21 Endocrine Emergencies: Diabetes Mellitus - Hypoglycemia

Introduction Diabetes mellitus (DM) is a condition in which the body no longer metabolizes glucose correctly. This inability can lead to seriously high or low levels of blood sugar. The Advanced EMT must quickly identify the problem and support lost function to reduce morbidity and mortality. Diabetes mellitus (DM) is a condition in which the patient experiences a chronically elevated blood glucose level. Although EMS frequently responds for those with a low blood glucose level (hypoglycemia), most diabetes mellitus patients struggle on a daily basis to decrease their blood glucose levels to within a normal range. However, the occasional acute hypoglycemic event carries a high risk of morbidity and mortality. Thus, it is imperative that the Advanced EMT quickly recognize the signs and symptoms of hypoglycemia and manage the patient accordingly to prevent any long-term effects from the episode.

Epidemiology (cont’d) Type 1 diabetes mellitus Autoimmune disease process Characteristic to younger patients Requires supplemental insulin Prone to hypoglycemia and diabetic ketoacidosis (DKA) Review the traditional description of Type 1 DM.

Epidemiology (cont’d) Type 2 diabetes mellitus Impaired insulin production Impaired insulin effects Commonly an adult onset Associated with a higher BMI Controlled through diet and oral pills Prone to hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Review the traditional description of Type 2 DM.

Pathophysiology Role of hormones in glucose regulation Insulin and glucagon Cellular metabolism of glucose Review the role of insulin in transporting glucose into the cell for energy production. Review the role of glucagon in stimulating glycogenolysis (breaking down glycogen stores); also, it stimulates gluconeogenesis.

Glucose movement into the cell with insulin and the inability of glucose to get into the cell without insulin.

Pathophysiology (cont’d) Hypoglycemia Precipitating causes Patients become symptomatic when BGL falls to 40-50 mg/dL Brain most sensitive to low levels of glucose Body then releases additional hormones aimed at trying to raise glucose back up Identify the common causes for a patient to have low blood sugar (too much insulin, not enough food, changes in physical exertion, etc). Discuss the negative feedback system attempt to raise blood sugar by releasing: Glucagon Epinephrine Cortisol Vasopressin

Assessment Findings General considerations Findings can be broadly categorized Hyperadrenergic – increases sympathetic tone Neuroglucopenic – brain dysfunction from lack of glucose Review and discuss the basic differences in symptoms based on body pathology.

Signs and Symptoms of Hypoglycemia

Assessment Findings (cont’d) Other notable assessment characteristics Hypoglycemia may occur suddenly. Hypoglycemia may present like a stroke. Once referred to as “insulin shock” as many presentation findings mirrored hypovolemic shock. These are characteristic findings, not specific, nor always present. Since epinephrine is released in hypovolemic and hypoglycemic shock, many of the vital signs and skin changes are similar in nature, hence the reference to “insulin shock”.

Emergency Medical Care Keep airway patent; be alert for vomiting. Place patient in lateral recumbent position. Administer oxygen based on ventilatory needs. Keep SpO2 >95%. Beyond managing the airway, remaining alert for vomiting, providing oxygen, and positioning the patient, the Advanced EMT may also administer oral glucose or intravenous dextrose. Administration of oral glucose should only be done if the patient: Has an intact airway Can swallow Shows symptoms of hypoglycemia Has a monitored BGL less than 60 mg/dl If the patient has a BGL less than 60 mg/dL in addition to an altered mental status and inability to swallow, intravenous dextrose should be given since oral glucose would place the patient at risk for aspiration.

Emergency Medical Care (cont’d) Administer oral glucose if criteria is met Administer 50% dextrose if criteria is met Beyond managing the airway, remaining alert for vomiting, providing oxygen, and positioning the patient, the Advanced EMT may also administer oral glucose or intravenous dextrose. Administration of oral glucose should only be done if the patient: Has an intact airway Can swallow Shows symptoms of hypoglycemia Has a monitored BGL less than 60 mg/dl If the patient has a BGL less than 60 mg/dL in addition to an altered mental status and inability to swallow, intravenous dextrose should be given since oral glucose would place the patient at risk for aspiration.

Hyperglycemia Review the frequency with which hyperglycemic emergencies occur. Discuss the etiologies of hyperglycemia. Discuss physiology and pathophysiology of hyperglycemic episodes. DKA and HHNS Review appropriate treatment strategies. Discuss the objectives. 14

Introduction Hyperglycemic episodes are at the opposite end of diabetic emergencies. DKA or HHNS must be considered in all patients with altered consciousness. History of onset and monitored BGL levels are the best way to differentiate hyperglycemic episodes from other problems. Hyperglycemia refers to conditions in which the blood glucose is excessively elevated beyond a normal level. It is on the opposite end of the continuum of diabetic emergencies as compared with hypoglycemia. Two acute hyperglycemic conditions that EMTs will encounter in the prehospital environment are: Diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) HHNS is also frequently referred to as hyperglycemic hyperosmolar nonketotic coma (HHNC). DKA and HHNS must be considered while forming a differential diagnosis when assessing and managing a patient with an altered mental status. This is especially true if the patient has a history of diabetes mellitus (DM). However, be aware that the onset of DKA or HHNS may be the first sign of DM in a patient with no known history. Thus, it is imperative to obtain a blood glucose reading on any patient with an altered mental status, especially if the patient appears to be dehydrated, regardless of a positive or negative history of DM. 15

Epidemiology DKA is more common in Type 1 DM. HHNS is more common in Type 2 DM. HHNS occurs with higher frequency than DKA does, and is more prevalent in females. Mortality rates can be 10-20% in hyperglycemic emergencies. Review statistics. Also discuss how elderly patients in nursing homes are at high risk for hyperglycemic episodes. 16

Pathophysiology Diabetic ketoacidosis (DKA) A relative of absolute insulin deficiency. BGL rises greater than 300 mg/dL. The brain has plenty of glucose, but the body cannot use it without insulin. Progression produces: Metabolic acidosis Osmotic diuresis Electrolyte disturbance Discuss the pathology of DKA. Relate it to Type 1 diabetic patients. Also discuss the pathophysiologic changes due to the excessive glucose and the body's attempt to remedy the situation: Acidosis from body's attempt to convert nonglucose structures into glucose (even though the body does not need it). Osmotic diuresis from glucose spilling over into the kidneys and drawing large amounts of water with it. Electrolyte disturbance from large amounts of urine leaving the body. 17

Assessment Findings Diabetic ketoacidosis Slow change in mental status History and findings consistent with severe dehydration Nausea and vomiting, abdominal pain Fatigue, weakness, lethargy, confusion Kussmaul respirations Discuss the pathology of DKA. Relate it to Type 1 diabetic patients. Also discuss the pathophysiologic changes due to the excessive glucose and the body's attempt to remedy the situation: Acidosis from body's attempt to convert nonglucose structures into glucose (even though the body does not need it). Osmotic diuresis from glucose spilling over into the kidneys and drawing large amounts of water with it. Electrolyte disturbance from large amounts of urine leaving the body. 18

Kussmaul respirations

Pathophysiology (cont’d) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Severe elevations in BGL (>600 mg/dL) Some insulin still present Not enough or not effective Changes in physiology Osmotic diuresis Electrolyte disturbance No ketogenesis Discuss the slightly different progression of HHNS: Some insulin still present, just not effective. Glucose levels raise very high levels. Patient sill has osmotic diuresis and electrolyte disturbance. No ketogenesis due to some insulin still being circulated (enough to prevent gluconeogenesis, but not enough to prevent osmosis or electrolyte disturbances). 20

Assessment Findings HHNS Slow progression of symptoms Dehydration findings Polyuria early, oliguria late Changes in mental status Possible seizure activity Findings of volume depletion Relate the presentation of DKA with the underlying pathophysiologic changes: Effects of osmotic diuresis Effects if electrolyte disturbance 21

Signs and Symptoms of Diabetic Emergency Conditions

Signs and Symptoms of Diabetic Emergency Conditions

Treatment Considerations General considerations Focus of hypoglycemia is the administration of glucose. Focus of DKA and HHNS is rehydration of the patient. Discuss goals for management. 24

Emergency Medical Care Establish and maintain a patent airway. Establish and maintain adequate ventilation. Establish and maintain adequate oxygenation. Assess blood glucose level. Initiate intravenous therapy. Beyond managing the airway, remaining alert for vomiting, providing oxygen, treating seizures if present, and positioning the patient, the Advanced EMT will also need to initiate intravenous access for fluid therapy. 25

Case Study You are called one afternoon to evaluate an elderly female patient at home. Upon arrival PD is on scene and has forced entry into the home based on the neighbor saying that the elderly occupant has not been seen for days. You find the patient lying on the couch, dried vomit on the face, with loud sonorous respirations. Discuss the case presentation. 26

Case Study (cont’d) Scene Size-Up Standard precautions taken. Scene is safe, no entry or egress problems. One patient, elderly female, looks unresponsive on the couch. NOI is unknown mental status change. No signs of struggle or trauma. Discuss the case presentation. 27

Case Study (cont’d) What are some concerns you have based on the scene size-up? What are possible conditions you suspect at this time? Since the patient did not recognize or respond to your arrival in their living room, the logical conclusion is an altered mental status. For this reason, the Advanced EMT should be concerned for: Airway maintenance Breathing adequacy Whether a pulse is present The possibilities for the patient's unresponsiveness are almost endless. As of yet, the Advanced EMT cannot rule out: Metabolic causes for unresponsiveness (e.g., hypoxia, electrolyte disorder, hypercapnia, low perfusion state, glucose levels) Structural causes (e.g., stroke, cerebral abscess) 28

Case Study (cont’d) Primary Assessment Findings Patient does not respond to painful stimuli. Sonorous respirations. Breathing is tachypneic with alveolar breath sounds. Peripheral perfusion absent; skin dry, carotid pulse present. No indication of significant trauma. Discuss as needed. 29

Case Study (cont’d) Is this patient a high or low priority? Why? What are the life threats to this patient? What emergency care should you provide based on the primary assessment findings? The person presents as a high priority due to: The change in mental status The partial airway occlusion Life threats include a potential deterioration of the airway or breathing mechanics if the patient's mental status diminishes any further. The sonorous breathing requires immediate attention. If the patient does not have a gag reflex, an OPA can be inserted in conjunction with a manual airway technique. Also be sure to visualize the airway for any remaining vomit or fluid that needs to be suctioned out. 30

Case Study (cont’d) Medical History Medications Allergies Unknown Tell the participants that a quick “run through” of the apartment did not lead to any medications in the typical places or other indications as to the patient's problem. 31

Case Study (cont’d) Pertinent Secondary Assessment Findings Pupils midsize and midposition. Airway now maintained with OPA. Breathing still adequate, rate fast. Carotid pulse present, peripheral perfusion absent. Skin cool and dry, tongue furrowed, membranes pale. Discuss the case progression. 32

Case Study (cont’d) Pertinent Secondary Assessment Findings (continued) B/P 84/64, heart rate 128, respirations 30/min. Finger prick test of BGL reveals 860 mg/dL. Pulse oximeter intermittently reading 94%. Discuss the case progression. 33

Case Study (cont’d) Pertinent Secondary Assessment Findings (continued) No other findings contributory to presentation. Dried urine stains on patient's clothing and couch. Discuss the case progression. 34

Case Study (cont’d) With this information, has your field impression changed at all? What would be the next steps in management you would provide to the patient? Given the presentation, the Advanced EMT should lean towards a hyperglycemic episode. With the absence of ketone odor to the breath, the patient's likely problem is HHNS. Next steps of management would be to: Insure good oxygenation Reassess airway and breathing to make sure both components are intact Paramedic intercept should be initiated in order to start rehydration as soon as possible. 35

Case Study (cont’d) Care provided: Patient placed in lateral recumbent position. High-flow oxygen administered via NRB mask. OPA kept in place, airway remained patent. If the patient is hypotensive, administer normal saline to maintain the systolic blood pressure above 100 mmHg; otherwise, infuse fluid at a rate of 1 to 2 liters over 1 to 3 hours. In pediatric patients, administer a 20 mL/kg fluid bolus over 1 hour. 36

Case Study (cont’d) Care provided: Intravenous therapy and fluid resuscitation. Patient packaged and prepared for transport to hospital. If the patient is hypotensive, administer normal saline to maintain the systolic blood pressure above 100 mmHg; otherwise, infuse fluid at a rate of 1 to 2 liters over 1 to 3 hours. In pediatric patients, administer a 20 mL/kg fluid bolus over 1 hour. 37

Case Study (cont’d) In a patient with this field impression, discuss why the following findings were present: Decrease in mental status Tachycardia Dry skin and furrowed tongue Low blood pressure High glucose level The change in mental status is likely due to a combination of electrolyte disturbance and volume depletion. A patient with HHNS has plenty of glucose for the brain to metabolize, so a change in mental status was not due to low glucose. Instead it was probably gradual. The brain cannot store glucose, so if the level of circulating glucose drops, the brain will be the first organ to dysfunction. This dysfunction usually turns into a drop in mental status. With the subsequent sympathetic discharge, the patient may also become aggressive. The tachycardia is secondary to the sympathetic discharge that causes the release of epinephrine (beta1 effects) due to volume depletion for diuresis. Along with this is the drop in blood pressure for the same reason (volume depletion). The dry skin and furrowed tongue occurs as the body attempts to shift fluid from interstitial spaces back inside the vascular space for perfusion needs. Over time the skin will become dry, the tongue becomes furrowed, mucous membranes become dry, and urine production will cease. The high sugar level is due to a relative inability of insulin to work in this patient. Because the cells of the body are starving for glucose, the body responds by releasing more glycogen stores and producing glucose from non-carbohydrate sources. The problem is, that the cells need more insulin, not more glucose. 38

Summary Hyperglycemia can be recognized by its onset and elements of dehydration. Although the Advanced EMT's treatment of this problem is supportive in nature, immediate initiation of intravenous therapy can allow for rehydration to begin during transport to the hospital. Discuss as needed. 39

Summary Diabetic patients are a fairly common type of patient seen by the Advanced EMT. Based on the type of diabetes they have, the resulting emergency may cause high or low levels of glucose to develop. Discuss as needed.

Summary (cont’d) The Advanced EMT's goal is to recognize the type of diabetic reaction and provide appropriate care. Discuss as needed.