Curriculum Update: Endocrinology, Gastrointestinal Disorders, Renal/Urology Disorders

1. Curriculum Update:Endocrinology, Gastrointestinal Disorders, Renal/Urology Disorders Condell Medical Center EMS System March, 2007 Site Code #10-7200E-1207 S. Hopkins, RN, BSN, EMT-P

2. Objectives • Upon successful completion of this module, the EMS provider should be able to: • identify the function of the endocrine system • distinguish a variety of medical disorders of the endocrine system • describe pain for gastrointestinal and genitourinary disorders • identify and appropriately state interventions for a variety of EKG rhythms • successfully complete the quiz with a score of 80% or better

3. Endocrine System • Composed of glands that secrete hormones into the circulatory system • Helps regulate various metabolic functions • Hormones function in a lock and key fashion • All hormones operate within a feedback system

4. Hormones • Act on target organs elsewhere in the body • Controls and coordinates wide spread processes on organs, tissues, or general effects on the entire body • homeostasis • reproduction • growth & development • metabolism • response to stress

5. Endocrine Glands • Hypothalamus • located deep within the cerebrum of the brain; serves as connection between the central nervous system (CNS) and endocrine system • secretes hormones that make other endocrine glands secrete hormones • Pituitary - anterior & posterior • located in the brain; size of a pea • secretes hormones essential to growth, reproduction, and water balance in the body

6. Endocrine Glands cont’d • Thyroid • 2 lobes located in anterior neck • plays important role in controlling metabolism • Parathyroid • normally 4 glands found next to thyroid gland • secretes hormone to increase blood calcium levels

7. Endocrine Glands cont’d • Thymus gland • located in mediastinum behind sternum • during childhood secretes a hormone critical in maturing T lymphocytes (cells responsible for cell-mediated immunity) • Pancreas • located in upper retroperitoneum behind stomach • secretes digestive enzymes for digestion of fats & proteins • controls production or inhibition of the hormones glucagon & insulin

8. Endocrine Glands cont’d • Adrenal gland • located on superior surface of each kidney • adrenal medulla - secretes the catecholamine hormones epinephrine & norepinephrine • adrenal cortex - secretes 3 steroidal hormones • Gonads • chief responsibility for sexual maturation or puberty and subsequent reproduction • ovaries produce eggs • testes produce sperm

10. Regulation of Hormone Secretion • Hormones operate within a positive or negative feedback system to maintain homeostasis • Negative feedback • Most common feedback mechanism • Usually refers to an increase in the serum level of hormone or hormone-related substance that suppresses further hormone output • Hormone production is stimulated when the serum levels fall

11. Negative Feedback Mechanism

12. Specific Disorders of the Endocrine System • Disorders of the endocrine system arise from: • the effects of an imbalance in the production of one or more hormones • the effects of an alteration in the body’s ability to use the hormones produced

13. Specific Disorders of the Endocrine System • Clinical effects of endocrine gland imbalance are determined by: • the degree of dysfunction • the age and gender of the affected person

14. Disorders of Thyroid Gland • Usually seen more as part of the medical history than as a medical emergency • Complications of thyroid disorders more likely to be seen • hyperthyroidism - too much thyroid hormone in the blood (goiter) • thyrotoxicosis - prolonged exposure to excess thyroid hormones (Grave’s disease) • hypothyroidism - inadequate thyroid hormone • myxedema - long term exposure to inadequate levels of thyroid hormones

17. Grave’s Disease • A type of excessive thyroid activity characterized by a generalized enlargement of the gland (goiter), leading to a swollen neck and often protruding eyes (exophthalmos) • More common in women than men (6 times) • Typical onset young adulthood (20’s & 30’s) • May be due to an autoimmune process in which an antibody stimulates the thyroid cells • Strong hereditary role in predisposition of the disorder

19. Grave’s Disease • EMS significance • cardiac dysfunction the most common EMS event • tachycardia or new-onset atrial fibrillation in absence of cardiac history • Other signs & symptoms • agitation, emotional changeability, insomnia, poor heat tolerance, weight loss with increased appetite, weakness, dyspnea

20. Thyrotoxicosis • A term that refers to any toxic condition that results from prolonged excess thyroid hormone • Thyroid storm is a heightened and life-threatening manifestation of thyroid hyperfunction • A relatively rare condition; can be fatal • Usually associated with exposure to physiological stress (trauma, infection) • signs & symptoms indicate extreme hypermetabolic state (high fever (1060F), irritability, delirium or coma, tachycardia, hypotension, vomiting, diarrhea) • EMS care - supportive, rapid transport

21. Rare condition of long term exposure to inadequate levels thyroid hormones x4 more common in women Low metabolic state with poor organ function Lethargy, cold intolerance,  mental function, puffy face, thin hair, pale & cool skin Triggers for myxedema coma infection, trauma, cold temp Myxedema

22. Myxedema Coma • Myxedema coma difficult to identify • EMS impact • Heart failure not uncommon • Focus on maintenance of ABC’s • Monitor pulmonary and cardiac systems closely • Rapid transport important • Active rewarming in field not indicated • may cause cardiac dysrhythmias • vasodilation may cause cardiovascular collapse

23. Disorders of Adrenal Glands Adrenal cortex - outer portion of adrenal gland • Secretes steroidal hormones • glucocorticoids - increase blood glucose levels • mineralocorticoids - contributes to salt & fluid balance • androgenic hormones - influences similar to the gonads (role in puberty and reproduction) • Two medical emergencies of the adrenal cortex • Cushing’s syndrome • Addison’s disease

24. Cushing’s Syndrome • Caused by an abnormally high circulating level of corticosteroid hormones produced naturally by the adrenal glands • May be produced: • Directly by an adrenal gland tumor • By prolonged administration of corticosteroid drugs (ie: prednisone, hydrocortisone) • By enlargement of both adrenal glands due to a pituitary tumor • Relatively common problem of adrenals

25. Adrenal glands Adrenal glands Kidneys

26. Cushing’s Syndrome • Characteristic appearance • Face appears round (“moon-faced”) and red • Trunk tends to become obese from disturbances in fat metabolism; “buffalo hump” on back • Limbs become wasted from muscle atrophy • Mood swings , impaired concentration • Purple stretch marks may appear on the abdomen, thighs, and breasts • Skin often thins and bruises easily • Weakened bones are at increased risk for fracture

27. Moon Face

28. Cushing’s Syndrome Signs & Symptoms

29. Management Cushing’s Syndrome • FYI: higher incidence of cardiovascular disease • stroke • hypertension • Fragile skin • caution with IV starts • handle the patient carefully to avoid trauma to their skin • Treat symptoms as presented

30. Addison’s Disease • Pathophysiology • Adrenal steroids reduced • Glucocorticoids • Mineralocorticoids • Androgens • Most common cause is idiopathic atrophy of adrenal tissue (cause unknown) • Less common causes include hemorrhage, infarctions, fungal infections, auto immune disease, therapy with steroids (ie: prednisone)

31. Addison’s Disease • Signs and symptoms • Progressive weakness, fatigue • Decreased appetite & weight loss • Hyperpigmentation of skin, especially over sun-exposed skin areas • Disturbances in water & electrolyte balance • Low blood volume • EKG changes • Abrupt stoppage of steroids may trigger Addisonian crisis with cardiovascular collapse

32. Addison’s Disease • Management • Evaluate ABC’s & correct issues • Cardiac status - watch for dysrhythmias and circulatory collapse • Fluid resuscitation • Respiratory status - evaluate SaO2 levels • Blood glucose levels • Hypoglycemia very common

33. Diabetes Mellitus • Disease marked by inadequate insulin activity in the body • Glucose is important to all body cells but critical for the brain • Glucose only substance used by the brain for energy • Insulin maintains normal blood glucose levels • Enables body to store energy as glycogen, protein & fats • Action of insulin allows glucose to flow into cells

34. Normal Blood Glucose Levels • Healthy persons • Overnight fast - 80-90 mg/dL • 1st hour after a meal - 120-140 mg/dL • <80mg/dL reflects hypoglycemia • >140 mg/dL reflects hyperglycemia • Intervention necessary • Hypoglycemia -blood glucose <60 mg/dL • Hyperglycemia - blood glucose >300mg/dL not uncommon

35. Type I Diabetes • Low or absent production of insulin in the pancreas • Too much sugar, not enough insulin • Patients require supplemental insulin • If untreated, glucose levels rise • excess glucose spills into urine; patient loses large amounts of water (becomes dehydrated); fatty acids used as energy source resulting in ketosis from fat catabolism

36. Untreated Type I Diabetes • Signs & symptoms due to elevated blood glucose levels • Polydipsia (constant thirst) • Polyuria (excessive urination) • Polyphagia (ravenous appetite) • Weakness • Weight loss • Above signs & symptoms are what usually prompt people to seek a medical checkup for “not feeling well”

37. Type II Diabetes • More common than Type I diabetes (90% of cases) • Moderate decline in insulin production and inefficient use of the insulin that is produced • Risk factors: heredity, obesity • Treatment: dietary changes, increased exercise, oral hypoglycemics (to stimulate insulin production), possible addition of insulin if necessary

38. Diabetic Ketoacidosis (Diabetic Coma) • Too much sugar, not enough insulin • Onset slow (12 - 24 hours) • Increased urination; dehydration (warm, dry skin) • Excessive hunger and thirst • Tachycardia & weakness (volume depletion) • Ketoacidosis  Kussmaul’s respirations (deep and rapid) to exhale CO2 (an acid) • Decline in mental function • Low potassium - cardiac dysrhythmias

39. Diabetic Coma - Hyperglycemia • ABC’s addressed • Search for medic alert bracelet or insulin in refrigerator • Blood glucose levels (not uncommon to be >300) • Fluid resuscitation to treat dehydration • The higher the glucose level, the more critical the situation and the sicker the patient

40. Insulin Shock - Hypoglycemia • Too much insulin, not enough sugar • Onset rapid • Bizarre, unusual, inappropriate behavior • Diaphoretic, tachycardic • Seizures at critically low glucose levels • Rapid recovery with correct treatment • supplemental glucose

41. Insulin Shock - Hypoglycemia • ABC’s addressed • Search for medical alert bracelet or insulin in refrigerator • Treated when blood sugar drops below 60 • IV access to administer dextrose • Adult - D50 (50 ml) • Child (1to 15) - D25 (2 ml/kg) • Child <1 - D12.5% (4 ml/kg) • 1:1 dilution of D25% and normal saline • Lack of IV access • Glucagon IM: adult 1 mg; peds 0.1 mg/kg (max 1mg)

42. Glucagon vs Dextrose • Glucagon • a hormone, not a sugar • helps release stores of sugar if there is any in the liver but does not supply sugar itself • What do I do if no IV access, glucagon given, patient remains with altered level of consciousness and now I get an IV??? • Recheck the glucose level and if indicated, administer dextrose IVP

43. Gestational Diabetes • Onset can occur during pregnancy • While pregnant, most women require 2-3 times more insulin than would usually be required when not pregnant • During pregnancy, must be treated with insulin vs oral medication • insulin does not cross placental barrier, oral medication does • After delivery blood glucose levels return to normal

44. Skill Review Precision Xtra Glucose Monitoring System

45. Precision Xtra Calibration • Done when every new bottle opened • Calibration strip remains with those strips • Machine turns on when calibration strip slid into monitor • Confirm that LOT number displayed matches LOT number on strips • Turn monitor off • Monitor preprogrammed to display in English and results in mg/dL

46. Precision Xtra Glucose Testing • Insert glucose strip into monitor • Verify machine on & lot number correct • Obtain blood sample • hang hand dependently • cleanse area with alcohol wipe, let air dry • Use lancet to prick finger • use site on ulnar side of finger (easier for patient to hold hand in good position to obtain sample)

47. Precision Xtra Glucose Testing • Touch blood drop to target area on strip • blood may be applied to edge or top of test strip • continue touching the test strip to blood drop until monitor begins test (--- shows) • a second drop of blood may be applied, if needed, up to 30 seconds after 1st drop • Monitor turns off automatically after 30 seconds • View (& record) your results

48. Now You Know • Your Precision Xtra strips are designed to give accurate results based on capillary samples • You cannot be using venous samples (ie: from IV starts) • Venous results will be inaccurate

49. Gastrointestinal System

50. Gastrointestinal Emergencies • GI system includes from the mouth to anus and all parts in between • Risk factors for disease (usually self-induced) • excessive alcohol consumption • excessive smoking • increased stress • ingestion of caustic substances • poor bowel habits • Pain is the hallmark of acute abdominal problems • visceral, somatic, or referred