Diabetic Emergency

• 6% of population
• Disorder of Glucose Metabolism
• Difficulty metabolizing carbohydrates, fats, and Proteins
• Complications of:
  • Blindness
  • Cardio-vascular disease
  • Kidney Failure

Treatment to lower high glucose can go too far - causing life-threatening hypoglycemia

Diabetes (A passer-through, a siphon)

Characterized by:

• Passage of large quantities of urine containing glucose
• Sig. thirst
• Deterioration of body functions

Diabetes

• Glucose - Primary fuel for cellular metabolism
• Central Problem:
  • Lack or Ineffective action of insulin
  • Endocrine glands on the pancreas - enables glucose to enter the cells
• Without insulin - cells starve
• Insulin = key = let glucose into the cells

Metabolic Disorder

Diabetes Insipidus

• Rare 
• Caused by missing hormone that regulates urinary fluid reabsorption

Types of Diabetes - 2 Distinct Onset Patterns

Type 1

• Type 1 -
• Most patients do not produce insulin at all
• Insulin dependant
• Daily injections
• Generally strikes children
• Can develop later in life
• More likely to have metabolic problems and organ damage

• Common problems and organ damage:
  • Blindness
  • Heart Disease
  • Kidney Failure
  • Nerve Disorders
  • Circulation problems

• Usually appears later in life
• Patients produce inadequate amounts of insulin
• Produce a normal amount, but insulin does not function effectively
• May require some insulin, most treated with diet and exercise, non-insulin type medications

Hypoglycemic Agents - Non-Insulin Type Oral Medications

Diabinase - chlorpropamide 

Orinase - tolbutamide

Micronase - glyburide

Glucotrol - glipizide

Glucophage - metformin

Avandia - rosiglitazone

• These medications stimulate the pancreas to produce more insulin = lowers blood glucose levels
• Sometimes - these medications may lead to hypoglycemia, esp. when activity and exercise levels are too vigorous or excessive

Type 1

• Autoimmune problem - body becomes allergic to the insulin producing cells of the endocrine gland on the pancreas, and literally destroys them
• Severity is related to how high the average blood glucose level is and how early it begins

The Role of Glucose & Insulin

• Without glucose, or low levels - Brain cells rapidly suffer permanent damage
• With the exception of the brain:
• Insulin is needed to allow glucose into the cells
• Without insulin, glucose from food remains in the blood - gradually rises to extremely high levels = Hyperglycemia

• Once Blood Glucose levels reach 200mg/dL or twice the usual amount - excess glucose is excreted by the kidneys
• Requires a large amount of water
• Loss of water - causes classic symptoms of uncontrolled diabetes (3 Ps)
  • Polyuria - frequent and plentiful urination
  • Polydipsia - Frequent drinking to satisfy thirst
  • Polyphagia - Excessive eating - result of cellular hunger - seen occassionally

• Without glucose, body turns to other fuel sources
• Fat is the most abundant
• Unfortunately, when fat is used as an immediate energy source, chemicals called ketones and fatty acids are formed as waste products
• Difficult for the body to excrete

• As Ketones accumulate in blood and tissue - some produce a dangerous condition - Acidosis
• Diabetic Ketoacidosis (DKA) - an accumulation of certain acids occur when insulin is not available

• Vomiting
• Abdominal Pain
• Kussmaul Respirations - Deep Rapid Breathing
• When acid levels become too high - cells will cease to function
• If patient is not given proper fluid and insullin to reverse fat motabolism - and restore use of glucose as energy DKA will progress to:
  • Unconsciousness
  • Diabetic Coma
  • Death

The Role of Glucose & Insulin

Levels

• Diabetic Coma = 800 & Above
• DKA or HHNC = 400 - > 800mg/Dl
• Hyperglycemia = 120 - 400mg/Dl
• Normal = 80 - 120mg/Dl
• Hypoglycemia = 40 -80mg/Dl
• Insulin Shock = >40mg/DL

Hyperglycemia

(Above Normal)

Signs & Symptoms

• Ketoacidosis - prolonged & Exceptionally high Glucose
• If not treated = diabetic Coma
• Diabetic Coma caused by:
  • Ketoacidosis
  • Dehydration
  • Hyperglycemia

• Physical Signs:
  • Not under medical treatment
  • Insufficient Insulin
  • Markedly overeats
  • Undergoing stress - Infection, Illness, Over-exertion, fatigue, alcohol consumption

• Kussmaul Respiration (fast & shallow)
• Dehydration - dry warm skin, sunken eyes
• Sweet or fruity breath (ketones in the blood)
• Rapid Pulse
• Normal or slightly low BP
• Varying degrees of unresponsiveness

Hypoglycemia

(Below Normal)

Signs & Symptoms

• Insulin Shock (insufficient glucose in the blood):
• Insufficient amount to supply the brain
• If it remains low:
• Unconsciousness
• Permanent brain damage

• Insulin Shock Occurs when:
  • Taken too much insulin
  • Taken a regular dose of insulin, but has not eaten enough, or vomits
  • Had an unusual amount of activity, or vigorous exercise - using up all available glucose

• May not have identifiable predisposing factor
• Particular problem in children:
• High levels of activity - use glucose more quickly
• Do not always eat correctly, or on schedule
• Develops much more quickly than Diabetic Coma
• Can Occur in a matter of minutes

Hypoglycemia

(Below Normal)

Signs & Symptoms

• Normal or rapid respirations
• Pale, moist, clammy skin skin
• Diaphoresis (sweating)
• Dizziness
• Headache
• Rapid Pulse
• Normal to low BP

• Altered Mental Status:
  • Aggressive
  • Confused
  • Lethargic
  • Unusual Behavior
• Anxious or Combative Behavior
• Hunger
• Seizure
• Fainting
• Coma
• Weakness on 1 side of body

Treating Diabetic Coma

• Develops over time
• Involves all tissues of the body
• Correcting - hospital

• Acute - can develop rapidly
• Very Quickly reversed by administering glucose
• Patient will suffer permanent brain damage without it - Minutes count

Signs and Symptoms of Hyper and Hypo

Glycemia

• Staggering - intoxicating appearance
• Complete unrespomsiveness
• May have silent (painless) heart attacks
• Only Symptom - "not feeling so well"

Assessment of the Diabetic Patient

• Scene Size-up:
• Trauma may have occurred from a medical incident
• BSI - gloves and glasses (min)
• Be careful of used needles
• Important Clues:
• Insulin Syringes
• Insulin Bottles in fridge
• Plate of food or OJ

Does the patient appear:

• Anxious
• Restless
• Listless
• Apathetic
• Irritable
• Interacting w/ environment appropriately
• LOC
• Chief Complaint
• Unresponsive - call for ALS - ASAP

• Inadequate breathing or altered mental - high flow oxygen @ 10 - 15L - non-rebreathing mask
• Diabetic Coma:
  • Kussmaul breathing
  • Sweet, fruity Breath
• Insulin Shock:
• Normal - rapid respirations

• Diabetic Coma
  • Dry, Warm Skin
• Insulin Shock:
  • Moist, Pale skin
  • Rapid, Weak Pulse

• LOC and ability to swallow determine transport
• Transport promptly if altered mental status or breathing difficulty
• Evaluate and intervene patients further if conscious and can maintain open airway

• Assess Unresponsive patients with Rapid Physical Exam
• Perhaps trama
• Vital Signs
• History

• Responsive Patients:
• SAMPLE History
• Additional Questions:
  • Do you take insulin or pills to lower blood sugar?
  • Have you take the usual dose today?
  • Have you eaten normally, today?
  • Have you had any illness, unusual amount of activity, or stress, today?

• If the patient has eaten, but not taken insulin - more likely they have kenoacidosis developing
• Potential Diabetic Coma
• If the patient has taken insulin, but has not eaten - more likely - insulin shock

• Focus on patient's mental status and ability to swallow (protect airway)
• Obtain a Glasgow Coma Scale Score - to track patient's mental ability
• Physical signs:
  • Tremors
  • Abdominal Cramps
  • Vomiting
  • Fruity breath
  • Dry Mouth

• Obtain a complete set
• Including glucose level

• Have patient drink juice or milk
• Provide Oxygen
• Provide Glucose gel  (oral glucose)
• Prompt Transport