Diabetes For EMS Providers

Humongous Insurance

Diabetes

Diabetes (Terms)

• Diabetes mellitus – (DM) A chronic disease characterized by an altered relationship between sugar (glucose) and insulin.

Diabetes

• Insulin – A hormone secreted by the pancreas that is needed to promote the movement of glucose (sugar) from the blood into the cells.

• Glucose – A simple form of sugar, the body’s main source of energy.

Diabetes

• Type I (IDDM)- Insulin dependent diabetes mellitus, usually acquired in childhood, produce no insulin (inheritable, auto-immune)– Requires insulin administration

Diabetes

• Type II (NIDDM) – Non-insulin dependent diabetes mellitus, usually acquired in adulthood (related to overweight), produce some insulin – not enough, or tissue sensitivity diminished– Can be controlled by diet, exercise, oral meds

Role of the Pancreas

• Primary role is the regulation of blood glucose concentrations.

DiabetesRole of the Pancreas

• Islets of Langerhans produce insulin– Alpha cells – Glucagon– Beta cells – Insulin– Delta cells – Somatostatin (inhibits the

secretaries of growth hormone)

Islets of Langerhans

DiabetesBeta Cells

• Insulin– Increase glucose transport into the cell– Increase liver glycogen levels (storage)– Decrease blood glucose concentration– Glucagon Antagonist

DiabetesAlpha Cells

• Glucagon –– Released when blood sugar levels drop– Increase blood glucose levels– Breaks down fats and fatty acids (storage

removal)– Insulin Antagonist

High/Low Blood Sugar

DiabetesGlucagon

• Triggered by exercise, stress, sleep, hypoglycemia

• Insulin antagonist (decreases insulin’s actions)

DiabetesLong Term Effects

• Blindness• Kidney disease• Peripheral neuropathy• Heart disease and stroke

(atherosclerosis)– HD: 2X - 4X non-diabetic– S: 2X - 6X non-diabetic

• Limb amputations

Diabetes• Hyperglycemia – Lack of insulin, glucose

cannot enter the cells. Remains in the blood stream increases the level of blood sugar.

• Hypoglycemia (Insulin Shock) – Lack of glucose in the blood stream, cells deprived of glucose.

• Normal sugar level – 80-120 mg/dL

DiabetesOnset

• Type I – May occur at birth, usually occurs in teenage or young adult years– Typically a sudden onset of – Polyuria (excessive urination), – Polydipsia (excessive thirst), – Polyphagia (excessive ingestion of food), dizziness,

blurred vision, rapid and unexplained weight loss.

DiabetesOnset

• Type II – – Generally occurs in patients older than 40 y/o– Overweight patients– Same onset S/S as Type I and fatigue, changes in

appetite.

Get Off MeWoman!!!

DiabetesHypoglycemia (Insulin Shock)

• Hypo (Low), Glyce (Sugar), Emia (Blood)

• Excessive response to glucose absorption– Physical exertion– Alcohol– Drug effects– Pregnancy– Poor dietary intake

DiabetesHypoglycemia (Insulin Shock)

• Adult– Blood sugar less than 80 mg/dL (non-diabetic)– Blood sugar less than 110 mg/dL (diabetic)

• Pediatric– Blood sugar less than 60 mg/dL (non-diabetic)– Blood sugar less than 90 mg/dL (diabetic)

DiabetesHypoglycemia (Insulin Shock)

• Too much insulin• Decreased dietary intake (missed

meal)• Vigorous activity

Diabetes

Hypoglycemia (Insulin Shock)• S/S

– Rapid onset– Nervousness– Irritability– Combative

behavior– Weakness– Confusion

– Appearance of intoxication

– Weak, rapid pulse– Cold, clammy skin– Drowsiness– Seizures

– Coma (severe case)

Hyperglycemia

• Hyper (High), Glyce (Sugar), Emia (Blood)

• Slow onset• Absence or lack of insulin• Glucose accumulates in the blood• Cells are starved

– Search for alternate fuel • Excessive urination (dehydration)

Hyperglycemia Diabetic Ketoacidosis

(DKA)• Results in a low pH

(acidosis)– Fruity breath

• Vomiting, dehydration, altered electrolyte balance, seizures

• Abnormal breathing pattern.– Kussmaul respirations

• Deep & fast• Warm, dry skin

Hyperosmolar Hyperglycemic Nonketotic

(HHNK) Coma• Life-threatening emergency• Older patients with type 2 diabetes or

undiagnosed diabetics• Causes• Precipitating factors• Signs and symptoms

Pathophysiology of HHNK Coma

Diabetic Emergency Management• Scene Size Up / BSI• Initial Assessment

– LOC– ABC’s– C/C– Priority/Transport

Diabetic Emergency Management

• Focused History and Physical Examination/Rapid Assessment– Responsive - Focused – Unresponsive – Rapid Medical Assessment

• OPQRST• SAMPLE

Diabetic Emergency Management

• OPQRST– Onset– Provocation– Radiating– Quality– Severity– Time

• SAMPLE– Signs & Symptoms– Allergies– Medications– Past Medical Hx– Last oral intake– Events Leading to 911

call

Diabetic Emergency Management

– Glynase– Tolinase– Glucotrol– Humalog– Rezulin– Glucophage

• Common Meds identified in SAMPLE:– Insulin– Diabanese– Orinase– Micronase– Diabeta

Diabetic Emergency Management

• Treatment– High flow oxygenation

• (BVM vs. NRB)

– Suction• Oral/nasal airway

Diabetic Emergency Management• Can the Patient Swallow?

– If so, oral glucose PO– If not, NPO, rapid transport

• Oral glucose:– Raises the blood sugar, may take as long as 20

min.– Indications – Altered mental status, history of

diabetes, ability to swallow– Page 475

Oral Glucose Drug Sheet

Oral Glucose• Class: Carbohydrates• Route: Oral• Supplied: Squeezable Tubes• Dose:

– Adult: Full Tube (25-50gm) given in small doses– Pediatric: 0.5 gm/kg given in small doses

Oral Glucose Cont.• Drug Action: Increases Blood Glucose Level• Indications:

– Altered mental status caused by hypoglycemia:– Adult

• Blood sugar less than 80 mg/dL (non-diabetic)• Blood sugar less than 110 mg/dL (diabetic)

– Pediatric• Blood sugar less than 60 mg/dL (non-diabetic)• Blood sugar less than 90 mg/dL (diabetic)

Oral Glucose Cont.• Precautions:

– Assure gag reflex is present• Side Effects: Aspiration• Contraindications:

– Absent gag reflex– Patents unable to protect their airway– Patents unable to swallow.

Diabetic Emergency Management

• Baseline Vital Signs (Q 5 or 15 min)• Detailed Patient Assessment• Ongoing Assessment

– ABC– LOC– Consider other causes

Scenarios

Scenario 1

• Dispatched to an unconscious person. 32 y/o female. She has a history of DM.

• S/S – Sudden onset of altered LOC, did not eat supper, cool moist skin, rapid thready pulse, did take insulin.

What is the level?

What is wrong with her?

• Hypoglycemic• Treatment

– High flow oxygenation – Suction Oral/nasal airway if needed – Oral glucose PO if able to swallow– If not, rapid transport

Scenario 2

• Dispatched to a 46 y/o old male. Large patient, family brings meds to you. They include Diabeta.

• Patient has not been feeling well for the past day or so.

Scenario 2

• S/S: Rapid and deep respirations, skin warm and dry, dry mucous membranes, patient exhibiting bizarre behavior, pulse rapid and thready, history of Polyuria, Polydypsia, and Polyphagia.

What is wrong with him?

• Hyperglycemia or DKA• Treatment:

– High flow oxygenation – Anything else?– Rapid transport

Scenario 3

• Dispatched to 80 y/o for altered mental status. History of diabetes that is normally controlled with insulin.

• S/S: Nausea, vomiting, irritability, altered mental status, weak, rapid pulse, and no range of motion of the right side of body.

What is wrong with her?

• CVA or Stroke• Treatment:

– High flow oxygenation – Anything else?– Rapid transport

Other factors to consider

• Intoxication• Other causes of AMS

Glucometer• A device used to determine blood

glucose levels.

Indications for blood sugar analysis

• Altered Mental Status• Unconscious patients of unknown cause• Suspected diabetic patients

Procedure

• Clean finger with alcohol

• Wipe dry• Wipe away first

drop of blood• Use second drop

of blood

Abnormal Glucose Values

• Outside the normal range (60-120)– Hyperglycemia – Greater than 300– Hypoglycemia – Less than 60

Conditions Diminishing Accuracy

• Margin of error (10-15%)

• Missing calibration

• Temperatures• Outdated strips• Improper

technique

• Insufficient sample size

• Contamination• Wrong sample

source• Neonates

Review

Review• IDDM

– Insulin Dependant Diabetic– Type I

Review• NIDDM

– Non-insulin Dependant Diabetic– Type II

Review

• 3 P’s–Polydipsia–Ployphagia–Polyuria

Review• Hypoglycemia• Adult

– Blood sugar less than 80 mg/dL (non-diabetic)– Blood sugar less than 110 mg/dL (diabetic)

• Pediatric– Blood sugar less than 60 mg/dL (non-diabetic)– Blood sugar less than 90 mg/dL (diabetic)

Review• Hyperglycemia

– >120 mg/dl

Review• DKA

– Diabetic Ketoacidosis– Kussmaul Respirations– D-stick normally > 350 mg/dl

The End

•Questions?