Endocrinology, Gastrointestinal Disorders, Renal/Urology Disorders, Rhythm Review

1. Endocrinology, Gastrointestinal Disorders, Renal/Urology Disorders, Rhythm Review Condell Medical Center EMS System ECRN CE Prepared by: S. Hopkins, RN, BSN, EMT-P

2. Objectives • Upon successful completion of this module, the ECRN should be able to: • identify the function of the endocrine system • distinguish a variety of medical disorders of the endocrine system • describe the type of pain experienced for gastrointestinal and genitourinary disorders • identify and appropriately state interventions for a variety of EKG rhythms • understand a variety of Region X SOP’s and the ECRN impact • successfully complete the quiz with a score of > 80%

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 • Control and coordinate 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 a connection between the central nervous system (CNS) and the 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 The 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 • Impact on EMS providers & ED staff • cardiac dysfunction is a common event prompting an ED visit • 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 field care - supportive, rapid transport

21. Rare condition of long term exposure to inadequate levels thyroid hormones 4 times 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 • Impact on EMS providers & ED staff • Heart failure not uncommon • Focus on maintenance of ABC’s • Monitor pulmonary and cardiac systems closely • Rapid transport from the field is 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 of 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 • Reduction in Adrenal steroids • 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. Typical 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 & get rid of increased CO2 levels (an acid) • Decline in mental function • Low potassium - cardiac dysrhythmias

39. Diabetic Coma - Hyperglycemia • ABC’s addressed • Search for medic alert bracelet (EMS should check for insulin in refrigerator at home) • Elevated 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 • These seizures are most effectively treated by administering Dextrose to restore the glucose levels • Rapid recovery with correct treatment • supplemental glucose

41. Insulin Shock - Hypoglycemia • ABC’s addressed • Search for medical alert bracelet (EMS to check for insulin in refrigerator at home) • Treated when blood sugar drops below 60 • Obtain IV access to administer dextrose (EMS dosing) • 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 (EMS dosing protocol) • 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 are any in the liver; does not supply sugar itself • is not always effective; can take up to 20 minutes • EMS calls and states they had no IV access, Glucagon was given, patient remains with an altered level of consciousness and now they have IV access. Can they give Dextrose IVP? • The ECRN should order EMS to recheck the glucose level and, if indicated (<60), administer Dextrose

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 diabetic medication does • After delivery blood glucose levels usually return to normal

44. Gastrointestinal System

45. 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

46. Visceral Pain • Caused by inflammation, distention (inflation of the organ), or ischemia (inadequate blood flow) • Pain vague, dull, or crampy • Is generally diffuse and difficult to localize • Examples (most often hollow organs) • gallbladder (cholecystitis) • appendix (appendicitis) • Presentation (from sympathetic stimulation) • nausea & vomiting • diaphoresis • tachycardia

47. Somatic Pain • Produced by bacterial or chemical irritation of nerve fibers in the peritoneum (peritonitis) • Is usually constant and localized to a specific area • Often described as sharp or stabbing • Examples • ruptured appendix • perforated ulcer • inflamed pancreas • Peritonitis can lead to sepsis & death

48. Somatic Pain • Presentation • Patient often hesitant to move • Lies on their back or side with legs flexed to prevent additional pain from stimulation of the peritoneal area • Often exhibits involuntary guarding of the abdomen • Rebound tenderness often noted during the physical examination

49. Referred Pain • Pain in a part of the body considerably removed from the tissues that cause the pain • Results from neural pathways from various organs passing thru or over a region where the organ was initially formed in the fetal stage • Examples • diaphragm injury refers pain to neck or shoulders • dissecting abdominal aneurysm refers pain between shoulder blades • appendicitis refers pain to periumbilical area • gallbladder refers pain to right shoulder

50. Referred Pain: Anterior View