Endocrine Emergencies

1. Endocrine Emergencies Outreach Education ARCH Air Medical Service

2. Diabetic EmergenciesObjectives • Define Diabetes Mellitus Type I (IDDM) Type II (NIDDM) • State clinical presentation and transport considerations for: Altered mental status Hypoglycemia DKA HHNK

3. Objectives • Discuss and understand the pathophysiology related to the major endocrine disorders that may be encountered when caring for a critically ill patient. • Review and recognize the signs and symptoms of major endocrine conditions. • Implement standards of care practices when managing this special patient population.

4. Diabetes Mellitus Diabetes Insipidus SIADH Cushing Disease Addison Disease Hypothyroidsm Hyperthyroidism Pheochromocytoma Major Endocrine Disorders

5. Diabetes Mellitus • Chronic and progressive disease • Impacts almost every aspect of life • Affects infants, children, young people, and adults of all ages • Can result in premature death, ill health and disability • 14 million people have Diabetes

6. What is Diabetes Mellitus? • Disturbance in the metabolism of carbohydrates, fats and proteins • Altered relationship between glucose and insulin • A disorder that results from the body’s inability to produce or utilize insulin.

7. Why? • Lack of insulin being secreted by the pancreas TYPE I or • Inability of the cell receptors to recognize insulin and allow the glucose to enter at a normal rate TYPE II

8. Type II • Most common type of DM >90% • Insulin exists, but inadequate to meet the body’s needs, but enough to prevent ketone production. • Caused by tissue insensitivity to insulin or an impaired insulin production. • Associated with obesity • Not linked to antigens or antibodies. • Insidious onset-patients may by asymptomatic

9. Special Considerations • Secondary DM: Hyperglycemia occurs due to another established cause: • Pancreatic diseases • Pancreatectomy • Cushing’s syndrome • Acromegaly • Genetic disorders

10. Special Considerations • Gestational DM • Occurs during pregnancy • Usually reverts to normal glucose tolerance following delivery

11. Insulin • Hormone secreted by the pancreas • Needed to promote the movement of glucose from the blood into the cells

12. Glucose • Simple form of sugar • Body’s main source of energy • Crucial to normal function of cells • Brain cells are not able to use anything but glucose to function

13. Food is eaten Digestion begins in the stomach Food is broken down into glucose in the small intestine Glucose enters the bloodstream Insulin is released by pancreas Glucose enters body cells with aid of insulin Food is eaten Digestion begins in the stomach Food is broken down into glucose in the small intestine Glucose enters the bloodstream Little or no insulin is released Glucose accumulates in bloodstream and eventually is eliminated in the urine The cells use fat for energy Normal VS. Type I use of Glucose Normal Type I

14. Diabetic EmergencyAltered Mental Status Conditions that may Alter Mental Status • Shock • Poisoning/drug overdose • Post seizure • Infection • Traumatic head injury • Hypoxia • Alcohol/drug intoxication • Stroke • Diabetes

15. Altered Mental StatusScene Size-up • Gather clues… • Medical alert tag • Is there any evidence of injury • Ask questions… • Are there syringes laying around • Is there insulin in the fridge

16. ABC’s Patent airway Provide Oxygen Establish IV access SAMPLE Signs and Symptoms Allergies Medications Pertinent past history Last oral intake Events leading to the injury or illness Altered Mental Status with History of DiabetesAssessment and Care:

17. Altered Mental Status with History of DiabetesSigns and Symptoms • Rapid onset after missing a meal, vomiting, unusual exercise, or physical work • Intoxicated appearance: staggering or slurred speech to complete unresponsiveness • Tachycardia • Cool moist skin • Hunger • Seizure activity • 3 P’s (polydispia, polyphagia, polyuria)

18. Altered Mental Status with History of DiabetesSigns and Symptoms: • Bizarre behavior, combativeness • Anxiousness or restlessness • Bruising on the abdomen • Elderly patients frequently suffer signs and symptoms that mimic a stroke, such as weakness or paralysis on one side of the body

19. Altered Mental Status with History of DiabetesSigns and Symptoms: • Blood glucose reading of <60 mg/dl (normal glucose range is 80-120mg/dl

20. Allergies and Medication • “Sugar” is often used by diabetic patients in regards to their illness and/or medication • All medications and list that may indicate allergies should be taken with the patient to the hospital • Insulin is usually kept in the refrigerator

21. Pertinent Last Events • Is there a history of DM • When was the last PO intake (you may find out the patient has been drinking a lot more than usual) • What were the events leading up to the 911 call

22. Obtaining a Blood Glucose Level • Test BGL prior to giving glucose • Glucometers are available to most pre-hospital providers • The patient may also have a Glucometer in the home with a record of recent blood sugar readings

23. Antidiabetic Agents • Tolbutamide (Orinase) • Tolazamide (Ronase) • Gilipizide (Glucotrol) • Acetohexamide (Dymelor) • Glyburide (DiaBeta, Glynase, Micronase) • Chorpropamide (Diabinese, Glucamide)

24. Antidiabetic Agents Considerations • Drugs such as Anabolic steroids, MAO inhibitors, Dilantin, Salicylates increase hypoglycemic activity • Beta blockers, clonidine prolong hypoglycemic effect and mask symptoms of hypoglycemia • Corticosteroids, glucagon, rifampin, thiazide diuretics decreased hypoglycemic response

25. Methods of Glucose AdministrationSugar / Glucose gel • May be administered only to the patient that is alert with a gag reflex and able to swallow • Administration in the form of a candy bar, OJ mixed with sugar, or a nondiet soft drink • Sublingual or buccal administration of a glucose gel preparation

26. Glucagon • Raises blood glucose level • Supplied in powder form • Dose 0.5-1mg IM, SQ, or IV • Give after coma occurs • Usually used only when IV access is not available • May repeat every 20 min. x 2 doses

27. Dextrose (D-Glucose) • Used to treat insulin induced hypoglycemia • Administer slow IV push through a stable peripheral vein • 50% Dextrose used in adults • 25% Dextrose used in children

28. Special Considerations with the administration of Glucose • If alcoholism or other drug abuse is suspected, medical direction may recommend the administration of Thiamine, Narcan or both, before the administration of glucose

29. 911 call to residence On arrival 76yr male whose wife states he has been confused all morning. She tells you he had his insulin this morning, but didn’t eat much breakfast Treatment ABC’s Assess mental status Obtain BGL Administer oral gulcose Transport Recheck BGL Scenario of Treatment

30. Diabetic EmergenciesHypogylcemia • The diabetic is suffering from a low blood sugar (< 60 mg/dl with S&S or <50 with or without S&S) • Most common cause of coma in the diabetic patient • More common in Type I (IDDM)

31. Diabetic EmergenciesHypogylcemia: common causes • Pt. Failed to eat after taking insulin • Takes insulin, eats a meal, but drastically increases activity beyond normal • Takes too much insulin

32. HypogylcemiaSigns and symptoms caused by release of epinephrine • Diaphoresis • Tremors • Weakness • Hunger • Tachycardia • Dizziness • Pale, cool, clammy skin • Warm sensation

33. HypogylcemiaSigns and symptomscaused by brain cell dysfunction • Confusion • Drowsiness • Disorientation • Unresponsiveness • Seizures may occur in severe cases • Stroke-like symptoms including hemiparesis

34. HypoglycemiaTreatment • ABC’s • Management is based on mental status • Give sugar to increase blood glucose

35. HypoglycemiaUnresponsive patient, unable to swallow, unable to obey commands: • Establish an open airway • Provide oxygen; NRB @15L • Positive pressure ventilation if breathing is inadequate • Contact medical control • Assess blood glucose level • Establish IV access • Give glucose

36. 911 call for a MVC Arrive at scene to find a 40 yr male that is belligerent and combative Pt. Was a restrained driver that struck a parked vehicle He appears intoxicated Treatment ABC’s Spinal immobilization Establish IV access and obtain BGL Administer 1 amp D50 Transport and recheck BGL Scenario of Treatment

37. Diabetic Emergencies:Hyperglycemia • The diabetic patient is suffering from a high blood glucose level • Lack of insulin and an excessive amount of glucose • The brain has more glucose than it knows what to do with

38. HyperglycemiaRelated conditions • Diabetic ketoacidosis (DKA) Most common TYPE I diabetics • Hyperglycemic hyperosmolar nonketoctic syndrome (HHNK) Most common TYPE II diabetics • In both conditions there is a lack of insulin and excessive amount of glucose

39. Diabetic EmergenciesHyperglycemia: DKA • Typically blood glucose is >350mg/dl • Excess glucose begins to spill into urine resulting in: • Frequent urination • Dehydration • Production of ketones resulting in: • Acidosis

40. DKA: Common Causes • Infection • Inadequate dose of insulin • Complication of other meds (thiazide, Dilantin, or steroids) • Stress such as surgery, trauma, pregnancy, or heart attack • Change in diet with overeating or increase in carbohydrate or sugar intake

41. DKA: Signs and Symptoms • Excessive urination, hunger and thirst • Nausea and vomiting • Poor skin turgor • Tachycardia • Kussmaul’s respirations • Altered mental status; Coma • Fruity or acetone odor on the breath • Positive orthostatic tilt test • BGL >350 mg/dl • Muscle cramps • Abd.pain (more common in kids) • Warm, dry skin • Slow onset of signs and symptoms; up to several days • Occur from dehydration and acid build up

42. DKA: Treatment • Goals are to reduce blood glucose and rehydrate the patient • Establish and maintain a patent airway • Provide oxygen • Obtain blood glucose level • Contact Medical Control • Establish IV • Provide hydration and insulin as ordered

43. DKA: Treatment; special consideration • If you are unable to obtain a BGL then you don’t know for sure if the patient is hypo or hyperglycemic • Oral glucose should be considered in any patient who has a history of diabetes and presents with an altered mental status

44. 911 call to residence 26 yr male found unresponsive Inspirations are deep and rapid A fruity breath odor is noted Treatment ABC’s Establish IV access Check BGL Administer NS Transport / contact medical control Scenario of Treatment

45. 911 call to local high school School nurse states 15 yr. Diabetic student came to her after football practice complaining of nausea and muscle cramps She checked his BGL and found it to be 446 As she was notifying his parents, he became anxious followed by unresponsiveness Treatment ABC’s Establish IV access Recheck BGL Administer IV NS Transport/notify medical control Scenario of Treatment

46. Hyperosmolar Hyperglycemia Non-Ketosis HHNK • Blood glucose >600-1200 mg/dl • Kidneys spill large amounts of glucose • Glucose draws large amounts of water with it into the urine • More common in Type II • Ketones are not collected causing an acid load in the body • ELEVATED SERUM OSMOLITY>350

47. HHNK: Common Causes • May be the first indicator of Diabetes • May be precipitated by trauma, burns, dialysis, drugs, heart attack, stroke, infections, and head injuries.

48. HHNK: Signs and Symptoms • Tachycardia • Fever • Positive orthostatic tilt test • Dehydration • Thirst • Dizziness • Poor skin turgor • Altered mental status • Confusion • Weakness • Dry oral mucosa • Dry warm skin • Polyuria or oliguria • Nausea and vomiting • Carries a high mortality rate • More likely to seize than are hypoglycemic patients

49. HHNK: Treatment • Basically the same as for DKA • Establish and maintain airway • Provide oxygen • Determine BGL • Establish IV and rehydrate • If unsure about condition, administer oral glucose if able to swallow • Contact Medical Control

50. Overview DKA vs HNNK