical History

Unknown

Medications

Unknown

Allergies

Unknown


Case study cont d5
Case Study (cont’d) inability of glucose to get into the cell without insulin.

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.


Case study cont d6
Case Study (cont’d) inability of glucose to get into the cell without insulin.

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%.


Case study cont d7
Case Study (cont’d) inability of glucose to get into the cell without insulin.

Pertinent Secondary Assessment Findings (continued)

No other findings contributory to presentation.

Dried urine stains on patient's clothing and couch.


Case study cont d8
Case Study (cont’d) inability of glucose to get into the cell without insulin.

With this information, has your field impression changed at all?

What would be the next steps in management you would provide to the patient?


Case study cont d9
Case Study (cont’d) inability of glucose to get into the cell without insulin.

Care provided:

Patient placed in lateral recumbent position.

High-flow oxygen administered via NRB mask.

OPA kept in place, airway remained patent.


Case study cont d10
Case Study (cont’d) inability of glucose to get into the cell without insulin.

Care provided:

Intravenous therapy and fluid resuscitation.

Patient packaged and prepared for transport to hospital.


Case study cont d11
Case Study (cont’d) inability of glucose to get into the cell without insulin.

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


Summary
Summary inability of glucose to get into the cell without insulin.

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.


Summary1
Summary inability of glucose to get into the cell without insulin.

  • 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.


Summary cont d
Summary (cont’d) inability of glucose to get into the cell without insulin.

  • The Advanced EMT's goal is to recognize the type of diabetic reaction and provide appropriate care.


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