Endocrine and Hematologic Emergencies

Endocrine and Hematologic Emergencies
Chapter 19 Endocrine and Hematologic Emergencies Chapter 19: Endocrine and Hematologic Emergencies

Introduction Endocrine system influences nearly every cell, organ, and bodily function. Endocrine disorders can have many signs and symptoms. Hematologic emergencies Difficult to assess and treat Your actions may save a life. Lecture Outline I. Introduction A. The human endocrine system directly or indirectly influences nearly every: 1. Cell 2. Organ 3. Bodily function B. Endocrine disorders are often seen with a multiple of signs and symptoms. C. Hematologic emergencies 1. Difficult to assess and treat in a prehospital setting 2. Your actions may save a patient’s life

Anatomy and Physiology (1 of 2)
Endocrine system is a communication system that controls functions inside the body. Endocrine glands secrete messenger hormones. Endocrine disorders are caused by an internal communication problem. Lecture Outline II. Anatomy and Physiology A. The endocrine system is a communication system that controls functions inside the body. B. Endocrine glands secrete messenger hormones. 1. Hormones travel through the blood to end organs, tissues, or cells that they affect. 2. When it arrives, the message is received and an action takes place. C. Endocrine disorders are caused by an internal communication problem. 1. If a gland is not functioning normally, it may produce a. More hormone (hypersecretion) than needed b. Not enough hormone (hyposecretion) 2. A gland may be functioning correctly, but the receiving organ may not be responding.

Anatomy and Physiology (2 of 2)
Glucose metabolism The brain needs glucose and oxygen. Insulin is necessary for glucose to enter cells. The pancreas produces glucagon and insulin. Stores and secretes insulin and glucagon in response the blood glucose level Lecture Outline D. Glucose metabolism 1. The brain needs two things to survive: glucose and oxygen. a. Insulin is necessary for glucose to enter cells. b. Without enough insulin, the cells do not get fed. 2. The pancreas produces and stores two hormones: a. Glucagon b. Insulin 3. The pancreas stores and secretes insulin and glucagon in response to the level of glucose in the blood.

Pathophysiology (1 of 2) Diabetes mellitus impairs the body’s ability to use glucose for fuel. Without treatment, blood glucose levels become too high. In severe cases, may cause life-threatening illness, or coma and death Complications include blindness, cardiovascular disease, and kidney failure. Lecture Outline III. Pathophysiology A. Diabetes mellitus is a disorder of glucose metabolism, such that the body has an impaired ability to get glucose into the cells to be used for energy. 1. Without treatment, blood glucose levels become too high. a. In severe cases, may cause life-threatening illness, or coma and death. 2. If not managed well, it can have severe complications such as: a. Blindness b. Cardiovascular disease c. Kidney failure B. There are three types of diabetes. 1. Diabetes mellitus type 1 2. Diabetes mellitus type 2 3. Pregnancy-induced, gestational diabetes C. Treatments for diabetes 1. Medications and injectable hormones that lower blood glucose level a. If administered correctly or incorrectly, can create a medical emergency for the patient with diabetes. b. Low blood glucose level (hypoglycemia), if unrecognized and untreated, can be life threatening.

Pathophysiology (2 of 2) You need to know signs and symptoms of blood glucose that is: High (hyperglycemia) Low (hypoglycemia) Hyperglycemia and hypoglycemia can occur with diabetes mellitus type 1 and type 2. All hypoglycemic patients require prompt treatment. Lecture Outline D. You must also recognize the signs and symptoms of 1. High blood glucose level (hyperglycemia) a. Can result in coma or death b. If treatment exceeds a patient’s need, it can cause a life-threatening state of hypoglycemia. 2. Low blood glucose level (hypoglycemia) E. Hyperglycemia and hypoglycemia can occur with both diabetes mellitus type 1 and type 2. 1. You will encounter many patients displaying the signs and symptoms of high and low blood glucose levels. 2. Hyperglycemia and hypoglycemia can be quite similar in their presentation. a. Patients present with altered mental status. b. Can often mimic alcohol intoxication; intoxicated patients often have abnormal glucose levels 3. Hypoglycemia can develop: a. If a person takes his or her medications but fails to eat enough food. b. If a person takes too much medication, resulting in low blood glucose levels despite normal dietary intake 4. All hypoglycemic patients require prompt treatment.

Diabetes Mellitus Type 1 (1 of 5)
Autoimmune disorder where the immune system produces antibodies against the pancreatic beta cells Missing the pancreatic hormone insulin Onset usually happens from early childhood through the fourth decade of life. Patient must obtain insulin from an external source Lecture Outline F. Diabetes mellitus type 1 1. An autoimmune disorder in which the immune system produces antibodies against the pancreatic beta cells a. Missing the pancreatic hormone insulin 2. Onset usually happens from early childhood through the fourth decade of life. a. The patient must obtain insulin from an external source. b. Patients who inject insulin often need to check blood glucose levels up to six times or more a day.

Many people with type 1 diabetes have an implanted insulin pump. Continuously measures glucose levels and provides an adjustable infusion of insulin Can malfunction and diabetic emergencies can develop Always inquire about the presence of an insulin pump. Lecture Outline 3. Many people with type 1 diabetes have an implanted insulin pump. a. Continuously measures glucose levels and provides insulin and correction doses of insulin based on carbohydrate intake at mealtimes b. Limits the number of times patients have to check their fingerstick glucose level c. Can malfunction and diabetic emergencies can develop i. Always inquire about the presence of an insulin pump.

Most common metabolic disease of childhood New-onset patient symptoms: Polyuria Polydipsia Polyphagia Weight loss Fatigue Lecture Outline 4. Type 1 diabetes is the most common metabolic disease of childhood. A patient with new-onset type 1 diabetes will have symptoms related to eating and drinking: a. Polyuria: frequent urination b. Polydipsia: increase in fluid consumption c. Polyphagia: severe hunger and increased food intake d. Weight loss e. Fatigue

Patient’s blood glucose level is above normal Kidney’s filtration system becomes overwhelmed and glucose spills into the urine. Glucose is unavailable to cells. Body turns to burning fat. Produces acid waste (ketones) Kidneys cannot maintain acid–base balance. Kussmaul respirations result Lecture Outline 5. When a patient’s blood glucose level is above normal, the kidney’s filtration system becomes overwhelmed and glucose spills into the urine. 6. When glucose is unavailable to cells, the body turns to burning fat. a. When the body burns fat rather than glucose, it produces acid waste (ketones). i. As ketone levels go up in the blood, they spill into the urine. ii. Kidneys become saturated with glucose and ketones and cannot maintain acid–base balance in the body. iii. The patient breathes faster and deeper, as the body attempts to reduce the acid level by releasing more carbon dioxide through the lungs. (a) Known as Kussmaul respirations

If fat metabolism and ketone production continue, diabetic ketoacidosis (DKA) can develop. May present as generalized illness DKA can result in death. Obtain patient’s history and presentation. Obtain a glucose level. Generally higher than 400 mg/dL Lecture Outline iv. If fat metabolism and ketone production continue, a life-threatening illness called diabetic ketoacidosis (DKA) can develop. v. DKA may present as generalized illness plus: (a) Abdominal pain (b) Body aches (c) Nausea (d) Vomiting (e) Altered mental status or unconsciousness (if severe) vi. If not rapidly recognized and treated, DKA can result in death. vii. When a patient with DKA has altered mental status, ask family or friends about the patient’s history and presentation. viii. Obtain a glucose level with a fingerstick using a lancet and a glucometer. (a) Generally higher than 400 mg/dL

Caused by resistance to the effects of insulin at the cellular level An association between obesity and increased resistance to the effects of insulin Pancreas produces more insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors. Insulin resistance can sometimes be improved by exercise and dietary modification. Lecture Outline G. Diabetes mellitus type 2 1. Caused by resistance to the effects of insulin at the cellular level a. There is an association between obesity and increased resistance to the effects of insulin. b. The pancreas produces more insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors. c. Insulin resistance can sometimes be improved by exercise and dietary modification.

Oral medications used to treat type 2 diabetes Some increase secretion of insulin and pose a high risk of hypoglycemic reaction. Some stimulate receptors for insulin. Others decrease the effects of glucagon and decrease the release of glucose stored in the liver. Injectable medications and insulin are also used for type 2 diabetes. Lecture Outline 2. Oral medications used to treat type 2 diabetes a. Some increase secretion of insulin and pose a high risk of hypoglycemic reaction. b. Some stimulate receptors for insulin. c. Others decrease the effects of glucagon and decrease the release of glucose stored in the liver. 3. Injectable medications and insulin are also used for type 2 diabetes.

Often diagnosed at a yearly medical examination from complaints related to high blood glucose levels, including: Recurrent infection Change in vision Numbness in the feet Lecture Outline 4. Often diagnosed at a yearly medical examination from complaints related to high blood glucose levels, including: a. Recurrent infection b. Change in vision c. Numbness in the feet

Symptomatic Hyperglycemia (1 of 3)
Occurs when blood glucose levels are high Patient is in a state of altered mental status resulting from several combined problems. In type 1 diabetes, leads to ketoacidosis with dehydration from excessive urination In type 2 diabetes, leads to a nonketotic hyperosmolar state of dehydration Lecture Outline H. Symptomatic hyperglycemia 1. Occurs when blood glucose levels are very high; the patient is in a state of altered mental status resulting from several combined problems. a. In type 1 diabetes, leads to ketoacidosis with dehydration from excessive urination b. In type 2 diabetes, leads to a nonketotic hyperosmolar state of dehydration due to the discharge of fluids from all of the body systems and eventually out through the kidneys, leading to fluid imbalance c. If an individual has hyperglycemia for a protracted length of time, consequences of diabetes may present.

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) When blood glucose levels are not controlled in diabetes mellitus type 2 Key signs and symptoms Lecture Outline 2. When blood glucose levels are not controlled in diabetes mellitus type 2, a condition known as hyperosmolar hyperglycemic nonketotic syndrome (HHNS) can develop. a. Signs and symptoms of HHNS include: i. Hyperglycemia ii. Altered mental status, drowsiness, lethargy iii. Severe dehydration, thirst, dark urine iv. Visual or sensory deficits v. Partial paralysis or muscle weakness vi. Seizures

Higher glucose levels in the blood cause the excretion of glucose in the urine. Patient increases fluid intake. Patient cannot drink enough fluid to keep up with the exceedingly high glucose levels in the blood. Urine becomes dark and concentrated. Patient may become unconscious or have seizure activity due to severe dehydration. Lecture Outline 3. Higher glucose levels in the blood cause the excretion of glucose in the urine. a. Patients respond by increasing their fluid intake, which causes polyuria. b. In HHNS, the patient cannot drink enough fluid to keep up with the exceedingly high glucose levels in the blood. c. The urine becomes dark and concentrated. d. The patient may become unconscious or have seizure activity due to severe dehydration.

Symptomatic Hypoglycemia (1 of 3)
Acute emergency where a patient’s blood glucose level drops and must be corrected swiftly Can occur in patients who inject insulin or use oral medications When insulin levels remain high, glucose is rapidly taken out of the blood. If glucose levels fall, there may be an insufficient amount to supply the brain. Lecture Outline I. Symptomatic hypoglycemia 1. An acute emergency in which a patient’s blood glucose level drops and must be corrected swiftly a. Can occur in patients who inject insulin or use oral medications that stimulate the pancreas to produce more insulin i. When insulin levels remain high, glucose is rapidly taken out of the blood. ii. If glucose levels fall, there may be an insufficient amount to supply the brain.

Mental status declines. Patient may become aggressive or display unusual behavior. Unconsciousness or permanent brain damage can quickly follow. Hypoglycemia develops much more quickly than hyperglycemia. Signs and symptoms of hypoglycemia Lecture Outline 2. The mental status of the patient declines and he or she may become aggressive or display unusual behavior. a. Unconsciousness and permanent brain damage can quickly follow. 3. Common reasons for a low blood glucose level to develop 4. Hypoglycemia develops much more quickly than hyperglycemia. 5. Signs and symptoms of hypoglycemia

Hypoglycemia is quickly reversed by giving the patient glucose. Lecture Outline 6. Hypoglycemia is quickly reversed by giving the patient glucose. © Jones and Bartlett Learning.

Scene Size-up Scene safety Determine MOI/NOI.
Patients with diabetes may use syringes. Be alert for clues. Use standard precautions. Question bystanders on events leading to your arrival. Keep open the possibility that trauma may have occurred. Determine MOI/NOI. Lecture Outline IV. Patient Assessment of Diabetes A. Scene size-up 1. Evaluate scene safety and ensure all hazards are addressed. a. Be careful of the presence of syringes, used by patients with diabetes for insulin. b. Be alert for clues (eg, syringes, insulin bottles, plate of food, glass of orange juice) that may help you decide what is possibly wrong with the patient. c. Use standard precautions. d. Question bystanders on events leading to your arrival. e. Keep open the possibility that trauma may have occurred. 2. Determine the mechanism of injury (MOI)/nature of illness (NOI).

Primary Assessment (1 of 3)
Form a general impression. Airway and breathing Patients showing signs of inadequate breathing, a pulse oximetry level less than or equal to 94%, or altered mental status should receive high-flow oxygen (12 to 15 L/min via nonrebreathing mask). Lecture Outline B. Primary assessment 1. Form a general impression. a. How does the patient look? b. Identify life threats and provide lifesaving interventions, particularly airway management. c. Determine level of consciousness using the AVPU scale. i. If unresponsive and you suspect the patient has diabetes: (a) Call for ALS. (b) Patient may have undiagnosed diabetes. ii. If patient has altered mental status: (a) Assess blood glucose level if you have proper equipment and training. d. Perform cervical spine immobilization, when necessary, and provide rapid transport. 2. Assess the patient’s airway and breathing. a. Patients showing signs of inadequate breathing, a pulse oximetry level less than or equal to 94%, or altered mental status should receive high-flow oxygen (12 to 15 L/min via nonrebreathing mask).

Airway and breathing (cont’d) Hyperglycemic patients may have Kussmaul respirations and sweet, fruity breath. Hypoglycemic patients will have normal or shallow to rapid respirations. Manage respiratory distress. Lecture Outline b. Hyperglycemic patients may have rapid, deep (Kussmaul) respirations and sweet, fruity breath. c. Hypoglycemic patients will have normal or shallow to rapid respirations. d. If the patient is not breathing or having difficulty breathing: i. Open the airway; insert airway adjunct. ii. Administer oxygen. iii. Assist ventilations. iv. Continue to monitor ventilations throughout patient care.

Circulatory status Dry, warm skin: hyperglycemia Moist, pale skin: hypoglycemia Rapid, weak pulse: symptomatic hypoglycemia Transport decision Transport promptly patients with altered mental status and impaired ability to swallow. Lecture Outline 3. Assess the patient’s circulatory status. a. Dry, warm skin: hyperglycemia b. Moist, pale skin: hypoglycemia c. Rapid, weak pulse: symptomatic hypoglycemia 4. Make a transport decision. a. Patients with altered mental status and impaired ability to swallow should be transported promptly.

History Taking (1 of 2) Investigate chief complaint.
Obtain history of present illness from responsive patient, family, or bystanders. If patient has eaten but not taken insulin, hyperglycemia is more likely. If patient has taken insulin but not eaten, hypoglycemia is more likely. Carefully observe signs and symptoms; determine whether hypo- or hyperglycemic. Lecture Outline C. History taking 1. Investigate the chief complaint. a. Obtain a history of the present illness from responsive patients, family, or bystanders. b. If patient has eaten but not taken insulin, hyperglycemia is more likely. c. If patient has taken insulin but not eaten, hypoglycemia is more likely. d. Observe physical signs and symptoms to determine whether the patient is hyperglycemic or hypoglycemic.

History Taking (2 of 2) SAMPLE history—ask the patient:
Do you take insulin or pills to lower blood sugar? Do you wear an insulin pump? Have you taken your usual insulin dose (or pills) today? Have you eaten normally today? Have you had any illness, unusual amount of activity, or stress? Lecture Outline 2. Obtain the SAMPLE history from a responsive patient or a family member or bystander. a. For a known patient with diabetes, ask: i. Do you take insulin or pills that lower your blood sugar? ii. Do you wear an insulin pump? iii. Have you taken your usual insulin dose (or pills) today? iv. Have you eaten normally today? v. Have you had any illness, unusual amount of activity, or stress? b. Look for an emergency medical identification device (eg, wallet card, necklace, or bracelet).

Secondary Assessment (1 of 3)
Physical examination Assess unresponsive patients from head to toe. When you suspect a diabetes-related problem, focus on mental status, ability to swallow, and ability to protect airway. Obtain a Glasgow Coma Scale score. Lecture Outline D. Secondary assessment 1. Physical examination a. Assess unresponsive patients from head to toe with a secondary assessment of the entire body. b. When you suspect a diabetes-related problem, focus on mental status, ability to swallow, and ability to protect the airway. i. Obtain a Glasgow Coma Scale (GCS) score.

Vital signs Use a glucometer, if available and protocols allow. Hypoglycemia: Respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure Hyperglycemia: Respirations may be deep and rapid; pulse may be rapid, weak, and thready; and skin may be warm and dry with a normal blood pressure Lecture Outline 2. Vital signs, including blood glucose level. a. Use a glucometer, if available and protocols allow. b. Overall i. Hypoglycemia: respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure ii. Hyperglycemia: respirations may be deep and rapid; pulse may be rapid, weak, and thready; and skin may be warm and dry with a normal blood pressure

Portable glucometer Study the operator’s manual for proper use in the field. Know the upper and lower ranges at which your glucometer functions. Normal nonfasting adult and child blood glucose level range: 80 to 120 mg/dL; neonates should be above 70 mg/dL Lecture Outline c. Portable glucometer i. Study the operator’s manual for proper use in the field. ii. Know the upper and lower ranges at which your glucometer functions. iii. Normal nonfasting adult and child blood glucose level range: 80 to 120 mg/dL; neonates should be above 70 mg/dL

Reassessment (1 of 3) Interventions
Reassess patient with diabetes frequently. For hypoglycemic, conscious patients who can swallow: Encourage patient to take glucose tablets or drink juice containing sugar. Administer gel preparation or sugar drink (if protocols allow). Provide rapid transport. Lecture Outline E. Reassessment 1. Reassess the patient with diabetes frequently to assess changes. a. Improved mental status? b. Are ABCs intact? c. How is patient reacting to interventions performed? d. Base administration of glucose on serial glucometer readings or a deteriorating level of consciousness. 2. Provide the indicated interventions. a. For hypoglycemic, conscious patients who can swallow without the risk of aspiration (inhalation of a substance): i. Encourage patient to take glucose tablets, if available, or drink juice containing sugar. ii. Administer gel preparation or sugar drink, if local protocol permits. iii. Provide rapid transport to hospital.

Reassessment (2 of 3) Interventions (cont’d)
Hypoglycemic, unconscious patient at risk of aspiration: Patient needs intravenous (IV) glucose or intramuscular (IM) or intranasal (IN) glucagon (beyond EMT competencies). When in doubt, consult medical control. Lecture Outline b. For unconscious, hypoglycemic patients, or patients with risk of aspiration: i. Intravenous (IV) glucose or intramuscular (IM) or intranasal (IN) glucagon is needed, which most EMTs are not permitted to give. c. If in doubt whether that patient has symptomatic hyperglycemia or hypoglycemia, most protocols will err on the side of giving glucose i. When in doubt, consult medical control.

Reassessment (3 of 3) If unable to test for a blood glucose value:
Perform a thorough assessment. Contact the hospital to help sort out the signs and symptoms. Coordinate communication and documentation. Patients who refuse transport after oral glucose may require more thorough documentation. Lecture Outline 3. Determining blood glucose level in a patient with diagnosed diabetes can be difficult when signs and symptoms are confusing and you have no way to test for a blood glucose value. In these situations: a. Perform a thorough assessment. b. Contact the hospital to help sort out the signs and symptoms. 4. Coordinate communication and documentation. a. Patients who refuse transport because their symptoms improve after taking oral glucose may require even more thorough documentation.

Emergency Medical Care for Diabetic Emergencies (1 of 2)
Giving oral glucose Three types of oral glucose: Rapidly dissolving gel Large chewable tablets Liquid formulation Accu-Chek® Aviva used with permission of Roche Diagnostics. Lecture Outline V. Emergency Medical Care for Diabetic Emergencies A. Giving oral glucose 1. Three types of oral glucose preparations available commercially a. Rapidly dissolving gel b. Large chewable tablets c. Liquid formulation

Emergency Medical Care for Diabetic Emergencies (2 of 2)
Oral glucose (cont’d) Contraindications: inability to swallow and unconsciousness Wear gloves before putting anything in patient’s mouth. Follow local protocols for glucose administration. Reassess frequently. Provide transport. Lecture Outline 2. The only contraindications are the inability to swallow and unconsciousness. 3. Wear gloves before putting anything in the patient’s mouth. 4. Follow local protocols for glucose administration (see Skill Drill 19-1). 5. Reassess the patient frequently. 6. Provide transport to the next level of care.

The Presentation of Hypoglycemia (1 of 4)
Seizures should be considered very serious. Hypoglycemia is a possible cause of seizures. May indicate a potentially life-threatening underlying condition Management Lecture Outline VI. The Presentation of Hypoglycemia A. Seizures 1. Should be considered very serious, even in patients with a history of chronic seizures. Hypoglycemia is a possible cause of seizures. 2. Though brief seizures are not harmful, they may indicate a potentially life-threatening underlying condition. 3. Management a. Ensure that the airway is clear. b. Place the patient on his or her side, if there is no possibility of cervical trauma. c. Do not place anything in the patient’s mouth (eg, bite stick or oral airway). d. Have suctioning equipment ready in case the patient vomits. e. If the patient is cyanotic or appears to be breathing inadequately, provide oxygen or artificial ventilations. f. Transport promptly.

Altered mental status May be caused by other conditions May be caused by diabetes complications Use the mnemonic AEIOU-TIPS. Management Lecture Outline B. Altered mental status 1. May be from other conditions 2. May be caused by complications of diabetes a. Hypoglycemia b. Ketoacidosis 3. Use the mnemonic AEIOU-TIPS. a. Always suspect and check for low blood glucose in a patient with altered mental status. 4. Management a. Ensure that the airway is clear. b. Be prepared to provide artificial ventilations. c. Be prepared to suction if the patient vomits. d. Provide prompt transport.

Misdiagnosis of neurologic dysfunction Symptoms mistaken for intoxication A patient with diabetes confined by police is at risk. Look for emergency medical identification. Perform blood glucose test at scene (if protocols allow). Diabetes and alcoholism can coexist in a patient. Lecture Outline C. Misdiagnosis of neurologic dysfunction 1. Occasionally patients with diabetic emergencies are thought to be intoxicated. 2. A diabetic patient confined by police is at risk. 3. An emergency medical identification bracelet, necklace, or card may help to save the patient’s life in such situations. 4. A blood glucose test performed at the scene (if protocols allow) or in the ED will identify the real problem. 5. Be alert to the potential for diabetes and alcoholism to coexist in a patient.

Relationship to airway management May not have a gag reflex Vomit or tongue may obstruct airway. Carefully monitor airway. Place patient in lateral recumbent position. Make sure suction is available. Lecture Outline D. Relationship to airway management. 1. May not have a gag reflex and vomit or tongue may obstruct the airway. 2. Carefully monitor the airway. 3. Place the patient in a lateral recumbent position. 4. Make sure that suction is readily available.

Hematologic Emergencies
Hematology is the study of blood-related diseases. Three disorders that can create a prehospital emergency: Sickle cell disease Hemophilia A Thrombophilia Lecture Outline VII. Hematologic Emergencies A. Hematology is the study of blood-related diseases. 1. Three disorders that can create a prehospital emergency: a. Sickle cell disease b. Hemophilia A c. Thrombophilia

Anatomy and Physiology
Blood is made up of four components. Red blood cells contain hemoglobin, which carries oxygen to the tissues. White blood cells respond to infection and collect dead cells for their correct disposal. Platelets assist in clot formation. Plasma serves as the transportation medium. Lecture Outline VIII. Anatomy and Physiology A. Blood is made up of four components: erythrocytes, leukocytes, platelets, and plasma. 1. Each of the components of the blood serves a purpose in maintaining the body’s homeostatic balance. 2. Red blood cells (RBCs or erythrocytes) contain hemoglobin, which carries oxygen to the tissues. 3. White blood cells (WBCs or leukocytes) respond to infection and collect dead cells for their correct disposal. 4. Platelets assist in forming a clot to stop bleeding. 5. Plasma serves as the transportation medium for blood components, proteins, and minerals.

Pathophysiology (1 of 7) Sickle cell disease
Inherited disorder, affects red blood cells Predominantly in people of African, Caribbean, and South American ancestry People with sickle cell disease have misshapen RBCs that lead to dysfunction in oxygen binding and unintentional clot formation. Clots may result in a blockage known as vasoocclusive crisis. Can result in hypoxia, pain, and organ damage Lecture Outline IX. Pathophysiology A. Sickle cell disease, also called hemoglobin S disease 1. An inherited blood disorder that affects RBCs 2. Found predominantly in people of African, Caribbean, and South American ancestry 3. People with sickle cell disease have misshapen RBCs that lead to dysfunction in oxygen binding and unintentional clot formation. a. Clots may result in a blockage known as vasoocclusive crisis. b. Can result in hypoxia, substantial pain, and organ damage

Pathophysiology (2 of 7) Sickle cell disease (cont’d)
Sickled cells have a short life span Results in more cellular waste products and contributing to sludging of the blood Complications include: Anemia Gallstones Jaundice Splenic dysfunction Vascular occlusion with ischemia Lecture Outline 4. Sickled cells have a short life span, resulting in more cellular waste products in the bloodstream and contributing to sludging (clumping) of the blood. a. Maintaining hydration is important, as insufficient hydration leads to increased clumping. 5. Complications associated with sickle cell disease include: a. Anemia b. Gallstones c. Jaundice d. Splenic dysfunction e. Vascular occlusion with ischemia

© Science Picture Co/Science Source.
Pathophysiology (3 of 7) Sickle cell disease (cont’d) Many of these complications are very painful and potentially life threatening. Lecture Outline 6. Many of these complications are very painful and potentially life threatening. a. The patient is also more susceptible to infections. © Science Picture Co/Science Source.

Pathophysiology (4 of 7) Clotting disorders—hemophilia
Rare: Only about 20,000 Americans have the disorder. Hemophilia A affects mostly males. Decreased ability to create a clot after an injury, which can be life threatening Patients typically have intravenous factor VIII replacement infusions (which help the blood clot) close at hand. Lecture Outline B. Clotting disorders 1. Hemophilia a. Rare: only about 20,000 Americans have the disorder. i. Hemophilia A affects mostly males. b. People with hemophilia A have a decreased ability to create a clot after an injury, which can be life threatening. c. Patients with hemophilia A typically have intravenous factor VIII replacement infusions, which help the blood clot, close at hand.

Pathophysiology (5 of 7) Clotting disorders—thrombophilia
Disorder in the body’s ability to maintain the smooth flow of blood through the venous and arterial systems Concentration of particular elements in the blood creates clogging or blockage issues General term for many conditions that result in blood clotting more easily than normal Clots can spontaneously develop in the blood of the patient. Lecture Outline 2. Thrombophilia a. A disorder in the body’s ability to maintain the smooth flow of blood through the venous and arterial systems b. The concentration of particular elements in the blood creates clogging or blockage issues. c. Thrombophilia is a general term for many different conditions that result in the blood clotting more easily than normal. i. Inherited (genetic) disorders ii. Medications or other factors iii. Patients with cancer d. Clots can spontaneously develop in the blood of the patient.

Pathophysiology (6 of 7) Clotting disorders—deep vein thrombosis (DVT)
Common medical problem in sedentary patients and in patients who have had recent injury or surgery Methods designed to prevent blood clot formation, include: Blood-thinning medications Compression stockings Mechanical devices Lecture Outline 3. Deep vein thrombosis (DVT) a. A common medical problem in sedentary patients and in patients who have had recent injury or surgery b. You may encounter several methods prevent blood clot formation, including: i. Blood-thinning medications ii. Compression stockings iii. Mechanical devices

Pathophysiology (7 of 7) Clotting disorders—DVT (cont’d) Risk factors
Treatment Anticoagulation therapy Oral medications typically administered for at least 3 months after diagnosis of a DVT A clot from the DVT can travel from the patient’s lower extremity to the lung, causing a pulmonary embolus. Lecture Outline c. Risk factors d. Treatment i. Anticoagulation therapy (a) In-hospital IV medications transitioned to oral medications before discharge (b) Self-administered subcutaneous injectable or oral medications ii. Oral medications are typically administered for at least 3 months after diagnosis of a DVT f. A clot from the DVT can travel from the patient’s lower extremity to the lung, causing a pulmonary embolus.

Scene Size-up Scene safety MOI/NOI
Most sickle cell patients will have had a crisis before. Wear gloves and eye protection at a minimum. Consider ALS support. MOI/NOI Remember, trauma may also have occurred. Lecture Outline X. Patient Assessment of Hematologic Disorders A. Scene size-up 1. Ensure scene safety. a. Most sickle cell patients will have had a crisis before. b. Wear gloves and eye protection at a minimum. c. Consider ALS support (eg, analgesic administration for vasoocclusive crisis pain). 2. Determine the MOI/NOI. a. Remember that trauma may also have occurred.

Perform cervical spine immobilization, if necessary. Form a general impression. Airway and breathing Inadequate breathing or altered mental status: High-flow oxygen at 12 to 15 L/min via nonrebreathing mask Sickle cell crisis patients may have increased respirations or signs of pneumonia. Lecture Outline B. Primary assessment 1. Perform cervical spine immobilization, if necessary. 2. Form a general impression. 3. Assess the patient’s airway and breathing. a. For patients with inadequate breathing or altered mental status: i. Provide high-flow oxygen at 12 to 15 L/min via nonrebreathing mask. b. Patients experiencing a sickle cell crisis may have increased respirations or exhibit signs of pneumonia. c. For patients with breathing difficulty: i. Open the airway; insert airway adjunct. ii. Administer oxygen; assist ventilations.

Circulation Sickle cell patients: increased heart rate Hemophilia: Be alert for signs of acute blood loss. Note bleeding of unknown origin. Be alert for signs of hypoxia. Make a transport decision. Transport to an ED is recommended for any patient with sickle cell crisis or hemophilia. Lecture Outline 4. Assess the patient’s circulatory status. a. Sickle cell crisis patients will have increased heart rate to “force” sickled cells through smaller blood vessels. b. For suspected hemophilia patients: i. Be alert for signs of acute blood loss. ii. Note bleeding of unknown origin iii. Be alert for signs of hypoxia, which is due to blood loss. 5. Make a transport decision. a. Transport to an ED should always be recommended to any patient who is experiencing a sickle cell crisis or hemophilia.

History Taking (1 of 3) Investigate chief complaint.
Obtain history of present illness from responsive patients, family, or bystanders. Be alert for physical signs indicating sickle cell crisis. Lecture Outline C. History taking 1. Investigate the chief complaint. a. Obtain a history of the present illness from responsive patients, family, or bystanders. b. Be alert for physical signs indicating sickle cell crisis

History Taking (2 of 3) Ask about:
Is pain isolated in single location or felt throughout body? Visual disturbances? Nausea, vomiting, or abdominal cramping? Chest pain or shortness of breath? Lecture Outline 2. You should also ask following questions: a. Is pain isolated to a single location or felt throughout the body? b. Is the patient having visual disturbances? c. Is the patient experiencing nausea, vomiting, or abdominal cramping? d. Is the patient experiencing chest pain or shortness of breath?

History Taking (3 of 3) Obtain SAMPLE history from responsive patient or family member. Have you had a crisis before? When was the last time you had a crisis? How did your last crisis resolve? Recent illness, unusual amount of activity, or stress? Lecture Outline 3. Obtain the SAMPLE history from a responsive patient or family member. a. Have you had a crisis before? b. When was the last time you had a crisis? c. How did your last crisis resolve? d. Have you had any illnesses, unusual amount of activity, or stress lately?

Secondary Assessment Physical examination Vital signs
Focus on major joints. Evaluate and document mental status using AVPU. Vital signs Obtain complete set of vital signs. Look for signs of sickle cell crisis. Use pulse oximeter, if available. Lecture Outline D. Secondary assessment 1. Systematically examine the patient. a. Focus on major joints at which cells congregate. b. Evaluate and document mental status using the AVPU scale. 2. Obtain a complete set of vital signs, including oxygen saturation level. a. Normal sickle cell crisis vital signs: i. Normal to rapid respirations ii. Weak, rapid pulse iii. Pale, clammy skin iv. Low blood pressure b. Use pulse oximeter, if available, to monitor oxygen saturation. i. Reading may be inaccurate due to patient’s anemic state.

Reassessment Reassess vital signs frequently.
Evaluate interventions and adjust or change as necessary. Administer supplemental oxygen via nonrebreathing mask at 12 to 15 L/min. Communicate with hospital staff for continuity of care and document clearly. Lecture Outline E. Reassessment 1. Reassess vital signs frequently to determine changes in the patient’s condition. a. Are there changes in mental status? b. Are the ABCs intact? 2. How is the patient responding to the interventions performed? 3. Administer supplemental oxygen via nonrebreathing mask at 12 to 15 L/min to attempt to compensate for decreased cellular oxygenation related to the sickled cells or hemophilia. 4. Communicate with hospital staff for continuity of care and document clearly.

Emergency Medical Care for Hematologic Disorders
Mainly supportive and symptomatic Patients with inadequate breathing or altered mental status: Administer high-flow oxygen at 12 to 15 L/min via nonrebreathing mask. Place in a position of comfort. Transport rapidly to hospital. Lecture Outline XI. Emergency Medical Care for Hematologic Disorders A. Emergency care is mainly supportive and symptomatic. B. For patients with inadequate breathing or altered mental status: 1. Administer high-flow oxygen 12 to 15 L/min via nonrebreathing mask. 2. Place in position of comfort. 3. Transport rapidly to hospital.

Review Type 1 diabetes is a condition in which:
too much insulin is produced. glucose utilization is impaired. too much glucose enters the cell. the body does not produce glucose.

Review Answer: B Rationale: Type 1 diabetes is a disease in which the pancreas fails to produce enough insulin (or produces none at all). Insulin is a hormone that promotes the uptake of sugar from the bloodstream and into the cells. Without insulin, glucose utilization is impaired because it cannot enter the cell.

Review (1 of 2) Type 1 diabetes is a condition in which:
too much insulin is produced. Rationale: The body only produces the amount of insulin that is needed to enable glucose to enter cells. glucose utilization is impaired. Rationale: Correct answer

Review (2 of 2) Type 1 diabetes is a condition in which:
too much glucose enters the cell. Rationale: An abnormally high blood glucose level is known as hyperglycemia. the body does not produce glucose. Rationale: Glucose is derived from the oral intake of carbohydrates. It is stored in different body structures and then metabolized by cells.

Review A 45-year-old man with type 1 diabetes is found unresponsive. Which of the following questions is MOST important to ask his wife? “Did he take his insulin today?” “How long has he been a diabetic?” “Has he seen his physician recently?” “What kind of insulin does he take?”

Review Answer: A Rationale: All of these questions are important to ask the spouse of an unconscious diabetic. However, it is critical to ask if the patient took his insulin. This will help you differentiate hypoglycemic crisis from hyperglycemic crisis. For example, if the patient took his insulin and did not eat, or accidentally took too much insulin, you should suspect hypoglycemic crisis. If the patient did not take his insulin, you should suspect hyperglycemic crisis.

Review (1 of 2) A 45-year-old man with type 1 diabetes is found unresponsive. Which of the following questions is MOST important to ask his wife? “Did he take his insulin today?” Rationale: Correct answer “How long has he been a diabetic?” Rationale: This is useful SAMPLE history information.

Review (2 of 2) A 45-year-old man with type 1 diabetes is found unresponsive. Which of the following questions is MOST important to ask his wife? “Has he seen his physician recently?” Rationale: This is also important SAMPLE history information. “What kind of insulin does he take?” Rationale: This provides important information about a patient’s medications.

Review A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of: excretion of glucose and water from the kidneys. a deficiency of insulin that causes internal fluid loss. an infection that often accompanies hyperglycemia. an inability to produce energy because of insulin depletion.

Review Answer: A Rationale: In severe hyperglycemia, the kidneys excrete excess glucose from the body. This process requires a large amount of water to accomplish; therefore, water is excreted with the glucose, resulting in dehydration.

Review (1 of 4) A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of: excretion of glucose and water from the kidneys. Rationale: Correct answer

Review (2 of 4) A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of: a deficiency of insulin that causes internal fluid loss. Rationale: A lack of insulin will cause the glucose level to rise, and it is the glucose that causes the fluid loss.

Review (3 of 4) A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of: an infection that often accompanies hyperglycemia. Rationale: An infection is an invasion of the body by an organism—glucose is not a foreign element.

Review (4 of 4) A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of: an inability to produce energy because of insulin depletion. Rationale: A body’s inability to metabolize glucose does not cause a fever.

Review Which combination of factors would MOST likely cause a hypoglycemic crisis in a diabetic patient? Eating a meal and taking insulin Skipping a meal and taking insulin Eating a meal and not taking insulin Skipping a meal and not taking insulin

Review Answer: B Rationale: The combination that would most likely cause a hypoglycemic crisis is skipping a meal and taking insulin. The patient will use up all available glucose in the bloodstream and become hypoglycemic. Left untreated, hypoglycemic crisis may cause permanent brain damage or even death.

Review (1 of 2) Which combination of factors would MOST likely cause a hypoglycemic crisis in a diabetic patient? Eating a meal and taking insulin Rationale: This process will maintain the body’s glucose level. Skipping a meal and taking insulin Rationale: Correct answer

Review (2 of 2) Which combination of factors would MOST likely cause a hypoglycemic crisis in a diabetic patient? Eating a meal and not taking insulin Rationale: Eating will cause the glucose levels to rise. Skipping a meal and not taking insulin Rationale: Glucose levels should remain the same but may be influenced by the patient’s metabolic rate or physical activities. This does not cause a hypoglycemic crisis.

Review A 19-year-old diabetic male was found unresponsive on the couch by his roommate. After confirming that the patient is unresponsive, you should: suction his oropharynx. manually open his airway. administer high-flow oxygen. begin assisting his ventilations.

Review Answer: B Rationale: Immediately after determining that a patient is unresponsive, your first action should be to manually open his or her airway (eg, head tilt–chin lift, jaw-thrust). Use suction as needed to clear secretions from the patient’s mouth. After manually opening the airway and ensuring it is clear of obstructions, insert an nasal airway adjunct and then assess the patient’s breathing.

Review (1 of 2) A 19-year-old diabetic male was found unresponsive on the couch by his roommate. After confirming that the patient is unresponsive, you should: suction his oropharynx. Rationale: After opening the airway, suction as needed to remove any secretions. manually open his airway. Rationale: Correct answer

Review (2 of 2) A 19-year-old diabetic male was found unresponsive on the couch by his roommate. After confirming that the patient is unresponsive, you should: administer high-flow oxygen. Rationale: After opening the airway, provide oxygen only as clinically indicated. begin assisting his ventilations. Rationale: After opening the airway, assist with ventilations if the patient’s breathing is inadequate.

Review What breathing pattern would you MOST likely encounter in a patient with diabetic ketoacidosis (DKA)? Slow and shallow Shallow and irregular Rapid and deep Slow and irregular

Review Answer: C Rationale: Kussmaul respirations—a rapid and deep breathing pattern seen in patients with DKA—indicates that the body is attempting to eliminate ketones via the respiratory system. A fruity or acetone breath odor is usually present in patients with Kussmaul respirations.

Review (1 of 2) What breathing pattern would you MOST likely encounter in a patient with diabetic ketoacidosis (DKA)? Slow and shallow Rationale: Agonal respirations are seen with cerebral anoxia and may have an occasional gasp. Shallow and irregular Rationale: Agonal respirations are seen with cerebral anoxia and may have an occasional gasp.

Review (2 of 2) What breathing pattern would you MOST likely encounter in a patient with diabetic ketoacidosis (DKA)? Rapid and deep Rationale: Correct answer Slow and irregular Rationale: Slow and irregular respiration results from increased intracranial pressure and can also have periods of apnea.

Review A woman called EMS because her 12-year-old son, who had been experiencing excessive urination, thirst, and hunger for the past 36 hours, has an altered mental status and is breathing fast. You should be MOST suspicious for: low blood sugar. hypoglycemia. hypoglycemic crisis. hyperglycemic crisis.

Review Answer: D Rationale: The child is experiencing a hyperglycemic crisis secondary to severe hyperglycemia. Hyperglycemic crisis is characterized by a slow onset and excessive urination (polyuria), thirst (polydipsia), and hunger (polyphagia). Other signs include rapid, deep breathing with a fruity or acetone breath odor (Kussmaul respirations); a rapid, thready pulse; and an altered mental status.

Review (1 of 2) A woman called EMS because her 12-year-old son, who had been experiencing excessive urination, thirst, and hunger for the past 36 hours, has an altered mental status and is breathing fast. You should be MOST suspicious for: low blood sugar. Rationale: Low blood sugar does not cause frequent urination. hypoglycemia. Rationale: Hypoglycemia is low blood sugar.

Review (2 of 2) A woman called EMS because her 12-year-old son, who had been experiencing excessive urination, thirst, and hunger for the past 36 hours, has an altered mental status and is breathing fast. You should be MOST suspicious for: hypoglycemic crisis. Rationale: Hypoglycemic crisis does not produce any of these symptoms. hyperglycemic crisis. Rationale: Correct answer

Review If the cells do not receive glucose, they will begin to metabolize: fat. acid. sugar. ketones.

Review Answer: A Rationale: If the body’s cells do not receive glucose, they will begin to metabolize the next most readily available substance—fat. Fat metabolism results in the production of ketoacids, which are released into the bloodstream (hence the term “ketoacidosis”).

Review (1 of 2) If the cells do not receive glucose, they will begin to metabolize: fat. Rationale: Correct answer acid. Rationale: Fatty acids are a by-product (waste product) of the metabolism of fat.

Review (2 of 2) If the cells do not receive glucose, they will begin to metabolize: sugar. Rationale: Sugar is glucose. ketones. Rationale: Ketones are a by-product (waste product) of the metabolism of fat.

Review In contrast to a hyperglycemic crisis, a hypoglycemic crisis:
rarely presents with seizures. presents over a period of hours to days. should not routinely be treated with glucose. usually responds immediately after treatment.

Review Answer: D Rationale: Hypoglycemic crisis usually responds immediately following treatment with glucose. Patients with hyperglycemic crisis generally respond to treatment gradually, within 6–12 hours following the appropriate treatment. Seizures can occur with both hyperglycemic crisis and hypoglycemic crisis, but are more common in patients with hypoglycemic crisis.

Review (1 of 2) In contrast to a hyperglycemic crisis, a hypoglycemic crisis: rarely presents with seizures. Rationale: Hypoglycemic crisis can produce seizures. presents over a period of hours to days. Rationale: Hypoglycemic crisis has a rapid onset of symptoms (possible minutes).

Review (2 of 2) In contrast to a hyperglycemic crisis, a hypoglycemic crisis: should not routinely be treated with glucose. Rationale: Hypoglycemic crisis is always treated with glucose. usually responds immediately after treatment. Rationale: Correct answer

Review Patients with diabetic ketoacidosis experience polydipsia because: they are dehydrated secondary to excessive urination. the cells of the body are starved due to a lack of glucose. fatty acids are being metabolized at the cellular level. hyperglycemia usually causes severe internal water loss.

Review Answer: A Rationale: Severe hyperglycemia—which leads to diabetic ketoacidosis—causes the body to excrete large amounts of glucose and water. As a result, the patient becomes severely dehydrated, which leads to excessive thirst (polydipsia).

Review (1 of 2) Patients with diabetic ketoacidosis experience polydipsia because: they are dehydrated secondary to excessive urination. Rationale: Correct answer the cells of the body are starved due to a lack of glucose. Rationale: True, but the lack of glucose does not cause thirst.

Review (2 of 2) Patients with diabetic ketoacidosis experience polydipsia because: fatty acids are being metabolized at the cellular level. Rationale: Fats are metabolized by the cells instead of glucose, which produces acids and ketones—thus the term ketoacidosis. hyperglycemia usually causes severe internal water loss. Rationale: This is false. It causes water loss due to glucose being excreted (externally) in the urine solution.

Review When dealing with hematologic disorders, the EMT must be familiar with the composition of blood. Which of the following is considered a hematologic disease? Sickle cell disease Hemophilia Lou Gehrig’s disease Both A and B

Review Answer: D Rationale: Hematology is the study and prevention of blood-related diseases, such as sickle cell disease and hemophilia.

Review (1 of 2) When dealing with hematologic disorders, the EMT must be familiar with the composition of blood. Which of the following is considered a hematologic disease? Sickle cell disease Rationale: Sickle cell disease is a hematologic disorder affecting the red blood cells. Hemophilia Rationale: Hemophilia is a hematologic disorder affecting the blood’s ability to clot.

Review (2 of 2) When dealing with hematologic disorders, the EMT must be familiar with the composition of blood. Which of the following is considered a hematologic disease? Lou Gehrig’s disease Rationale: Lou Gehrig’s disease affects the nerve cells in the brain and spinal cord. Both A and B Rationale: Correct answer

Review What are the two main components of blood?
Erythrocytes and hemoglobin Cells and plasma Leukocytes and white blood cells Platelets and neutrophils

Review Answer: B Rationale: The blood is made up of two main components: cells and plasma. The cells in the blood include red blood cells (erythrocytes), white blood cells (leukocytes), and platelets. These cells are suspended in a straw-colored fluid called plasma.

Review (1 of 2) What are the two main components of blood?
Erythrocytes and hemoglobin Rationale: Erythrocytes are a type of blood cell, and hemoglobin is a chemical that is contained within blood cells. Cells and plasma Rationale: Correct answer

Review (2 of 2) What are the two main components of blood?
Leukocytes and white blood cells Rationale: Leukocytes are white blood cells, which are a type of blood cell. Platelets and neutrophils Rationale: Platelets are a type of blood cell, and neutrophils are a type of white blood cell.

Review The assessment of a patient with a hematologic disorder is the same as it is with all other patients an EMT will encounter. In addition to obtaining a SAMPLE history, EMTs should ask which of the following questions? Have you had a crisis before? When was the last time you had a crisis? How did your crisis resolve? All of the above.

Review Answer: D Rationale: SAMPLE is the mnemonic used in taking the history of all patients. In addition to asking the SAMPLE, EMTs should also ask about past crises.

Review (1 of 2) The assessment of a patient with a hematologic disorder is the same as it is with all other patients an EMT will encounter. In addition to obtaining a SAMPLE history, EMTs should ask which of the following questions? Have you had a crisis before? Rationale: You should ask the patient this question. When was the last time you had a crisis? Rationale: You should ask the patient this question.

Review (2 of 2) The assessment of a patient with a hematologic disorder is the same as it is with all other patients an EMT will encounter. In addition to obtaining a SAMPLE history, EMTs should ask which of the following questions? How did your crisis resolve? Rationale: You should ask the patient this question. All of the above. Rationale: Correct answer

Review Which one of the following is NOT an appropriate treatment for EMTs to provide to a patient who has a hematologic disorder? Analgesics for pain Support of symptoms High-flow oxygen therapy at 12 to 15 L/min Rapid transport

Review Answer: A Rationale: Although analgesics would benefit a patient suffering from a hematologic disorder, the administration of such medications is not in the scope of practice for the EMT. ALS providers would have to be present to provide this emergency care.

Review (1 of 2) Which one of the following is NOT an appropriate treatment for EMTs to provide to a patient who has a hematologic disorder? Analgesics for pain Rationale: Correct answer Support of symptoms Rationale: This is an appropriate treatment.

Review (2 of 2) Which one of the following is NOT an appropriate treatment for EMTs to provide to a patient who has a hematologic disorder? High-flow oxygen therapy at 12 to 15 L/min Rationale: This is an appropriate treatment. Rapid transport Rationale: This is an appropriate treatment.

Endocrine and Hematologic Emergencies

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Endocrine and Hematologic Emergencies

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