1. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 3 Medical Emergencies

2. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 4 Endocrinology

3. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Anatomy and Physiology Endocrine Disorders and Emergencies

4. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction The endocrine system controls the body through specialized chemical messengers. –Hormones –Glands Endocrine glands differ from other glands in that they are ductless. –Secrete their hormones directly into capillaries to circulate in the blood –Exocrine glands Secrete their chemical products directly onto tissues through ducts

5. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Endocrine Glands –Have systemic effects –Act on specific target tissues in specific ways –May have single or multiple targets Homeostatic Mechanism –Hormones keep in motion, or regulate, numerous vital cell processes Disorders –Disorders result from over or underproduction of hormone(s) Introduction

6. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology

7. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology Eight major glands in the endocrine system –Certain tissues also secrete hormones Kidneys, heart Endocrine glands are located throughout the body

8. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Location of Endocrine Glands Click here to view an animation on endocrine glands.here

9. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology Hypothalamus –Cells act both as nerve cells, or neurons, and as gland cells –Junction between CNS and ANS

10. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology The hypothalamus can regulate release of many hormones Most hypothalamic hormones stimulate secretion of pituitary hormones Click here to view the endocrine system.here

11. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology Pituitary Gland –Divided into posterior and anterior pituitary lobes Posterior responds to nerve impulses from hypothalamus Anterior responds to hypothalamic hormone secretion –Pituitary hormones have a direct impact on endocrine glands throughout the body

12. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Posterior Pituitary Produces two hormones: –Anti-diuretic hormone (ADH) Vasopressin Causes retention of water Can counteract losses of blood volume up to about 25 percent –Oxytocin Stimulates uterine contraction and lactation Has a mild antidiuretic effect Fluid bolus in pre-term pregnancy

13. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anterior Pituitary Six hormones are secreted by the anterior pituitary GH affects all cells

14. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Thyroid Gland Located in the neck anterior to and just below the cartilage of the larynx Produces three hormones –Thyroxine (T4)—stimulates cell metabolism –Triiodothyronine (T3)— stimulates cell metabolism –Calcitonin—lowers blood calcium levels

15. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Parathyroid Glands –Small, pea-shaped glands, located in the neck near the thyroid –Parathyroid hormone (PTH) Increases blood calcium levels –Typically 4 individual glands –Regulate the level of calcium in the body

16. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Thymus Gland Located in the mediastinum just behind the sternum –Large in children –Shrinks in adulthood Thymosin —promotes maturation of T lymphocytes –T Cells responsible for cell-mediated immunity

17. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pancreas Combination Organ –Exocrine tissues called acini secrete digestive enzymes into the small intestine. Pancreatic juice –Endocrine tissues secrete hormones. Insulin Glucagon

18. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pancreas Three types of cells: –Alpha (α) –Beta (β) –Delta (δ)

19. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Alpha Cells (α) Stimulate the release of glucagon –Glucagon stimulates breakdown of glycogen Glycogenolysis Storage form of glucose Promote gluconeogenesis Action in the liver is most prevalent

20. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Beta Cells (β) Produce the hormone insulin –Antagonist of Glucagon –Lower the blood glucose level –Promotes energy storage in the body by increasing the synthesis of glycogen, protein, and fat

21. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Delta Cells (δ) Produce somatostatin –Inhibit glucagon –Inhibit insulin –Retards nutrient absorption from the intestines

22. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Adrenal Glands Adrenal Medulla –Inner segment of adrenal gland –Secretes the catecholamine hormones epinephrine (or adrenalin) and norepinephrine –Closely tied to autonomic nervous system Cells behave both as nerve cells and as gland cells

23. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Adrenal Glands Adrenal Cortex –Outer layers of endocrine tissue, which secrete steroidal hormones

24. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Gonads Female –Ovaries Estrogen Progesterone Male –Testes Testosterone

25. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pineal Gland Located in the roof of the thalamus –Related to the body’s “biological clock” Related to reproductive function –Releases the hormone melatonin –Implicated in Seasonal Affective Disorder

26. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Organs with Endocrine Activity Placenta –Releases hCG throughout gestation Digestive Tract –Gastrin and secretin Heart –ANH An antagonist to ADH Reduces circulating blood volume

27. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Other Organs with Endocrine Activity Kidneys –Renin Decreased blood volume Works with angiotensinogen Potent vasoconstrictor –Erythropoietin Stimulates RBC production

28. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Endocrine Disorders and Emergencies

29. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Endocrine Disorders and Emergencies Disorders of the Pancreas Disorders of the Thyroid Gland Disorders of the Adrenal Glands

30. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disorders of the Pancreas Diabetes Mellitus –Glucose Metabolism

31. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetes Mellitus Glucose Metabolism –Metabolism –Insulin is required for glucose metabolism Presence of enough insulin to meet cellular needs Ability to bind in a manner to stimulate the cells –When unable to obtain energy from glucose, the body begins to use fatty stores Ketones and ketosis

32. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetes Mellitus Regulation of Blood Glucose –Fasting blood glucose is usually between 80 to 90 mg glucose/dL blood –Hypoglycemia and hyperglycemia –Role of pancreas, liver, and kidneys –Osmotic diuresis and glycosuria

33. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetes Mellitus Type I Diabetes Mellitus –Also called juvenile or insulin-dependent diabetes mellitus (IDDM) –Characterized by low production of insulin Closely related to heredity –Results in pronounced hyperglycemia Symptoms include polydipsia, polyuria, polyphagia, weight loss, and weakness Untreated or noncompliant patients may progress to ketosis and diabetic ketoacidosis –Treatment

34. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetes Mellitus Type II Diabetes Mellitus –Also called adult-onset or non-insulin-dependent diabetes mellitus (NIDDM) –Results from decreased binding of insulin to cells Related to heredity and obesity Accounts for 90% of all diagnosed diabetes patients Less risk of fat-based metabolism –Results in less-pronounced hyperglycemia Hyperglycemic hyperosmolar nonketotic acidosis –Managed with dietary changes and oral drugs to stimulate insulin production and increase receptor effectiveness

35. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetic Emergencies Diabetic Ketoacidosis –Pathophysiology Results from the body’s change to fat metabolism Continuous buildup of ketones produces significant acidosis –Signs and Symptoms Extended period of onset (12–24 hours) Sweet, fruity breath odor Potassium-related cardiac dysrhythmias Kussmaul’s respiration Decline in mental status and coma

36. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetic Ketoacidosis Assessment and Management –Focused History and Physical Exam Obtain SAMPLE and OPQRST histories Look for medical identification –Focus field management on maintenance of the ABCs and fluid resuscitation

37. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetic Ketoacidosis Management –Maintain airway and support breathing as indicated –Determine blood glucose level and obtain blood sample –If blood glucose unknown, administer 25 g 50% dextrose –Establish IV and administer normal saline per local protocol –Monitor cardiac rhythm and vital signs –Expedite transport

38. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetic Emergencies Hyperglycemic Hyperosmolar Nonketotic Coma (HHNC) –Pathophysiology Found in Type II diabetics Results in blood glucose levels up to 1000mg/dL Insulin activity prevents buildup of ketones Sustained hyperglycemia results in marked dehydration Often related to dialysis, infection, and medications Very high mortality rate

39. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ HHNC Signs and Symptoms –Gradual onset over days –Increased urination and thirst, orthostatic hypotension, and altered mental status Assessment and Management –Difficult to distinguish from diabetic ketoacidosis in the prehospital setting –Treatment is identical to diabetic ketoacidosis

40. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetic Emergencies Hypoglycemia –Pathophysiology True medical emergency resulting from low blood glucose levels; rarely seen outside diabetics By the time signs and symptoms develop, most of the body’s stores have been used Diabetics with kidney failure are predisposed to hypoglycemia

41. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypoglycemia Signs and Symptoms –Altered mental status with rapid onset Frequently involves combativeness –Diaphoresis and tachycardia –Hypoglycemic seizure and coma Assessment and Management –Focused History and Physical Exam Obtain SAMPLE and OPQRST histories Look for medical identification

42. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hypoglycemia Management –Maintain airway and support breathing as indicated –Determine blood glucose level and obtain blood sample –Establish IV access –If blood glucose <60 mg/dL or is unknown, administer 25–50 g of 50% dextrose IV –If IV cannot be established, administer 0.5–1.0 mg glucagon intramuscularly –Monitor cardiac rhythm and vital signs –Expedite transport

43. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Diabetic Emergencies

44. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Graves’ Disease –Pathophysiology Probably hereditary in nature Autoantibodies are generated that stimulate thyroid tissue to produce excessive hormone –Signs and Symptoms Agitation, emotional changeability, insomnia, poor heat tolerance, weight loss, weakness, dyspnea Tachycardia and new-onset atrial fibrillation Protrusion of the eyeballs or goiters Disorders of the Thyroid Gland

45. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Graves’ Disease Assessment and Management –Emergency calls usually arise from cardiovascular signs/symptoms Use of b-adrenergic blockers such as propranolol may temporarily reduce cardiac stress Glucocorticoid therapy is sometimes helpful in quickly reducing the level of circulating T4. –Manage signs and symptoms

46. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disorders of the Thyroid Gland Thyrotoxic Crisis (Thyroid Storm) –Pathophysiology Life-threatening emergency, usually associated with severe physiologic stress or overdose of thyroid hormone –Signs and Symptoms High fever (106º F or higher) Reflected in increased activity of sympathetic nervous system Irritability, delirium, or coma Tachycardia and hypotension Vomiting and diarrhea –Assessment and Management Support airway, breathing, and circulation Monitor closely and expedite transport

47. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disorders of the Thyroid Gland Hypothyroidism and Myxedema –Pathophysiology Can be inherited or acquired Chronic untreated hypothyroidism creates myxedema Thickening of connective tissue in skin and other tissues Infection, trauma, CNS depressants, or a cold environment can trigger progression to a myxedemic coma

48. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms –Fatigue, slowed mental function –Cold intolerance, constipation, lethargy –Absence of emotion, thinning hair, enlarged tongue –Cool, pale doughlike skin –Coma, hypothermia, and bradycardia Hypothyroidism and Myxedema © Biophoto Associates/Photo Researchers, Inc.

49. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management –Focus on maintaining ABCs Patients with myxedema coma require intubation and ventilatory assistance –Closely monitor cardiac and pulmonary status –Establish IV access, but limit fluids –Expedite transport Hypothyroidism and Myxedema

50. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disorders of the Adrenal Gland Hyperadrenalism (Cushing’s Syndrome) –Pathophysiology Often due to abnormalities in the anterior pituitary or adrenal cortex May also be due to steroid therapy for non-endocrine conditions such as COPD or asthma Long-term cortisol elevation causes many changes Atherosclerosis, diabetes, hypertension Increased response to catecholamines Hypokalemia and susceptibility to infection

51. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms –Weight gain –“Moon-faced” appearance –Fat accumulation on the upper back –Skin changes and delayed healing of wounds –Mood swings –Impaired memory or concentration © Biophoto Associates/Photo Researchers, Inc. Cushing’s Syndrome

52. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Cushing’s Syndrome Assessment and Management –Support ABCs –Use caution when establishing IV access –Report any observations indicative of Cushing’s syndrome to the receiving facility

53. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Disorders of the Adrenal Gland Adrenal Insufficiency (Addison’s Disease) –Pathophysiology Due to destruction of the adrenal cortex Often related to heredity Stress may trigger Addisonian crisis May be related to steroid therapy Sudden withdrawal can trigger Addisonian crisis –Signs and Symptoms Progressive weakness, fatigue, decreased appetite, and weight loss Hyperpigmentation of skin and mucous membranes Vomiting or diarrhea Hypokalemia and other electrolyte disturbances Unexplained cardiovascular collapse

54. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Adrenal Insufficiency (Addison’s Disease) Assessment and Management –Maintain ABCs –Closely monitor cardiac and pulmonary status –Obtain blood glucose level and treat for hypoglycemia if present –Establish IV and provide aggressive fluid resuscitation –Expedite transport

55. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Anatomy and Physiology Endocrine Disorders and Emergencies