1. Chapter 20 Endocrine Disorders
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2. Objectives
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3. Glucose Glucose Sugar Basic fuel for body cells
Level of sugar in the blood must remain fairly constant
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Glucose, a sugar, is the basic fuel for body cells. The level of sugar in the blood (the “blood sugar”) must remain fairly constant to ensure proper functioning of the brain and body cells. The brain must constantly be supplied with glucose because it cannot store it. The brain is very sensitive to changes in glucose levels. Changes in glucose levels can result in changes in the patient’s behavior.

4. Glucose Regulation
The body’s blood glucose level is primarily regulated by the pancreas. Normal blood glucose levels generally range between 70 and 120 milligrams/deciliter (mg/dL). A rise in the blood glucose level (such as after a meal) stimulates beta cells in the pancreas to secrete the hormone insulin. Because glucose is a large molecule, it cannot easily enter the body’s cells where it is needed. Insulin helps glucose enter the body’s cells to be used for energy. As the blood glucose level drops toward normal, the release of insulin slows. Excess glucose is stored in the liver and muscles as glycogen. A drop in the blood glucose level stimulates the release of glucagon from alpha cells in the pancreas. Glucagon is a hormone that stimulates cells in the liver to break down stores of glycogen into glucose. This increases the blood glucose level. As the blood glucose level rises toward normal, the release of glucagon slows. Somatostatin is a hormone that is released by delta cells in the pancreas. This hormone inhibits the release of insulin and glucagon.

5. Pancreatic Cell Function
Pancreatic Cells
Hormone Released
Hormone Function
Alpha
Glucagon
Stimulates cells in the liver to break down stores of glycogen into glucose; increases blood sugar
Beta
Insulin
Helps glucose enter body cells to be used for energy; decreases blood sugar
Delta
Somatostatin
Inhibits release of insulin and glucagon

6. Insulin
Insulin
Helps transport glucose from the blood into cells where glucose is stored or used as fuel
For cells to use sugar properly there must be an adequate supply of insulin. In a healthy person, insulin secretion increases after eating. Insulin helps transport glucose from the blood into cells including muscle, liver, and fat cells where the glucose is stored or used as fuel.

7. Types of Diabetes Mellitus
Diabetes Type
Other Names
Possible Causes
Type I
Insulin-dependent diabetes mellitus (IDDM)
Juvenile diabetes
Usually unknown
Viral infection
Injury to pancreas
Immune system disorder
Type II
Noninsulin-dependent diabetes mellitus (NIDDM)
Adult-onset diabetes
Insulin resistance and relative insulin shortage
Gestational
Diabetes during pregnancy
Changes in body metabolism due to pregnancy

8. Type 1 Diabetes Mellitus
Little or no insulin is produced by beta cells in the pancreas
Buildup of glucose in the blood
Body’s cells are starved for glucose
Usually begins during childhood or young adulthood
In type 1 diabetes, little or no insulin is produced by beta cells in the pancreas. This results in a buildup of glucose in the blood. Despite the buildup of glucose in the blood, the body’s cells are starved for glucose because without insulin, glucose is unable to enter most body cells.
Although it may occur at any age, type 1 diabetes usually begins during childhood or young adulthood.

9. Common Signs and Symptoms
“Three polys”
Polyuria
Increased urination
Polydipsia
Increased thirst
Polyphagia
Increased appetite
Abdominal pain with vomiting
Fruity breath odor
Blurred vision
Tiredness
Signs and symptoms vary widely and may develop suddenly or gradually over days to weeks.

10. Usually requires treatment with insulin
Some patients also require treatment with oral medication
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Because the patient’s pancreas isn’t producing insulin, the patient with type 1 diabetes mellitus requires treatment with insulin. Some patients also require treatment with oral medication to manage their blood glucose level.

11. Type 2 Diabetes Mellitus
Most common type of diabetes
Usually affects people older than 40 years of age
Caused by a combination of insulin resistance and relative insulin shortage
Type 2 diabetes mellitus is the most common type of diabetes. It usually affects people older than 40 years of age, especially those who are overweight. Type 2 diabetes is caused by a combination of insulin resistance and relative insulin shortage. Insulin resistance refers to a condition in which the pancreas releases insulin, but the normal effect of insulin on the tissue cells of the body is diminished. In an attempt to counteract this resistance, the pancreas releases more insulin into the bloodstream. Insulin levels rise. In some cases, glucose builds up in the bloodstream despite the increased amount of insulin. This results in high blood glucose levels or type 2 diabetes.

12. Type 2 Diabetes Mellitus
Major causes of insulin resistance
Obesity
Genetics
Sedentary lifestyle
Stress
Major causes of insulin resistance include obesity, genetics, sedentary lifestyle, and stress. Type 2 diabetes mellitus can often be managed by diet, exercise, and oral medications that lower blood sugar levels. Some people require insulin.

13. Develops during pregnancy Treatment
Gestational Diabetes
Develops during pregnancy
Treatment
Special diet
Regular, moderate exercise
Daily blood glucose testing
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When a woman develops diabetes during pregnancy it is called gestational diabetes. Gestational diabetes does not include patients who were diabetic before pregnancy. According to the American Diabetes Association, gestational diabetes affects about 4% of all pregnant women. Hormones released during pregnancy can change the effectiveness of insulin. These changes usually begin in the 5th or 6th month of pregnancy. Diabetes develops if the pancreas cannot make enough insulin to control the level of glucose in the blood. Treatment for gestational diabetes includes a special diet; regular, moderate exercise (according to physician instructions), and daily blood glucose testing. Some patients require insulin injections.
Gestational diabetes usually goes away after the baby is born, but it may take several weeks. The mother is at increased risk for gestational diabetes in her next pregnancy and type 2 diabetes later in life.

14. Complications of Diabetes Mellitus
Changes in the retina that can lead to blindness
Kidney damage
Nerve damage
Can lead to loss of sensation and pain
Circulatory disorders
Complications of diabetes mellitus include:
Changes in the retina that can lead to blindness
Kidney damage
Nerve damage that can lead to loss of sensation and pain
Circulatory disorders such as a heart attack, stroke, blood vessel damage, and slow wound healing

15. Lower-than-normal blood sugar level Less than 70 mg/dL in adults
Hypoglycemia
Lower-than-normal blood sugar level
Less than 70 mg/dL in adults
Most common diabetic emergency
Symptom onset is sudden
Minutes to hours
Hypoglycemia is a lower-than-normal blood sugar level. In adults, hypoglycemia is a blood glucose level less than 70 mg/dL. Hypoglycemia is the most common diabetic emergency. The onset of hypoglycemia symptoms is sudden (minutes to hours).

16. Hypoglycemia Signs and Symptoms
Early
Late
Sweating
Palpitations
Increased heart rate
Tremors
Pale color
Hunger
Headache
Nervousness
Confusion, irritability
Tiredness
Staggering walk
Visual disturbances
Cool, pale, clammy skin
Fainting
Seizures
Coma
Early signs and symptoms of hypoglycemia include signs of stimulation of the sympathetic division of the autonomic nervous system. For example, the presence of sweating, palpitations, increased heart rate, tremors, pale color, hunger, and nervousness serves as an early warning system.
Remember that the brain cannot store glucose. If hypoglycemia is not corrected, signs and symptoms reflecting the brain’s lack of an adequate glucose supply will quickly follow. These signs and symptoms may include tiredness, irritability, visual disturbances, difficulty concentrating, confusion, combativeness, fainting, seizures, and loss of consciousness. Prolonged hypoglycemia can lead to irreversible brain damage.

17. The blood sugar level may become too low if the diabetic patient:
Hypoglycemia
The blood sugar level may become too low if the diabetic patient:
Has taken too much insulin
Has not eaten enough food
Has overexercised and burned off sugar faster than normal
Experiences significant physical or emotional stress
The blood sugar level may become too low if the diabetic patient:
Has taken too much insulin
Has not eaten enough food
Has overexercised and burned off sugar faster than normal
Experiences significant physical stress (such as an infection) or emotional stress

18. Higher-than-normal blood sugar level Gradual onset
Hyperglycemia
Higher-than-normal blood sugar level
Gradual onset
Hours to days
Hyperglycemia is a higher-than-normal blood sugar level. The onset of hyperglycemia symptoms is gradual (hours to days).

19. Hyperglycemia Signs and Symptoms
Altered mental status
Kussmaul respirations
Sweet or fruity (acetone) breath odor
Loss of appetite
Thirst
Dry skin
Abdominal pain
Nausea and/or vomiting
Increased heart rate
Normal or slightly decreased blood pressure
Weakness
Normally, the body metabolizes carbohydrates for energy. As hyperglycemia worsens, body cells become starved for sugar. Although sugar is present in the blood, it cannot be transported into the body’s cells without insulin. The buildup of sugar causes the kidneys to increase urine output, which leads to dehydration. Signs of dehydration include warm, dry skin and a loss of skin elasticity (poor skin turgor). Increased urine output results in the loss of large amounts of sodium, potassium, and other electrolytes. This can result in abnormal heart rhythms, abdominal pain, vomiting, and muscle cramping. The body begins breaking down fats and proteins to provide energy. The breakdown of fats and proteins produces waste products, including acids. The patient begins breathing deeply and rapidly in an attempt to get rid of the excess acid by “blowing off” carbon dioxide. This breathing pattern is called Kussmaul respirations. The patient’s breath may have a fruity (acetone) odor.

20. Diabetic Ketoacidosis (DKA)
Severe, uncontrolled hyperglycemia
Usually over 300 mg/dL
Usually occurs in people who have type 1 diabetes
May also occur in type 2 diabetes
DKA is also called diabetic coma
Diabetic ketoacidosis (DKA) is severe, uncontrolled hyperglycemia (usually over 300 mg/dL). DKA usually occurs in people who have type 1 diabetes, but may also occur in those who have type 2 diabetes. DKA is also called diabetic coma.

21. The blood sugar level may become too high when the diabetic patient:
Hyperglycemia
The blood sugar level may become too high when the diabetic patient:
Has not taken his insulin or oral diabetic medication, or has taken an incorrect dose
Has eaten too much food that contains or produces sugar
Has lost a large amount of fluid, such as through vomiting
Experiences physical or emotional stress that affects the body’s insulin production
The blood sugar level may become too high when the diabetic patient:
Has not taken his insulin or oral diabetic medication, or has taken an incorrect dose
Has eaten too much food that contains or produces sugar
Has lost a large amount of fluid, such as through vomiting
Experiences physical (such as infection, pregnancy, surgery) or emotional stress that affects the body’s insulin production

22. Patient Assessment
Scene size-up
Primary survey

23. Patient Assessment
Establish patient priorities
Determine the need for additional resources
Make a transport decision

24. Patient Assessment Secondary survey SAMPLE history OPQRST
Physical exam
Focused exam if patient responsive
Rapid medical assessment if unresponsive

25. Emergency Care Stabilize the spine if trauma is suspected
Assess need for oral or nasal airway
Suction as necessary
Give oxygen
Remove or loosen tight clothing
Maintain body temperature
Perform a blood glucose test
Give oral glucose per protocol if patient can swallow
Transport
Perform ongoing assessments
Stabilize the spine if trauma is suspected.
Any patient who has an altered mental status is at risk of not being able to manage his own airway. It is critical for you to aggressively assess the need for an oral or nasal airway, and to continuously monitor and reassess the patient’s airway. Suction as necessary.
Give oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min if not already done. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered.
Position the patient. If there is no possibility of cervical spine trauma, place the patient in a lateral recumbent (recovery) position to aid drainage of secretions. If the patient is immobilized due to suspected trauma and vomits, the patient and backboard should be turned as a unit and the patient’s airway cleared with suctioning.
Remove or loosen tight clothing.
Maintain body temperature.
Perform a blood glucose test (if permitted by state and local protocol).
If the patient is responsive, determine if the patient is alert enough to swallow. Give oral glucose according to local or state medical direction or protocol.
Transport. Perform ongoing assessments until patient care is turned over to ALS personnel or medical personnel at the receiving facility.

26. Performing a Blood Glucose Test
Purpose
Indications
Unresponsive patient, cause unknown (any age group, including trauma)
Known diabetic patient with signs and symptoms
Patients with altered mental status, cause unknown (including trauma)
Special situations
Blood glucose testing is used to assist in the management of patients with specific signs and symptoms. The results obtained from the test helps determine if the patient’s glucose level is too high, too low, or within normal limits. Patient care, treatment, and outcome may be improved with its use.

27. Performing a Blood Glucose Test
Skill Drill 20-1, Step 1
Performing a Blood Glucose Test with a Glucometer
Step 1:
Put on appropriate personal protective equipment.
Identify the need for blood glucose testing based on your assessment findings, the patient’s chief complaint, and past medical history.

28. Performing a Blood Glucose Test
[Insert skill drill 20-1 step 2]
Skill Drill 20-1, Step 2
Performing a Blood Glucose Test with a Glucometer (cont.)
Step 2:
Assemble and prepare the necessary equipment.
Explain the procedure to the patient.

29. Performing a Blood Glucose Test
[Insert skill drill 20-1 step 3]
Skill Drill 20-1, Step 3
Performing a Blood Glucose Test with a Glucometer (cont.)
Step 3:
Select and cleanse the puncture site. Be sure to allow the area to dry before pricking the skin. Any alcohol present on the skin will interfere with the test results.
Prick the skin quickly with the lancet to get a small drop of blood. Apply a drop of blood on the test strip. Be sure to completely cover the patch on the test strip with blood.

30. Performing a Blood Glucose Test
[Insert skill drill 20-1 step 4]
Skill Drill 20-1, Step 4
Performing a Blood Glucose Test with a Glucometer (cont.)
Step 4:
Turn on the glucometer. Insert the test strip. (Some manufacturers have the test strip placed in the machine before the drop of blood is obtained. Follow the manufacturer’s instructions.)
Wait for the glucometer to analyze the sample and display the patient’s glucose reading.
Apply a small adhesive bandage to the puncture site.

31. Oral Glucose
If approved by medical direction, you may give oral glucose to a patient who:
Has an altered mental status
Has a history of diabetes controlled by medication
Is able to swallow
If approved by medical direction (and your state and local EMS system), you may give oral glucose to a patient who has an altered mental status, has a history of diabetes controlled by medication, and is able to swallow. Oral glucose given to a patient with an altered mental status and a known history of diabetes can make a difference between development of coma (unconsciousness) and ability to maintain consciousness. If oral glucose is not available (and if approved by medical direction), other quick-sugar mixtures can be used.

32. Giving Oral Glucose [Insert skill drill 20-2 step 1]
Put on appropriate personal protective equipment.
Obtain an order from medical direction either on-line or off line.
Confirm that the patient has an altered mental status, has a history of diabetes controlled by medication, and is able to swallow and protect his or her airway.

33. Giving Oral Glucose [Insert skill drill 20-2 step 2]
Giving Oral Glucose (cont.)
Step 2:
Squeeze the glucose from the tube onto a tongue depressor.

34. Giving Oral Glucose [Insert skill drill 20-2 step 3]
Giving Oral Glucose (cont.)
Step 3:
Place the tongue depressor between the patient’s cheek and gum.
Remove the tongue depressor from the patient's mouth once the gel is dissolved or if the patient loses consciousness or seizes.

35. Giving Oral Glucose [Insert skill drill 20-2 step 4]
Giving Oral Glucose (cont.)
Step 4:
Document the patient's name, drug name and dose given, time of administration, and the patient's response to the drug.
If an on-line order was received by medical direction, document the name of the physician giving the order.
Perform ongoing assessments every 5 minutes, continuously monitoring the patient's airway and breathing.

36. Questions?