Acute Diabetic Emergencies

Chapter 20

Objectives

• Understanding Diabetes Mellitus• Acute Diabetic Emergencies• Assessment• Emergency Care

Understanding Diabetes Mellitus

Glucose (Sugar)• Major source of fuel for the cells• Significantly affects brain cells• Tendency to attract water when glucose

molecule moves• Excess spills off into urine

Hormones that control Glucose levelsInsulin• Increases the movement of glucose out of the blood into

the cells• Causes the liver to take up glucose out of the blood and

convert it to glycogen• Decreases the blood glucose level and facilitates the

movement of glucose into the cells and liver• Not needed to get glucose into the brain

Hormones that control Glucose levels

Glucagon• Converts glycogen stored in the liver back

into glucose and released it back into the blood (opposite of insulin)

• Converts non-carbohydrate substances into glucose

• Increases and maintains the blood glucose level, converting glucogen and other substances into glucose

Hormones that control Glucose levels

Other hormones (epinephrine)• Released by the adrenal glands when blood

glucose level is decreasing to a dangerous low level

• Stops the secretion of insulin and promotes the release of stored glucose from the liver and converts other substances to glucose

Normal metabolism and Glucose regulation• Blood glucose level (BGL)

increases within an hour of eating

• Insulin, released by the pancreas, increases movement of glucose into cells

• As body cells, liver and brain take up glucose, BGL lowers

• Pancreas secretes glucagon as BGL lowers

• Liver converts glycogen back to glucose, into bloodstream

• Glucose enters bloodstream and maintains normal range until next meal

Checking the BGLGlucose meters can determine blood glucose level• Normal level 80 – 120 mg/dL• Normal level after a meal 120 – 140 mg/dL• Determine when patient last ate or drank• Average BGL in a diabetic patient is 200 mg/dL• Hypoglycemia - BGL of 60 mg/dL or less with

signs/symptoms of 50 mg/dL with/without signs/symptoms• Hyperglycemia – persistent BGL above 120 mg/dL• Use glucometer in conjunction with information• Confirm protocols allow you to check BGL (Whatcom

county does)• Test BGL prior to administration of oral glucose or sugar

containing solution• Ensure that you have all of the needed test equipment

Understanding Diabetes Mellitus

Disturbance in metabolism of carbohydrates, fats, and proteins

• Lack of insulin being secreted by pancreas• Inability of the cell receptors to recognize the

insulin and allow glucose to enter at a normal rate• Brain has more glucose than it needs, it does not

require insulin, while the body cells are starving for glucose

Understanding Diabetes Mellitus

Signs and symptoms• Elevated BGL (hyperglycemia)• Polydipsia – frequent thirst• Polyuria – frequent urination• Polyphagia – frequent hunger• Prone to a wide variety of diseases and

disorders involving blood vessels

Understanding Diabetes Mellitus - Types

Type 1• Also called insulin-dependent diabetes

mellitus (IDDM)• Pancreas does not secrete insulin• Peak age is 10 – 14 years• Patient may suffer from diabetic

ketoacidosis (DKA) or hypoglycemia

Understanding Diabetes Mellitus - Types

Type 2• Also called non-insulin dependent mellitus• Typically overweight and middle-age or

older• May suffer from hyperglyemic hypersmolar

nonketotic syndrome (HHNS)• More common than Type 1

Acute Diabetic Emergencies - Hypoglycemia

• Patient suffers from low BGL• More common in Type IDDM patients• Most dangerous acute complication – can result

in brain cell death

Pathophysiology of hypoglycemiaInsulin Shock

• BGL less than 60 mg/dL with signs/symptoms of hypoglycemia or less than 50 mg/dL regardless of signs/symptoms

• Patient takes insulin but with excessive results for one of these reasons;• Patient takes insulin and does not eat a meal• Patient takes insulin, eats a meal, but drastically

increases activity beyond normal• Patient takes too much insulin (either at once or forgets

and takes another dose)

Signs/symptoms caused by epinephrine release

• Diaphoresis• Tremors• Weakness• Hunger• Tachycardia• Dizziness• Pale, cool, clammy skin• Warm sensation

Signs/symptoms caused by brain cell dysfunction

• Confusion• Drowsiness• Disorientation• Unresponsiveness (coma)• Seizures• Stroke-like symptoms

Misinterpretation of signs can be deadly!Hypoglycemia unawareness

Emergency care for Hypoglycemia• Important patient is given sugar to increase

BGL as soon as possible• Unresponsive patient, unable to swallow, or

unable to obey commands;• Establish airway• Provide oxygen via NRB @ 15 lpm if breathing

is adequate• Provide positive pressure ventilation if needed• Confirm ALS enroute or ask for upgrade• Assess BGL

Emergency care for Hypoglycemia

Responsive patient, patient able to swallow, or obey commands;

• Ensure airway is patent• Assess BGL• Administer one tube of oral glucose• Continuously assess patient

Oral Glucose• Heavy sugar gel raises

glucose circulating in the blood and increases the amount of glucose available to the brain

• Criteria for administration;• Not altered mental status• History of diabetes

controlled by medication or BGL below 60 mg/dL

• Ability to swallow• Patient does not meet all of

the three, treat as altered mental status with unknown history

Acute Diabetic Emergency - Hyperglycemia

• Diabetic patient is suffering from a lack of insulin and a high BGL

• Patients may suffer diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS) from being hyperglycemic

Diabetic Ketoacidosis

Pathophysiology • Most common in Type 1• Brain has an excess amount of glucose,

other body cells are starving due to insufficient amount of insulin

• Effects include dehydration, acidosis, and cardiac disturbances

Diabetic Ketoacidosis

Causes• Infection that has upset the insulin and glucose

balance• Inadequate dose of insulin• Medications such as Thiazide, Dilantin, or steroids• Types of stress such as surgery, trauma,

pregnancy, or heart attack• Change in diet

Diabetic Ketoacidosis

Assessment findings;• Polyuria• Polyphagia• Polydipsia• Nausea and vomiting• Poor skin turgor• Tachycardia• Rapid, deep respirations (Kussmaul respirations)• Fruity or acetone breath (ketone buildup)• Positive orthostatic tilt test

Diabetic Ketoacidosis

Other Assessment findings;• BGL greater than 350 mg/dL• Muscle cramps• Abdominal pain• Warm, dry, flushed skin• Altered mental status• Coma

Diabetic Ketoacidosis

Emergency Care• Establish and maintain patent airway• Provide oxygen via NRB @ 15 lpm • Provide positive pressure ventilation with

supplemental oxygen, if needed• Determine BGL• If unsure, administer glucose if patient is able to

swallow• Contact med control

Hyperglycemic Hperosmolar Nonketotic Syndrome (HHNS)

Pathophysiology• Most common in Type 2• Causes the BGL to increase dramatically 600 –

1200 mg/dL• Glucose draws large amounts of water into urine• Less fat burned for energy than in DKA (lesser

production of ketones)• May be first indication that patient is diabetic

Hyperglycemic Hperosmolar Nonketotic Syndrome (HHNS)

Causes;• Diabetic condition• Trauma• Burns• Dialysis• Drugs• Heart attack• Stroke• Infection• Head injuries

Hyperglycemic Hperosmolar Nonketotic Syndrome (HHNS)

Assessment findings;• Tachycardia• Fever• Positive orthostatic tilt test• Dehydration• Polydipsia• Dizziness• Poor skin turgor• Altered mental status• Confusion• Weakness • Dry oral mucosa• Dry, warm skin• Polyuria• Nausea and vomiting

Hyperglycemic Hperosmolar Nonketotic Syndrome (HHNS)

Emergency Care• Same as DKA• When in doubt, or protocol does not allow

to distinguish between the diabetic emergencies, treat the patient as if they are hypoglycemic to prevent brain death or patient’s death

Size-up and Primary Assessment

• Assess in same manner as Altered Mental Status with no know history of diabetes

• Err on caution, administer oral glucose if you do not have a glucometer

• Look for clues that may lead you to diabetes – medications

• Look for medical aler tags or other medical identification

History and Secondary Assessment

• Ask SAMPLE history questions• Medications to look for;

• Insulin (Humulin, Novolin, Iletin, Semilente• Actos• Diabanese, Glucamide• Orinase• Micronase, Diabeta• Tolinase• Glucotrol• Humalog• Glucohage• Glynase• Exantide (Byetta)• Exubra

History and Secondary Assessment

Important Questions• Did the patient take his medication the day of episode?• Did the patient eat or skip regular meals on that day?• Did the patient vomit after eating?• Did the patient do any unusual exercise or physical activity?• Was the onset of altered mental status gradual or fast?• Are there any other signs/symptoms associtated with the altered

mental status?• Is there any evidence of injury?• Was there a period in which the patient regained normal mental status

and deteriorated?• Did the patient have a seizure?• Does the patient appear to have a fever or other signs of an infection?

History and Secondary AssessmentSigns and symptoms;• Rapid onset of altered mental status after missing or

vomiting a meal, unusual exercise, or physical work• Intoxicated appearance• Tachycardia• Cool, moist skin• Hunger• Seizure activity• Uncharacteristic or bizarre behavior, combativeness• Anxiousness or restlessness• Bruising at insulin injection site on the abdomen• Stroke symptoms (in elderly patient)• BGL < 60 mg/dL

History and Secondary Assessment

Emergency Medical Care• Establish and maintain an open airway• Determine if patient is alert enough to swallow• Administer oral glucose • Whatcom County EMS Protocol page 17:

• Use of oral glucose or any other substance of similar consistency, is not recommended unless ALS is more than 15 minutes away

• If patient is able to swallow, administer oral glucose (15 min. threshold met) or substance high is simple sugar

• Be prepared for patient to vomit• Provide supplemental oxygen• Maintain body temperature

• Transport• Reassess to determine oral glucose is working• Retest BGL• If BGL improving and mental status, patient is likely suffering from

hypoglycemia• If not, patient may be suffering from another condition• Communicate and record any changes in the patient’s condition

Testing the Blood Glucose Level

Questions ????