Section 6Chapter 18:

Diabetic Emergencies

CWI AEMT Course Robert S. Cole

Endocrine Glands Controls many body functions

› exerts control by releasing special chemical substances into the blood called hormones

› Hormones affect other endocrine glands or body systems

Ductless glands Secrete hormones directly into

bloodstream› Hormones are quickly distributed by

bloodstream throughout the body

Hormones Chemicals produced by endocrine

glands Act on target organs elsewhere in body Control/coordinate widespread

processes:• Homeostasis• Reproduction• Growth & Development• Metabolism• Response to stress• Overlaps with the Sympathetic Nervous System

Hormones

Hormones are classified as:› Proteins› Polypeptides (amino acid derivatives)› Lipids (fatty acid derivatives or

steroids)

Hormones

Amount of hormone reaching target tissue directly correlates with concentration of hormone in blood.› Constant level hormones

Thyroid hormones› Variable level hormones

Epinephrine (adrenaline) release Insulin

› Cyclic level hormones Reproductive hormones

The Endocrine System Consists of several glands located in

various parts of the body Specific Glands

› Hypothalamus› Pituitary› Thyroid› Parathyroid› Adrenal› Kidneys› Pancreatic Islets› Ovaries› Testes

Endocrine Disorders and Emergencies

Primarily consist of:› Disorders of the Pancreas› Disorders of the Thyroid Gland› Disorders of the Adrenal Glands

Key POINT:

The Endocrine System is the control mechanism for the autonomic functions of the body.

Disorders of the Pancreas

What is the Pancreas?

The pancreas is a dual purpose gland organ in the digestive system and endocrine system of vertebrates.

It is both an endocrine gland producing several important hormones, including insulin, glucagon, somatostatin, and pancreatic polypeptide, and a digestive organ, secreting pancreatic juice containing digestive enzymes that assist the absorption of nutrients and the digestion in the small intestine.

These enzymes help to further break down the carbohydrates, proteins, and lipids in the chyme.

The Pancreas

Pancreas

Produces 3 types of cells:› Alpha (α)› Beta (β)› Delta (δ)

Alpha Cells (α)

Alpha () cells release glucagon to RAISE blood glucose level and stimulate glycogenolysis› When blood glucose levels fall, cells the

amount of glucagon in the blood› The surge of glucagon stimulates liver to

release glucose stores by the breakdown of glycogen into glucose (glycogenolysis)

› Also, glucagon stimulates the liver to produce glucose (gluconeogenesis)

Beta Cells (β)

Stimulate the release of insulin to Lower the blood glucose level

Beta Cells () release insulin (antagonistic to glucagon) to control blood glucose level› Insulin the rate at which various body cells

take up glucose insulin lowers the blood glucose level

› Promotes glycogenesis - storage of glycogen in the liver

› Insulin is rapidly broken down by the liver and must be secreted constantly

Delta Cells (δ)

Delta Cells () produce somatostatin, which inhibits both glucagon and insulin› inhibits insulin and glucagon secretion by the

pancreas› inhibits digestion by inhibiting secretion of

digestive enzymes› inhibits gastric motility› inhibits absorption of glucose in the intestine

The Role of Glucose and Insulin

Glucose is a major source of energy for the body.

Insulin is needed to allow glucose to enter cells (except for brain cells).› A “cellular key”

The Role of Glucose and Insulin

The Role of Glucose and Insulin

When glucose is unavailable, the body turns to other energy sources.› Fat is most abundant.

› Using fat for energy results in buildup of ketones and fatty acids in blood and tissue.

The Role of Glucose and Insulin

Diabetic ketoacidosis (DKA)› A form of acidosis seen in uncontrolled

diabetes

› Without insulin, certain acids accumulate.

› More common in type 1 diabetes

› Signs and symptoms: Weakness Nausea

Diabetes

Diabetes affects the body’s ability to use glucose (sugar) for fuel.

Occurs in about 7% of the population Complications include blindness,

cardiovascular disease, and kidney failure.

KEY POINTThe central problem in diabetes is lack, or ineffective action, or resistance to, of insulin.

Hypoglycemia, the most common diabetic emergency seen in EMS, is simply the result of over-correction of this problem, the result of loss of balance in the endocrine system, but is not the key problem with diabetes.

Diabetes

As an EMT, you need to know signs and symptoms of blood glucose that is:› High (hyperglycemia)

› Low (hypoglycemia)

Central problem in diabetes is lack, or ineffective action, of insulin.

Types of Diabetes Mellitus

Type I Type II Secondary Gestational

KEY POINT

The term “Insulin Dependent” and “non-Insulin Dependent” are no longer accurate definitions of Type I and Type II Diabetes.

Type I diabetics are now being occasionally prescribed anti-hyperglycemics as well as insulin; and Type 2 diabetics are (occasionally) being prescribed insulin in addition to their oral meds.

Type 1 Diabetes Mellitus

Type 1 patients do not produce insulin at all.› Need daily injections of insulin

› Typically develops during childhood

› Patients more likely to have metabolic problems and organ damage

› Considered an autoimmune problem

Type 1 Diabetes

More than 90% of children with diabetes suffer from Type 1 diabetes (previously known as insulin-dependent diabetes).

The body loses the ability to make insulin. This occurs when the immune system destroys the insulin-producing cells.

As a result of this attack, these cells stop making insulin over time.

Type 2 Diabetes Insipidus

Type 2 patients produce inadequate amounts of insulin, or normal amount that does not function effectively.› Usually appears later in life

› Treatment may be diet, exercise, oral medications, or insulin.

Key Point:

Type 1 and type 2 diabetes both:› Are equally serious

› Affect many tissues and functions

› Require life-long management.

New Onset Diabetes?

About 25% of new onset Diabetes (Type I) are discovered due to a DKA type event.

Type 2 Diabetes, by contrast is typically discovered during health screenings or other routine medical evaluations.

This DOES NOT IMPLY that Type 2 is less severe than Type 1. › Both can be fatal if

untreated/unrecognized.

Types of Diabetes

Secondary Diabetes : Pre-existing condition affects pancreas and its function› Pancreatitis› Trauma› Shock States› Cystic Fibrosis

Occurs during pregnancy› Usually resolves after delivery

Types of Diabetes Definition: Onset of diabetes with pregnancy. Most women need two to three times more insulin

when they are pregnant than they usually do. In gestational diabetes, there are often no warning

symptoms. All pregnant women need to be tested for diabetes during the second trimester. This is especially important for women who are already at risk.

After the baby is born, blood glucose levels usually return to normal. A woman who has had gestational diabetes is at risk for developing type 2 diabetes later in life.

No Pregnant?› Occurs rarely in non-pregnant women on BCPs› Increased estrogen, progesterone from BCPs

antagonize endogenous insulin

New Onset Diabetes?

Classic symptoms of uncontrolled diabetes (“3 Ps”):› Polyuria: frequent, plentiful urination

› Polydipsia: frequent drinking to satisfy continuous thirst

› Polyphagia: excessive eating

This is why we check a Bgon 90% of IV starts….

Monitoring Blood Glucose

Source: Accu-Chek® Aviva used with permission of Roche Diagnostics.

Blood glucose monitoring kit

Monitoring Blood Glucose

Perhaps the single most important factor in a diabetics health is how well they monitor their own BG.

Severity of diabetic complications depends on patient’s average blood glucose level.

Glucose Monitors Facts

Personal use: Calibrated Monthly (rare) For EMS use: Calibrated WEEKLY Most have a chip which need to be

changed with EVRY BOTTLE OF NEW STRIPS

Affected by temp Affected by time (samples must be

applied w/in 30 –60 seconds)

Blood Glucose Monitoring

Should be done daily or more often. When done by EMS, should be done in

the opposite ext. as D50 was given. Venous blood usually runs about 10

mg/dl higher than capillary blood.

Checking the Blood Glucose Level (BG)

› Glucometers are commonly found on EMS units.

› Determines the amount of glucose in the blood, the sample usually coming from a finger stick.

› Glucose is measured in milligrams per deciliter (mg/dl).

› A normal range is 80-120 mg/dl.› Hypoglycemia is a BGL <60 mg/dl.› Hyperglycemia is a BGL >150 mg/dl.

Typically not significant until greater than 250. Often not symptomatic until greater than 400 (not always true)

Benefit Of Frequent Testing

Breakfast

100 (5.6)

200 (11)

400 (22)

300 (17)

DinnerLunch Bed

1 test versus 7 tests a day

Testing Frequency In a Kaiser study of actual

prescription fulfillment among 44,181 patients with diabetes:› 60% of Type 1s were not testing

3-4 times a day as recommended by the ADA

› 67% of Type 2s were not testing once a day as recommended by the ADA

Diabetes Care 23:477-483, 2000

Why Aren’t People Testing?

Lack of understanding No direct /immediate reward/benefit No mechanism for long-term benefit No link to cause of BG problems Finger-pricking required (NOT FUN) No guidance for lowering highs No easy way to record other things

$2,000 a year for 7 x a day testing

LOG BOOKS:

Can be very useful in reviewing a patients control

What are the numbers?

Low: <60mg/dl (<3.0 mmol/L) Normal: 60-150mg/dl (3.0-8.0 mmol/L)

› Some recommend 120 mg/dl Hyperglycemic: >150 (>8.0 mmol/L) DKA usually seen at 250-500mg/dl

mmol/L vs. mg/dl

What is an MMOL? It is a unit of measurement commonly

used in chemistry based on the molecular weight of the substance it pertains to.

To convert mmol/l of glucose to mg/dl, multiply by 18. To convert mg/dl of glucose to mmol/l, divide by 18 or multiply by 0.055.

Hemoglobin A1c

Hg A1c is a 3 month Average of blood glucose control In the normal 120-day lifespan of the red blood cell,

glucose molecules react with hemoglobin, forming glycated hemoglobin. In individuals with poorly controlled diabetes, the quantities of these glycated hemoglobins are much higher than in healthy people.

Once a hemoglobin molecule is glycated, it remains that way. A buildup of glycated hemoglobin within the red cell, therefore, reflects the average level of glucose to which the cell has been exposed during its life-cycle. Measuring glycated hemoglobin assesses the effectiveness of therapy by monitoring long-term serum glucose regulation. The HbA1c level is proportional to average blood glucose concentration over the previous four weeks to three months.

Some researchers state that the major proportion of its value is related to a rather shorter period of two to four weeks.

A1c: the Numbers

 In general, the normal range (that found in healthy persons), is about 4%–5.9%

The 2010 American Diabetes Association added the A1c ≥ 6.5% as another criterion for the diagnosis of diabetes, but this is controversial and has not been universally adopted.

Target criteria for DM is typically 6-7% In diabetes , higher amounts of glycated

hemoglobin, indicating poorer control of blood glucose levels, have been associated with cardiovascular disease, nephropathy, and retinopathy.

Monitoring the HbA1c in type-1 diabetic patients may improve treatment.

Common Diabetic Emergencies

Hyperglycemia and Hypoglycemia

Both lead to diabetic emergencies. Hyperglycemia: Blood glucose is above

normal.› Result of lack of insulin› Untreated, results in DKA

Hypoglycemia: Blood glucose is below normal.› Untreated, results in unresponsiveness and

hypoglycemic crisis Signs and symptoms of hyperglycemia and

hypoglycemia are similar if your assessment is shoddy…..

Hypoglycemia

“Looks Shocky” used to be called Insulin shock. Pale, diaphoretic, altered mental tatus. May Vomit.

BG <60mg/dl Reality is this is a hypoglycemic state,

not a shock state.

Hypoglycemia:Definitions

“Mild”: Adrenergic (BG<60) (<4mmol)

“Moderate”: Cognitive (BG<50) (<3mmol)

“Severe”: Neurologic Unconscious (BG ???)

Hypoglycemia More common with Type I diabetics Most common complication of diabetes

mellitus seen by EMS› Most common cause of coma in the diabetic

patient

Common Causes

Common history is taking insulin:› And then not eating a meal› Eating a meal, but having heavier exertion than

normal› Taking too much insulin and depleting the

glucose levels in the body Also caused by Medication Interactions

› Beta Blockers (High Blood Pressure Meds) Change in exercise Recent illness

Hypoglycemia

Treatment for Hypoglycemia

Food (simple and Complex Carbs) Oral Glucose IV Dextrose Glucagon

Carbs!!!!!

Oral Glucose

Class: Simple Carbohydrate MOA: A heavy sugar gel that is absorbed across the

mucosal membranes of the mouth and the GI tract, and enters the blood stream.› Increases the BGL by providing sugar available for the

brain. Indications: Only administer if the following criteria are

met (all three must be met): The patient has an altered mental status. There is a history of diabetes controlled by

medications. The patient is responsive enough to swallow and

control their own airway. DOSE: 15-45 GM’s PO

IV Dextrose

IV Dextrose (D50) 12.5-50 GM SIVP

Consider mixing in a bag of 250cc and run in.

Always administer slowly….

Glucagon

MOA: Enzyme that promotes/stimulates gylcogenisis

Works opposite of insulin.› Primary action is to raise the

BGL if it becomes lower than normal (<60mg/dl).

› Helps the liver to release stored glycogen back into the bloodstream, where it is again restored to the simple sugar glucose (during a process called glycogenolysis).

DOSE: Glucagon 1-5 units IV or IM. (Uses stores in liver)› Sometimes patients have their

own glucagon. Route: IM or occasionally IV 1-5

units

OK…. their awake, NOW What?

When awake: f/u with complex carbohydrates (food)

Ensure that someone will be with the pt.

Assess for and treat hypothermia (common)

R/O other problems (trauma). Pt must be fully CA&O.

Consider T/R if desired after contact with medical control or per protocol

Releasing the (formerly Hypoglycemic) Diabetic

The Ada County Protocol:“APPENDIX V: TREAT AND RELEASE CHECK SHEET FOR HYPOGLYCEMIC

PATIENTS.”

11 Questions:

1. Is there a clear reason for the hypoglycemic episode? 2. Is the patient alert and oriented? 3. Is the patient’s repeat BG above 80 mg/dl? 4. Has the patient’s BG been well-controlled prior to this

episode? 5. Is the patient able to eat a complex carbohydrate meal? 6. Does the patient have regular, on-going physician care? 7. Is the patient comfortable with non-transport? 8. Is the patient/guardian willing to sign a release form? 9. Is there another responsible person with the patient? 10. Is the patient’s temperature within normal limits? (95°

to 100.4° Fahrenheit) 11. The patient is free of the influence of alcohol or other

CNS-altering drugs?

KEY POINTS:

Hypoglycemia is an Altered LOC (ALOC) emergency until proven to be hypoglycemia. › In other words, don’t get surprised by other

causes, i.e. CVA, Alcohol, drugs, etc

Insulin Pumps

Insulin Pumps

Patent issued September 14,

1971

for theAmes Reflectance

Meter

Classic Pump Features

More physiologic insulin delivery to mimic the pancreas

Basal: steady background insulin delivery to keep BG from rising while fasting

Bolus: spurts of insulin to cover carbs or lower high BGs

Pumps Offer More Normal Lifestyle

Liberalization of diet — timing & amount (by user)

Increased control with exercise (by user)

Able to work shifts & through lunch (by user)

Less hassle with travel and time zones (by user)

Aid to weight control (by user) Less anxiety in trying to keep on schedule (by

user)

Why a pump?Better Control Reduces Complications

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Retinopathy

Progression

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1. DCCT Research Group, Ophthalmology. 1995;102:647-661

2. DCCT Research Group, Kidney Int. 1995;47:1703-1720

3. DCCT Research Group. Ann Intern Med. 1995;122:561-568.

Problems with Pumps

Smart Pump – Boluses

Carb bolusesAccuracy improved with personal

carb factor adjusted for different times of day

Personal carb database Correction boluses

Personalized correction factors for different times of day

Safer correction of high BGsReports amount of correction bolus used (ie,

over 8% of TDD)

An accurate TDD --> accurate basals & boluses

Carb Bolus Assistance

Each manufacturer provides bolus dose recommendations differently.

Bolus on Board? Dose Size Affects Duration

As bolus size increases, so too does duration of action.

Woodworth et al. Diabetes. 1993;42(Suppl. 1):54A

Smart Pump – Bolus On Board

Bolus On Board (BOB)› Discounts bolus for residual

BOB› Improves accuracy› Avoids stacking of bolus

insulin› Acts as guide to whether

carbs or insulin are needed, ie, BG is 130 mg/dl but BOB = 5 u

Requires a blood sugar test, an accurate duration of insulin action, and BG targets

Prevents hypoglycemia!

Smart Pump – Reminders

Reminders (alarms) to› test glucose following a

bolus› test glucose after a low

reading› test glucose after a high

reading› give a bolus at certain

time of day› warn when bolus delivery

was not completed, etc.› change infusion site

Meter Talks to Pump

108

Pump And Meter Combos Direct glucose entry into database eliminates

data errors and offers optimum use of glucose/insulin data

• AccuChek Spirit + meter• CozMore System +

Therasense CoZmonitor• Soill Diabecare III pump +

meter • Medtronic 515/715 +

BD Paradigm Link• Soon: Animas + ? Lifescan

or Glucowatch

Gluco-watch

A watch type device worn for about 13 hours/day.

Uses a disposable pad and minute bioelectric charge to read glucose readings as often as every 10 minutes.

Is effected by sweat (poor readings) Is a supplement to (not a replacement

for ) normal glucometer readings. Downloadable info.

Glucowatch

GlucoWatch® BiographerFirst To Receive FDA Approval

Medtronic Guardian RT

Real time readings Add-on to routine BG

monitoring Radio communication

from sensor to monitor High and low glucose

alarms FDA pending

Caution: Investigational Device.Limited by U.S. Law to Investigational Use

Animas-Debiotech Microneedles

Silicon microneedles can be used to infuse insulin or allow glucose measurements in interstitial fluid. This needle array could replace the AutoSensor in a GlucoWatch for effective continuous monitoring.

FreeStyle NavigatorTheraSense Continuous Glucose Monitor

Caution: Investigational Device.Limited by U.S. Law to Investigational Use

Meter replacement

ADICOL Project –Disetronic / RocheAdvanced Insulin Infusion with a Control Loop

Open-flow Microperfusion System

Inserted into the subcutaneous adipose tissue

Double lumen catheter Acquires glucose

readings every 30 minutes

Goal – subcutaneous glucose sensing/insulin delivery system

Intelligent Timer For High Premeal BG

An intelligent pump would alert the user when the BG is likely to cross a selected threshold value, such as 120 mg/dl (6.7 mmol).

This safe meal delay reduces glucose exposure, especially when combined with a Super Bolus

Max. drop ~4-5 mg/dl per min

Insulin Pumps- Key note

Generally speaking, Insulin used in insulin pumps should not be used for standard injection!

Most insulin pump pt’s only take one type of insulin (fast acting)

When encountering a pump in a hypoglycemic patient, do not try to adjust it!› Remove it from the patient.

Pumps Have Come A Long Way

Hyperglycemic Emergencies

Hyperglycemic Emergencies

Usually presents as either DKA or HHNC› DKA more common to Type I diabetics› HHNC more common to Type II diabetics

Both syndromes have elevated BGL in the body.

Altered physiology leads to dehydration and acidosis.› Usually a slower onset than that of

hypoglycemic episodes.

Hyperglycemia (DKA)

Also known as “Diabetic Coma”

DKA usually > 350 mg/dl (occasionally as low as 250 mg/dl)

More common in type I diabetics› More common in

the 40’s (can be seen at all ages)

The body in an attempt to compensate for hyperglycemia, develops an acidosis state.DehydrationVomitingLoss of weightKussmaul respirationsAcetone smellImpaired sensoriumShock

(hypovolemic/dehydration)

Treatment For DKA

Oxygen, Airway Control, Rapid Transport ALS Intercept!

› EKG (look out for hyperK)› IV fluids (may require 4-6 liters over time)

Monitor B/P.› Recheck BG

Hospital Care:› Insulin › ICU Admission

Hyperglycemia (HHNC) Hyperglycemic Hyper-Osmolar Non-ketotic Coma

Only 10% actually severe enough for coma HHNC usually > 600 mg/dl More common in type 2 diabetics

Slightly more common than DKAMore common in very elderly (can be seen at all

ages) Some insulin still being produced is enough to

prevent Lactic metabolism. Thus no Ketones and no acidosis.

Just profound dehydration. Treated with lots of saline as well as glycemic correction High chance of severe electrolyte imbalances.

Mortality 10-20%

Interesting Factoid:

One third of patients with HHNC do not have a prior (known) history of diabetes.

-Emedicine.com

DKA and HHNC are treated the same by the BLS provider:

Protect the ABC’s High Flow O2 Call ALS Rapid Transport Look for other causes also.

AEMT Treatment….

All BLS care AND :› 2 Large Bore IV’s› Fluid Resuscitation

Watch for fluid overload though› Shock management› Airway Management

New Onset of Diabetes in the Child Scenario

The classical symptoms of child presenting with (new onset) Type 1 diabetes:› increasing thirst› increased drinking and › polyuria for some time

(May start having accidents)

› Weight Loss› Abd Pain› Tired and listless

New Onset of Diabetes in the Child Scenario

More Severe complaints:› Vomiting› Altered Mental Status› Kussmal Respirations› Coma› Profound dehydration

25-40% go untreated long enough to develop DKA 5-10% in diabetic coma from DKA. The condition is severe and is still the major cause of

death in children with diabetes. Consider abuse and/or neglect.

Telling the Difference Between Hypoglycemia and DKAHypoglycemia “Insulin Shock” BG <60 They Look Shocky! Pale, Diaphoretic, HR is normal or mildly

increased BP typically normal. Breathing is shallow Sudden Onset No real shock

Hyperglycemia: DKA & HHNC

“Diabetic Coma” Deep Respirations and fruity

Breath (DKA) BP decreased HR is very increased (120-150

or more) Hypotension and severe

dehydration Very Dry skin, Flushed or pale. Slower onset. Real Shock

Other Medical Problems with Diabetes

Infection› Especially on feet and hands

Atypical Heart Attacks Strokes Renal Failure Hypertension Poor recovery from major insults to the

body, prolonged healing.

Other Endocrine Emergencies and Conditions

After you obtain a good grasp of various diabetic conditions, you may want to learn about: › Graves Disease› Addison's Disease› Thyrotoxic Crisis (Thyroid Storm)› Hypothyroidism› Cushing's Syndrome

(not Cushing's response, which is different)

Summary (1 of 12)

The endocrine system maintains stability in the body’s internal environment (homeostasis).

Type 1 and type 2 diabetes involve abnormalities in the body’s ability to use glucose (sugar) for fuel.

Summary (2 of 12)

Polyuria (frequent, plentiful urination), polydipsia (frequent drinking to satisfy continuous thirst), and polyphagia (excessive eating due to cellular hunger) are common symptoms, or the “3 Ps,” of uncontrolled diabetes.

Summary (3 of 12)

Patients with diabetes have chronic complications that place them at risk for other diseases.

Hyperglycemia is the result of a lack of insulin, causing high blood glucose levels.

Summary (4 of 12)

Hypoglycemia is a state in which the blood glucose level is below normal. Without treatment, permanent brain damage and death can occur.

DKA is the buildup of ketones and fatty acids in the blood and body tissue that results when the body relies upon fat for energy.

Summary (5 of 12)

Hyperglycemic crisis (diabetic coma) is a state of unconsciousness resulting from DKA, hyperglycemia, and/or dehydration due to excessive urination.

Summary (6 of 12)

Hypoglycemic crisis (insulin shock) is caused by insufficient blood glucose levels. Treat quickly, by giving oral glucose (if protocols allow), to avoid brain damage.

Summary (7 of 12)

When assessing diabetic emergencies, err on the side of giving oral glucose (if protocols allow). Do not give oral glucose to patients who are unconscious or who cannot swallow properly and protect the airway. In all cases, provide rapid transport.

Summary (8 of 12)

Problems associated with diabetes include seizures, altered mental status, “intoxicated” appearance, and loss of a gag reflex, which affects airway management.

Hematology is the study and prevention of blood-related disorders.

Summary (9 of 12)

Sickle cell disease is a blood disorder the affects the shape of red blood cells. Symptoms include joint pain, fever, respiratory distress, and abdominal pain.

Summary (10 of 12)

Hemoglobin A is considered normal hemoglobin. Hemoglobin S is considered an abnormal type of hemoglobin and is responsible for sickle cell crisis.

Summary (11 of 12)

Patients with sickle cell disease have chronic complications that place them at risk for other diseases, such as heart attack, stroke, and infection.

Summary (12 of 12)

Patients with hemophilia are not able to control bleeding.

Emergency care in the prehospital setting is supportive for patients with sickle disease or a clotting disorder such as hemophilia.

Questions?