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

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 MellitusType 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 Mellitus Gestational

Diabetes Occurs during

pregnancy

Resolves with delivery most of the time.

Due to hormone levels and obesity

Diabetes

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 Vasculopathy - Vascular damage

Effects Nephropathy - Kidney Damage

Effects Neuropathy – nerve damage

Effects Retinopathy – eye damage

Effects Diabetic

Ketoacidosis

Effects Hypoglycemia – caused by treatment

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 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

Hypoglycemia Clinical symptoms

Lethargy

Unconsciousness

Stroke-like symptoms (especially in those with prior strokes)

Seizures

Trouble speaking

Confusion

Cardiac Arrest

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

DEMO TIME…

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 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 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… 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

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 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

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 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

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? 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 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?

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?

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 _________