1. BLS 2015 Endocrine Emergencies

2. Objectives  Appreciate the role of the endocrine system in maintaining homeostasis  Describe the roles of the hypothalamus and pituitary  Recognize the importance of the adrenal hormone epinephrine including its role in anaphylaxis  Appreciate the role of the pancreas in regulating blood sugar  Distinguish between high and low blood sugar and describe treatment for each

3. Endocrine Overview  Imagine your day – awake, asleep, outside, inside, eating, exercising  You body strives to maintain a constant internal environment – homeostasis. How?  Nervous system responds quickly – pull your hand away from a hot stove, run away from a lion  Endocrine system responds more slowly by producing chemicals – hormones – that are dumped into the bloodstream and affect body systems  Let’s take a tour!

4. E NDOCRINE O RGANS : H YPOTHALAMUS, P ITUITARY, T HYROID, AND A DRENALS

5. Hypothalamus and Pituitary  Hypothalamus: specialized cells located deep in the brain, just above the brainstem  Responds to input from the brain  Gateway between the nervous system and the endocrine system  Hormones secreted by the hypothalamus are funneled to the pituitary just below it  Pituitary gland then releases other hormones

6. Case Study: the “Love Hormone”  25-year-old female has just delivered a healthy baby boy. You put the baby to his mother’s breast, and he begins suckling vigorously.  What’s happening in mom’s body?  Suckling by the baby stimulates the release of oxytocin (which is produced by the hypothalamus but stored in the pituitary)  Oxytocin causes uterine contraction, reducing post- partum hemorrhage. It also promotes social bonding between mom and baby, hence its nickname

7. Thyroid Gland  Found in the neck just below the Adam’s apple  Produces hormones that circulate in the blood and regulate metabolism and growth  Thyroid gland disorders  Hypothyroidism: fatigue, intolerance to cold, dry skin, even hypotension and hypothermia  Hyperthyroidism: sudden weight loss, tachycardia, sweating, hypertension, fever, even seizures

8. Case Study  911 call for woman with altered mental status  Agitated, confused, does not follow commands  BP 160/90, HR 146 and irregular, R 24, blood sugar 130, oxygen saturation 98%  She has a history of “overactive thyroid” and recently ran out of her medications  Though there are many possibilities with this presentation, this patient was diagnosed with extreme hyperthyroidism – thyroid storm. (Question: how would you respond to this patient if you saw her in the field?)

9. Adrenal Glands  On top of the kidneys  ad = near  renal = kidneys  Produce stress hormones, sex hormones, hormones that regulate blood pressure  Also produce epinephrine and norepinephrine  Too much or too few of these hormones can cause problems (question: what would happen if there was a tumor on the adrenal glands causing it to produce too much epinephrine?)

10. Case Study: Anaphylaxis  You respond to the scene of a 20 year old male who has mistakenly eaten a cookie made with peanut oil. He is allergic to peanuts.  He is complaining of feeling “itchy all over,” lightheaded, and short of breath  BP is 76P, HR 140, R 30 with wheezes in all fields and oxygen saturation 92%  You administer epinephrine to this patient

11. Case Study: Epinephrine  How does epinephrine help your patient?  Opens bronchioles (makes breathing easier)  Constricts peripheral vasculature (raises blood pressure)  What does naturally occurring epinephrine do in the body?  The same thing!  If you are exerting yourself, it opens bronchioles (makes breathing easier) and constricts your peripheral vasculature (diverting blood to the muscles where it is needed)  Epinephrine has many other effects!  Increases heart rate, dilates pupils, increases blood sugar

12. E NDOCRINE O RGANS : T HE P ANCREAS AND D IABETES

13. Pancreas  Endocrine organ most familiar to EMTs  Located behind the stomach, secretes pancreatic juices that help break down fats, proteins and carbohydrates  Endocrine function of the pancreas is carried out by cells clusters called Islets of Langerhans  Alpha cells secrete glucagon, which raises blood sugar  Beta cells secrete insulin, which lowers blood sugar  What is the relationship between insulin, glucagon, and blood sugar?

14. Glucose Production  Food is broken down by digestive system into three main nutrients:  Fats  Carbohydrates  Proteins  Glucose - simple carbohydrate, first to be absorbed into the blood  Essential for all cells, especially brain cells

15. Glucose Production When a healthy person eats – glucose absorption looks like above In a healthy person who has not eaten, the pancreas compensates by releasing the hormone glucagon, causing liver to release glucose

16. Insulin  A hormone produced by pancreas  Is a “key” that helps glucose enter cells where it is essential for cellular metabolism  Diabetes is a disorder of insulin and sugar metabolism … let’s investigate

17. Types of Diabetes: Type 1  Insulin-producing cells are destroyed; the body does not produce insulin. Without insulin, sugar can’t get into the cells  Sugar builds up to dangerous level in the blood  Type 1 diabetics need to replace their missing insulin through an injection or pump  Usually arises early in life (childhood or young adulthood) Insulin Pumps deliver insulin 24 hours a day

18. Types of Diabetes: Type 2  The most common type of diabetes  The body does not produce enough insulin, or the cells become resistant to insulin  As with type 1 diabetes, without insulin, the body’s cells become deprived of glucose  Type 1 diabetes is typically managed with diet, exercise, oral medications, and sometimes insulin  Historically, was most common in older adults, but now, children and young adults are increasingly being diagnosed with Type 2 diabetes

19. Treatment of Diabetes

20. D IABETIC E MERGENCIES

21. Hypoglycemia  Too much insulin, too little food or too much exercise  Sometimes called “insulin shock” or an “insulin reaction” History can include:  Insufficient food intake  Excessive insulin dosage  Normal to excessive activity  Rapid onset  Recent Illness  Change in diet

22. Presentation  Low blood sugar (usually less than 60)  Cold, pale, clammy skin  Abnormal, hostile, bizarre behavior (appears intoxicated)  Shaking, trembling, weakness  Full, rapid pulse  Dizziness, headache, blurred vision  Extreme hunger  Seizures  Loss of consciousness  Coma

23. Hyperglycemia  Too little insulin, not enough exercise or too much food  History and presentation can include:  Recent infection  Three Ps (polyphagia, polydipsisa, polyurea)  Vomiting, abdominal pain  Nausea  Insufficient insulin dosage  Gradual onset  Normal activity level

24. Diabetic Coma  Unconsciousness from severe diabetic ketoacidosis or hyperglycemia combined with profound dehydration

25. Ketones  When glucose is not available to the cells, the body burns fat for energy  Ketones  Byproduct of fat metabolization  Acids build up in blood  Ketones can poison body by changing the pH balance  Kidneys respond by excreting glucose & ketones  Condition known as ketoacidosis

26. Diabetic Ketoacidosis (DKA)  Common for DKA present with high blood sugar, severe dehydration, rapid breathing (Kussmaul respirations), altered mental status & sometimes a distinctive fruity odor on the breath. Most common events that cause DKA are:  Infection  Missed insulin injection  Undiagnosed diabetes  Heart attack, stroke, trauma, stress and surgery  Ketoacidosis occurs rarely in people with type 2 diabetes  Especially elderly, can experience a similar condition called hyperosmolar hyperglycemic nonketotic coma (HHNC)

27. Summary: Hypo Vs. Hyper Hypoglycemia  Insufficient food intake or too much insulin  Pale, moist skin  Rapid onset  Weak, rapid pulse  Low BP (sometimes)  Low blood glucose Hyperglycemia  Insufficient insulin  Warm, dry skin  Gradual onset  Rapid, deep respirations  Intense thirst  Increased urination  High blood glucose

28. Gestational Diabetes  Begins during pregnancy  Usually becomes apparent in 24th to 28th weeks of pregnancy  In many cases, blood glucose level returns to normal after delivery  Majority of gestational diabetics adjust food intake & exercise to lower their blood sugar  Some cases may require insulin injections

29. P REHOSPITAL C ARE

30. Patient History  When did you eat last?  How much did you eat?  Do you take insulin or oral medications?  Have you taken your insulin today?  Has there been a change in your health, stress or exercise level?  When did the symptoms begin?

31. Glucometry 1.Don gloves and eye protection. 2.Clean fingertip with an alcohol pad. 3.Grasp finger near area to be pricked and squeeze. 4.Prick side of finger with a sterile lancet and squeeze finger gently. 5.Place drop of blood on the test strip. 6.Read meter and record reading and time.

32. Normal Blood Glucose  Individual’s blood glucose level varies throughout day depending on diet & exercise  Individual without diabetes, normal fasting blood glucose level is in the 60-100 mg/dL range  Diabetic patients may see low blood glucose (hypogylcemia) or elevated blood glucose (hyperglycemia)  If blood glucose drops below 50, progressive loss of mental function  If blood glucose gets above 180 to 200, exceeds what kidneys can reabsorb  If glucose level is very high, 400s or even 500s, it can be associated with altered LOC requiring ALS interventions

33. Care for Diabetic Emergency  Request medic unit, if indicated  Maintain airway  Administer oxygen  If able to swallow and blood sugar is below 60, give oral glucose  Repeat glucometry 5-10 minutes after providing oral glucose  Monitor vital signs and LOC

34. Oral Glucose  Ask patient if able to swallow; if not, don’t administer  Position upright  Ask patient to sip or chew sugar-containing substance  Monitor patient’s response to glucose  Repeat glucometry 5-10 minutes after giving oral glucose

35. Swallow Reflex  Ability to swallow is an effective indicator of the ability to maintain an airway If patient can’t swallow don’t give oral glucose

36. After Care Instructions  Some patients respond quickly to a sugar drink or glucose  They may not see need to be evaluated at hospital  They should eat a complete meal  In general, blood sugar should be above 60  Be familiar with your department's guidelines for leaving diabetic patient home  If patient stays home you must leave written after care instructions