1. Diabetes

2. Glucose n Required as fuel for cellular metabolism n Brain’s need for glucose parallels its demand for oxygen

3. Insulin n Hormone n Produced by Islets of Langerhans in pancreas n Required for sugar to enter most cells n Brain does not require insulin to use sugar

4. Pancreas n Located in retroperitoneal space n Produces, releases –Digestive enzymes into duodenum –Insulin, glucagon into blood

5. Islets of Langerhans n Alpha cells –Glucagon –Raises blood sugar n Beta cells –Insulin –Lowers blood sugar

6. Diabetes Mellitus Metabolic disease Characterized by inadequate, absent insulin production

7. Type I Diabetes n No insulin production n Takes insulin injections

8. Type II Diabetes n Inadequate insulin production n Increased tissue resistance to insulin effects n Controlled with –Diet –Oral medications: Diabeta, Diabinese, Dymelor, Glucotrol, Micronase, Orinase, Tolinase, Glucophage –Insulin injections as disease progresses

9. Problems in Diabetes

10. Blood Sugar Imbalance n Hyperglycemia –Diabetic ketoacidosis (DKA) –Hyperosmolar coma n Hypoglycemia

11. Hyperglycemia n Causes –Failure to take insulin –Overeating, eating wrong diet –Stress (fever, infection, emotional stress) New-onset diabetics usually present with an episode of hyperglycemia

12. Diabetic Ketoacidosis n Usually Type I diabetic (no insulin) n Blood sugar rises n Kidneys try to remove excess sugar n Urine production increases (polyuria) n Patient becomes volume depleted –Thirst (polydypsia) –Tachycardia –Hypotension –Dry skin, mucous membranes

13. Diabetic Ketoacidosis n Cells cannot burn sugar; patient experiences hunger (polyphagia) n Cells burn fat as alternative fuel n Acidic ketone bodies produced n Patient tries to correct acidosis; exhales CO 2 n Rapid, deep breathing (Kussmaul respirations) n Exhaled ketone bodies produce nail-polish remover or “fruity” breath odor

14. Diabetic Ketoacidosis n Volume depletion n Ketone body production (ketoacidosis)

15. Hyperosmolar Coma n Usually Type II diabetic (inadequate insulin) n Blood sugar rises n Kidneys try to remove excess sugar n Urine production increases (polyuria) n Patient becomes volume depleted –Thirst (polydypsia) –Tachycardia –Hypotension –Dry skin, mucous membranes

16. Hyperosmolar Coma n Cells continue to burn sugar n Acidic ketone bodies not produced n Nail-polish remover or “fruity” breath odor not present

17. Hyperosmolar Coma n Severe volume depletion n NO ketone body production

18. Hyperglycemia n Management –Support ABC’s –Treat for hypovolemic shock –Transport –When in doubt, give sugar!

19. Hypoglycemia n Causes –Insulin overdose –Normal insulin use without eating –Over-exercise

20. Hypoglycemia Pale, cool skin; sweating; nausea; tachycardia Is that why hypoglycemia sometimes is called “Insulin Shock?”

21. Hypoglycemia n Insulin shock isn’t really shock n Patient just looks “shocky” because of epinephrine adrenals are releasing

22. Hypoglycemia n Can occur in non-diabetics n Most common cause = EtOH on empty stomach n A patient is never, just drunk

23. Hypoglycemia Management n Conscious patient –Give sugar orally n Unconscious patient –Support ABC’s –Get ALS back-up for IV glucose n When in doubt, Give Sugar!

24. Ask All Diabetics n Have you eaten today? n Have you taken your medication today? n When in doubt, give Sugar!

25. Other Diabetes Complications n Atherosclerosis –Myocardial infarction –CVA –Peripheral vascular disease –Blindness –Renal failure

26. Other Diabetes Complications n Diabetic Neuropathy –Gangrene –Increased “silent” myocardial infarction risk

27. Silent MI n Acute MI in diabetic can present without chest pain n May resemble “flu” n Manage “sick” diabetics as if critically ill until proven otherwise