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Diabetes Mellitus Type I – insulin dependent
Usually starts at an early age
Caused by autoimmune destruction of Beta cells
No insulin production at all
No Insulin = Death
1922 – first successful use of insulin to treat kids with DKA – always fatal up until that point.
Currently – insulin pumps and various types of insulin are state of the art in treatment for Type I DM.
Diabetes MellitusType II – insulin resistant
Obesity, sedentary lifestyle
Beta blockers, glucocorticoids, thiazides
90% of all diabetes in US
Insulin is unable to do its work
Dietary changes, medications or insulin may be needed
Usually does not cause DKA
Diabetes Mellitus Gestational
Diabetes Occurs during
pregnancy
Resolves with delivery most of the time.
Due to hormone levels and obesity
Insulin What is Insulin?
A hormone made by Beta cells in the Pancreas
Insulin works on multiple cells to regulate blood Glucose levels
Muscle – prevents protein breakdown
Adipose tissue – increases fat production
Liver – increased glycogen synthesis
Increased glucose and amino acid uptake
Inhibits Glucagon production
Medications used in Treating Diabetes
Antihyperglycemics – stimulate insulin production Sulfunylureas – Diabinese, Glucotrol, Diabeta,
Amaryl
Meglitinides – Prandin, Starlix
Antihyperglycemics – do not stimulate insulin Biguanide – Metformin – Lactic acidosis
Thiazolidinediones – Avandia, Actos
Alpha-glucosidase inhibitor – Precose, Glyset
DPP-4 Inhibit – Januvia, Onglyza
Hypoglycemia The brain MUST have glucose to function
Brain is not affected by insulin.
Normal blood sugar levels range from 70-100
Low blood sugar can be caused by Taking insulin when you cannot eat or forget to eat
Intentionally overdosing on insulin
Taking the wrong type
Exercising more than normal and not adjusting diet
Certain diabetes medications, but not all
Infections/illness which prevent eating
Hypoglycemia Clinical symptoms
Lethargy
Unconsciousness
Stroke-like symptoms (especially in those with prior strokes)
Seizures
Trouble speaking
Confusion
Cardiac Arrest
Hypoglycemia Testing
Fingerstick blood sugar
Make sure machine gets calibrated regularly
Make sure you have the right test strips that are not expired
Clean finger off with alcohol
Prick side of finger with lancet
Squeeze finger (milk it) to get enough to cover testing area
Read machine when test is complete
Hypoglycemia Treatment – Glucose!
IV Dextrose – AEMTs/Paramedics
Adults – 50% 1 ampule (50ml = 25gm)
Children – 25% 2ml/kg
Neonates – 12.5% - 1ml/kg
Oral Glucose – EMR/EMTs
Must have gag reflex and be alert to avoid aspiration/choking
Glucagon – for adults
1-2 mg IM if cannot get an IV
Dextrose Class – carbohydrate
Mechanism – provides metabolic substrate
Contraindications Absolute – None
Relative – hyperglycemia
Dosage – 50ml of D50, repeat x1 if needed Peds – 2ml/kg of D25
Neonates – 1ml/kg of D12.5
Glucagon Class – hormone
Mechanism – stimulates glycogen breakdown in the liver and muscle, increasing glucose levels
Contraindications Absolute - sensitivity
Relavtive – starvation, fasting, adrenal insufficiency
Uses – hypoglycemia, beta-blocker overdose, calcium channel overdose, anaphylaxis (for folks on beta-blockers)
Dosage – hypoglycemia – 1mg IV/IM Q20 min; beta-antagonist OD – 3-5mg IV; anaphylaxis 1-2mg IV Kids - <20kg – 0.5mg IV/IM; >20mg – 1mg IV/IM
Side effects – Nausea, vomiting, diaphoresis, hypotension, rash
Meter is broken… Get as much history as possible.
Smell for ketones (only half of us can)
Are there empty insulin bottles on scene? Recent exercise or illness?
Err on the side of treating for hypoglycemia
DKA No insulin activity = high blood sugar levels
Can’t make glycogen, fatty acids and cannot move glucose into cells Cells starve Fatty Acid breakdown Ketosis
High blood sugar sugar in urine peeing a lot dehydration acidosis
Diabetic Ketoacidosis!
Fruity odor to breath
Increased respiratory rate
Abdominal pain
Nausea/Vomiting
Tachycardia / hypotension
Hyperglycemia Low Insulin activity = high blood sugars
Still able to get some glucose in cells = no starvation = no ketosis
Acidosis also less likely
No fruity odor
Generalized weakness
Less nausea/vomiting
Death very rare
Hyperglycemia Treatment
ABC’s
IV fluids!
Adults – 500ml – 1 liter WO
Children – 20ml/kg fluid boluses
May repeat if needed for hypotension or tachycardia
What about Insulin Pumps
If hypoglycemia – have patient turn off pump after you wake them up with D50
If hyperglycemia – don’t touch it May not be working
Patient may be able to do a bolus on their own based on their sliding scale
If infected, leave in place, but do not use.
Alcoholic Ketoacidosis
Chronic Alcoholics are malnourished Few glycogen stores
After a binge, their glucose levels can drop, stimulating fatty acid breakdown
Treatment is glucose with Thiamine Don’t withhold glucose if level is abnormal!
You wanna refuse? While people have a right to make their own
decisions, it must be an INFORMED decision
They must: Be alert, oriented to person, place, time, and
situation
Know of the risk for relapse
Have recovered within 10 minutes. FSBS >80
They should Have test strips available or have someone there to
call back if they get hypoglycemic again.
Have adequate follow-up.
Questions A diabetic’s family calls 911 for sudden onset
of left sided weakness that started 10 minutes prior to arrival. After ABCs, what is your next step?
Questions A Diabetic teen-ager decides to say “f&^%
you” to his diet, and eats an ice cream sundae. A day later, he calls 911 for vomiting and abdominal pain. His Glucose on fingerstick reads “Hi” What should you give?