1. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DOT National Standard EMT-Intermediate/85 Refresher DOT National Standard EMT-Intermediate/85 Refresher Welcome!

2. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease

3. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Diabetes Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment

4. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training definition Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both

5. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training description Hyperglycemia further results in acute & chronic complications of the disease, leading to significant morbidity and mortality

6. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training description American Diabetes Association (one of the following must be met): –Symptoms of diabetes & a causal plasma glucose >200mg/dL –Fasting plasma glucose >126mg/dL –Two-hour plasma glucose >200mg/dL during a 75g, 2-hr oral glucose tolerance test American Diabetes Association (one of the following must be met): –Symptoms of diabetes & a causal plasma glucose >200mg/dL –Fasting plasma glucose >126mg/dL –Two-hour plasma glucose >200mg/dL during a 75g, 2-hr oral glucose tolerance test

7. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training description Prediabetes –Impaired fasting glucose 100-125mg/dL –Impaired glucose tolerance 140-199mg/dL Prediabetes –Impaired fasting glucose 100-125mg/dL –Impaired glucose tolerance 140-199mg/dL

8. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology 7% of the US population has diabetes –5-10% Type 1 –90-95% Type 2 7% of the US population has diabetes –5-10% Type 1 –90-95% Type 2

9. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology T2DM prevalence among youth is rising –Old figure = 1 to 2% of diabetic children had T2DM –New figure = 8 to 45% of diabetic children have T2DM T2DM prevalence among youth is rising –Old figure = 1 to 2% of diabetic children had T2DM –New figure = 8 to 45% of diabetic children have T2DM

10. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training types The National Diabetes Data Group defines 4 major types of diabetes mellitus (DM) –Type 1 DM –Type 2 DM –Gestational Diabetes –Impaired Glucose Tolerance (Impaired fasting glucose) The National Diabetes Data Group defines 4 major types of diabetes mellitus (DM) –Type 1 DM –Type 2 DM –Gestational Diabetes –Impaired Glucose Tolerance (Impaired fasting glucose)

11. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training New versus Old Names Type 1 DM (aka: juvenile onset, insulin dependent diabetes mellitus) Type 2 DM (aka: adult onset, noninsulin dependent diabetes mellitus) Type 1 DM (aka: juvenile onset, insulin dependent diabetes mellitus) Type 2 DM (aka: adult onset, noninsulin dependent diabetes mellitus)

12. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Type 1 Diabetes Mellitus –Abrupt failure of production of insulin –Parental insulin required to sustain life –Autoantibodies implicated in the cell- mediated autoimmune destruction of beta cells of the pancreas Type 1 Diabetes Mellitus –Abrupt failure of production of insulin –Parental insulin required to sustain life –Autoantibodies implicated in the cell- mediated autoimmune destruction of beta cells of the pancreas

13. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type 1 DM Diabetic ketoacidosis (DKA) - initial onset –hyperglycemia Polyuria Polydipsia Polyphagia Ketosis –Osmotic diuresis –Eventual coma - hypovolemia Diabetic ketoacidosis (DKA) - initial onset –hyperglycemia Polyuria Polydipsia Polyphagia Ketosis –Osmotic diuresis –Eventual coma - hypovolemia

14. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training treatment Type 1 Diabetes Mellitus –Insulin SC injections Pumps –Oral hypoglycemics Insulin sensitizers with primary action in the liver –Metformin Insulin sensitizers with primary action in peripheral tissues –Pioglitazone, rosiglitarzone Insulin secretagogues –Repaglinide,, nateglinide Carbohydrate absorption slowing agents –Acarbose, miglitol Type 1 Diabetes Mellitus –Insulin SC injections Pumps –Oral hypoglycemics Insulin sensitizers with primary action in the liver –Metformin Insulin sensitizers with primary action in peripheral tissues –Pioglitazone, rosiglitarzone Insulin secretagogues –Repaglinide,, nateglinide Carbohydrate absorption slowing agents –Acarbose, miglitol

15. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training complications Type 1 Diabetes Mellitus –Complications Hypoglycemia Hyperglycemia Retinopathy, neuropathy, nephropathy, CAD, CVA, “silent MI” Type 1 Diabetes Mellitus –Complications Hypoglycemia Hyperglycemia Retinopathy, neuropathy, nephropathy, CAD, CVA, “silent MI”

16. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type 2 DM Pathophysiology –Usually middle-aged or older, overweight –Insulin deficiency (insulin secretory deficit) –Impaired insulin function related to poor insulin production –Failure of insulin to reach the site of action or, failure of end-organ response to insulin Pathophysiology –Usually middle-aged or older, overweight –Insulin deficiency (insulin secretory deficit) –Impaired insulin function related to poor insulin production –Failure of insulin to reach the site of action or, failure of end-organ response to insulin

17. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type 2 DM Initial onset –Hyperosmalar Hyperglycemic Nonketotic Coma (HHNC) Polyuria Polydipsia Polyphagia –Osmotic diuresis –Eventual coma - hypovolemia Initial onset –Hyperosmalar Hyperglycemic Nonketotic Coma (HHNC) Polyuria Polydipsia Polyphagia –Osmotic diuresis –Eventual coma - hypovolemia

18. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Type 2 DM Treatment Lower glucose levels on a consistent basis to normal or near normal –Lifestyle changes & metformin Other oral antidiabetic agents Insulin Lower glucose levels on a consistent basis to normal or near normal –Lifestyle changes & metformin Other oral antidiabetic agents Insulin

19. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Gestational Diabetes Glucose intolerance of variable degree with onset or 1st recognition during pregnancy

20. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Gestational Diabetes Complications –Miscarriages –Birth defects –Growth acceleration & fetal obesity Complications –Miscarriages –Birth defects –Growth acceleration & fetal obesity

21. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnotics, monitoring, management, pertinent positives Hypoglycemia –ALOC –Lethargy –Confusion –Combativeness –Agitation –Seizures –Focal neurologic deficits –Unresponsiveness Hypoglycemia –ALOC –Lethargy –Confusion –Combativeness –Agitation –Seizures –Focal neurologic deficits –Unresponsiveness Hypglycemia –Anxiety –Nervousness –Irritability –N/V –Palpitations –Tremor –Sweating –Bradycardia –Salivation

22. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DKA Diabetic ketoacidosis occurs primarily in patients with type 1 diabetes. The incidence is roughly 2 episodes per 100 patient years of diabetes, with about 3% of patients with type 1 diabetes initially presenting with diabetic ketoacidosis. It can occur in patients with type 2 diabetes as well; however, this is less common. Diabetic ketoacidosis occurs primarily in patients with type 1 diabetes. The incidence is roughly 2 episodes per 100 patient years of diabetes, with about 3% of patients with type 1 diabetes initially presenting with diabetic ketoacidosis. It can occur in patients with type 2 diabetes as well; however, this is less common.

23. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DKA The most common scenarios for DKA are –underlying or concomitant infection (40%) –missed insulin treatments (25%) –newly diagnosed, previously unknown diabetes (15%) –Other associated causes make up roughly 20% in the various series. The most common scenarios for DKA are –underlying or concomitant infection (40%) –missed insulin treatments (25%) –newly diagnosed, previously unknown diabetes (15%) –Other associated causes make up roughly 20% in the various series.

24. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training HHNC –The incidence of hyperosmolar hyperglycemic state (HHS) is <1 case per 1000 person/year –making it significantly less common than DKA. As the prevalence of type 2 diabetes mellitus increases, the incidence of HHS will likely increase as well. –The incidence of hyperosmolar hyperglycemic state (HHS) is <1 case per 1000 person/year –making it significantly less common than DKA. As the prevalence of type 2 diabetes mellitus increases, the incidence of HHS will likely increase as well.

25. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Physical Exam Findings, Diagnostic Findings, S/S, pertinent positives DKA Mild DKA Moderate DKA Severe HHS Glucose mg/dL >250mg/ dL >600mg/ dL pH 7.25-7.307.00- <7.25 <7.00>7.30 Mental status AlertAlert/ drowsy Stupor/ coma Stupor/ coma

26. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Hyperglycemia - DKA Hyperosmalar Hyperglycemia Nonketotic Coma –Adults - All IVs macrodrip set (10-15 drops/ml) –Pediatrics All IVs measured-vol solution administration (Volutrol) –0-6 yrs All IOs bolus with 60ml syringe, not Volutrol Hyperglycemia - DKA Hyperosmalar Hyperglycemia Nonketotic Coma –Adults - All IVs macrodrip set (10-15 drops/ml) –Pediatrics All IVs measured-vol solution administration (Volutrol) –0-6 yrs All IOs bolus with 60ml syringe, not Volutrol

27. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Hyperglycemia - DKA Hyperosmalar Hyperglycemia Nonketotic Coma –Saline Lock or TKO: may generally use interchangeably if fluid or medication not currently required but may be in future (exceptions are noted in specific PROTOCOLS). –Saline locks avoid IV line entanglement during complex extrications, however TKO allows for immediate administration of fluids as needed Hyperglycemia - DKA Hyperosmalar Hyperglycemia Nonketotic Coma –Saline Lock or TKO: may generally use interchangeably if fluid or medication not currently required but may be in future (exceptions are noted in specific PROTOCOLS). –Saline locks avoid IV line entanglement during complex extrications, however TKO allows for immediate administration of fluids as needed

28. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment: DKA & HHNC –Maintenance fluids: stable pts with no contraindications to fluid (pulmonary edema): –Adults: 120ml/hr (macrodrip 1 drop q 2-3 sec) –Pediatrics: 2 ml/kg/hr or reference Broselow tape – Fluid challenge: –Adults (SBP80-100 or HR>100): 500ml bolus (recheck VS after bolus) –Pediatrics: bolus only - no challenge indicated –Maintenance fluids: stable pts with no contraindications to fluid (pulmonary edema): –Adults: 120ml/hr (macrodrip 1 drop q 2-3 sec) –Pediatrics: 2 ml/kg/hr or reference Broselow tape – Fluid challenge: –Adults (SBP80-100 or HR>100): 500ml bolus (recheck VS after bolus) –Pediatrics: bolus only - no challenge indicated

29. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DKA & HHNC: Treatment Fluid bolus: Adults (SBP<80): 1-L bolus wide open under pressure Repeat SBP <80: repeat bolus once, then contact base Pediatrics: shock, indicated by protocol: 20ml/kg/bolus If improvement: repeat bolus once then contact base Fluid bolus: Adults (SBP<80): 1-L bolus wide open under pressure Repeat SBP <80: repeat bolus once, then contact base Pediatrics: shock, indicated by protocol: 20ml/kg/bolus If improvement: repeat bolus once then contact base

30. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DKA & HHNC: Treatment –Pediatric Shock: SBP<(70+2x age in years) per PROTOCOL: Pediatric Parameters –In the case of fluid challenge or bolus: Contact base as soon as possible. If communication failure, continue per guidelines to a maximum of 3-L in adults and 60ml/kg in pediatrics –Pediatric Shock: SBP<(70+2x age in years) per PROTOCOL: Pediatric Parameters –In the case of fluid challenge or bolus: Contact base as soon as possible. If communication failure, continue per guidelines to a maximum of 3-L in adults and 60ml/kg in pediatrics

31. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DKA & HHNC: Treatment Fluid Challenge or Bolus Procedure Check vitals & lung exam after each fluid challenge/bolus As vitals change refer back to the table above for fluid guidelines (I.e., initial SPB=80, give 1-L bolus; recheck SBP=90, give 500ml bolus; recheck) If signs of pulmonary edema (crackles, respiratory distress, increased respiratory rate) develop during IV fluid administration, decrease to TKO & contact base for fluid orders Fluid Challenge or Bolus Procedure Check vitals & lung exam after each fluid challenge/bolus As vitals change refer back to the table above for fluid guidelines (I.e., initial SPB=80, give 1-L bolus; recheck SBP=90, give 500ml bolus; recheck) If signs of pulmonary edema (crackles, respiratory distress, increased respiratory rate) develop during IV fluid administration, decrease to TKO & contact base for fluid orders

32. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DKA & HHNC: Treatment –Notes –If PROTOCOL orders IV fluid, refer to this PROCEDURE for gauge, IV number, & fluid rate. If IV fluid orders differ from this it will be indicated in the specific protocol. –If it is likely that pt will not be transported, contact base prior to IV attempts –Notes –If PROTOCOL orders IV fluid, refer to this PROCEDURE for gauge, IV number, & fluid rate. If IV fluid orders differ from this it will be indicated in the specific protocol. –If it is likely that pt will not be transported, contact base prior to IV attempts

33. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Hypoglycemia –See ALOC protocol- Adult & Peds Hyperglycemia –Support ABCs –Airway mtg | vomiting/aspiration prevention –Large bore IV –Fluids Hypoglycemia –See ALOC protocol- Adult & Peds Hyperglycemia –Support ABCs –Airway mtg | vomiting/aspiration prevention –Large bore IV –Fluids

34. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Differential diagnosis In the field: A lcohol E pilepsy I nsulin O verdose U remia T rauma I nfection P sychosis S troke In the field: A lcohol E pilepsy I nsulin O verdose U remia T rauma I nfection P sychosis S troke

35. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment

36. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Questions? References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010. References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.