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Diabetic Emergencies. Not too Sweet – Not too Sour. What is Diabetes?. Diabetes Mellitus – a disorder of Insulin. Diabetes Mellitus. Type I – insulin dependent Usually starts at an early age Caused by autoimmune destruction of Beta cells No insulin production at all No Insulin = Death

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diabetic emergencies

Diabetic Emergencies

Not too Sweet – Not too Sour

what is diabetes
What is Diabetes?
  • Diabetes Mellitus – a disorder of Insulin
diabetes mellitus
Diabetes Mellitus
  • Type I – insulin dependent
    • Usually starts at an early age
    • Caused by autoimmune destruction of Beta cells
    • No insulin production at all
    • No Insulin = Death
    • 1922 – first successful use of insulin to treat kids with DKA – always fatal up until that point.
    • Currently – insulin pumps and various types of insulin are state of the art in treatment for Type I DM.
diabetes mellitus1
Diabetes Mellitus

Type II – insulin resistant

  • Obesity, sedentary lifestyle
  • Beta blockers, glucocorticoids, thiazides
  • 90% of all diabetes in US
  • Insulin is unable to do its work
  • Dietary changes, medications or insulin may be needed
  • Usually does not cause DKA
diabetes mellitus2
Diabetes Mellitus
  • Gestational Diabetes
    • Occurs during pregnancy
    • Resolves with delivery most of the time.
    • Due to hormone levels and obesity
insulin
Insulin
  • What is Insulin?
    • A hormone made by Beta cells in the Pancreas
    • Insulin works on multiple cells to regulate blood Glucose levels
    • Muscle – prevents protein breakdown
    • Adipose tissue – increases fat production
    • Liver – increased glycogen synthesis
    • Increased glucose and amino acid uptake
    • Inhibits Glucagon production
effects
Effects
  • Vasculopathy- Vascular damage
effects1
Effects
  • Nephropathy - Kidney Damage
effects2
Effects
  • Neuropathy – nerve damage
effects3
Effects
  • Retinopathy – eye damage
effects4
Effects
  • Diabetic Ketoacidosis
effects5
Effects
  • Hypoglycemia – caused by treatment
medications used in treating diabetes
Medications used in Treating Diabetes
  • Antihyperglycemics – stimulate insulin production
    • Sulfunylureas – Diabinese, Glucotrol, Diabeta, Amaryl
    • Meglitinides – Prandin, Starlix
  • Antihyperglycemics – do not stimulate insulin
    • Biguanide – Metformin – Lactic acidosis
    • Thiazolidinediones – Avandia, Actos
    • Alpha-glucosidase inhibitor – Precose, Glyset
    • DPP-4 Inhibit – Januvia, Onglyza
hypoglycemia
Hypoglycemia
  • The brain MUST have glucose to function
  • Brain is not affected by insulin.
  • Normal blood sugar levels range from 70-100
  • Low blood sugar can be caused by
    • Taking insulin when you cannot eat or forget to eat
    • Intentionally overdosing on insulin
    • Taking the wrong type
    • Exercising more than normal and not adjusting diet
    • Certain diabetes medications, but not all
    • Infections/illness which prevent eating
hypoglycemia1
Hypoglycemia
  • Clinical symptoms
    • Lethargy
    • Unconsciousness
    • Stroke-like symptoms (especially in those with prior strokes)
    • Seizures
    • Trouble speaking
    • Confusion
    • Cardiac Arrest
hypoglycemia2
Hypoglycemia
  • Testing
    • Fingerstick blood sugar
      • Make sure machine gets calibrated regularly
      • Make sure you have the right test strips that are not expired
      • Clean finger off with alcohol
      • Prick side of finger with lancet
      • Squeeze finger (milk it) to get enough to cover testing area
      • Read machine when test is complete
hypoglycemia3
Hypoglycemia
  • Treatment – Glucose!
    • IV Dextrose – AEMTs/Paramedics
      • Adults – 50% 1 ampule (50ml = 25gm)
      • Children – 25% 2ml/kg
      • Neonates – 12.5% - 1ml/kg
    • Oral Glucose – EMR/EMTs
      • Must have gag reflex and be alert to avoid aspiration/choking
    • Glucagon – for adults
      • 1-2 mg IM if cannot get an IV
dextrose
Dextrose
  • Class – carbohydrate
  • Mechanism – provides metabolic substrate
  • Contraindications
    • Absolute – None
    • Relative – hyperglycemia
  • Dosage – 50ml of D50, repeat x1 if needed
    • Peds – 2ml/kg of D25
    • Neonates – 1ml/kg of D12.5
glucagon
Glucagon
  • Class – hormone
  • Mechanism – stimulates glycogen breakdown in the liver and muscle, increasing glucose levels
  • Contraindications
    • Absolute - sensitivity
    • Relavtive – starvation, fasting, adrenal insufficiency
  • Uses – hypoglycemia, beta-blocker overdose, calcium channel overdose, anaphylaxis (for folks on beta-blockers)
  • Dosage – hypoglycemia – 1mg IV/IM Q20 min; beta-antagonist OD – 3-5mg IV; anaphylaxis 1-2mg IV
    • Kids - <20kg – 0.5mg IV/IM; >20mg – 1mg IV/IM
  • Side effects – Nausea, vomiting, diaphoresis, hypotension, rash
meter is broken
Meter is broken…
  • Get as much history as possible.
  • Smell for ketones (only half of us can)
  • Are there empty insulin bottles on scene? Recent exercise or illness?
  • Err on the side of treating for hypoglycemia
slide26
DKA
  • No insulin activity = high blood sugar levels
    • Can’t make glycogen, fatty acids and cannot move glucose into cells  Cells starve  Fatty Acid breakdown  Ketosis
    • High blood sugar  sugar in urine  peeing a lot  dehydration  acidosis
    • Diabetic Ketoacidosis!
      • Fruity odor to breath
      • Increased respiratory rate
      • Abdominal pain
      • Nausea/Vomiting
      • Tachycardia / hypotension
hyperglycemia
Hyperglycemia
  • Low Insulin activity = high blood sugars
    • Still able to get some glucose in cells = no starvation = no ketosis
    • Acidosis also less likely
    • No fruity odor
    • Generalized weakness
    • Less nausea/vomiting
    • Death very rare
hyperglycemia1
Hyperglycemia
  • Treatment
    • ABC’s
    • IV fluids!
      • Adults – 500ml – 1 liter WO
      • Children – 20ml/kg fluid boluses
      • May repeat if needed for hypotension or tachycardia
what abou t insulin pumps
What about Insulin Pumps
  • If hypoglycemia – have patient turn off pump after you wake them up with D50
  • If hyperglycemia – don’t touch it
    • May not be working
    • Patient may be able to do a bolus on their own based on their sliding scale
  • If infected, leave in place, but do not use.
alcoholic ketoacidosis
Alcoholic Ketoacidosis
  • Chronic Alcoholics are malnourished
    • Few glycogen stores
  • After a binge, their glucose levels can drop, stimulating fatty acid breakdown
  • Treatment is glucose with Thiamine
    • Don’t withhold glucose if level is abnormal!
you wanna refuse
You wanna refuse?
  • While people have a right to make their own decisions, it must be an INFORMED decision
  • They must:
    • Be alert, oriented to person, place, time, and situation
    • Know of the risk for relapse
    • Have recovered within 10 minutes. FSBS >80
  • They should
    • Have test strips available or have someone there to call back if they get hypoglycemic again.
    • Have adequate follow-up.
questions
Questions
  • A diabetic’s family calls 911 for sudden onset of left sided weakness that started 10 minutes prior to arrival. After ABCs, what is your next step?
questions1
Questions
  • A Diabetic teen-ager decides to say “f&^% you” to his diet, and eats an ice cream sundae. A day later, he calls 911 for vomiting and abdominal pain. His Glucose on fingerstick reads “Hi” What should you give?
questions2
Questions
  • You come across a “local regular” beside the bar. He smells of alcohol, and is lethargic. He looks like he hasn’t been eating regularly for quite some time. You consider _____ as a possible diagnosis, and _________