On Exam: No evidence of trauma Loc—Groans to painful stimulus

2. You are dispatched Code 3 for a Diabetic….13C2, at 0730….You arrive at a townhouse and are led by the parents to the upstairs. They state their son is a insulin dependent diabetic and has been sick for two days with flu like symptoms. This morning they could not wake him and he sleep thru his alarm and they called for a Ambulance. You find a 13 year old male, lying supine in bed………

3. The parents also tell you he went to bed early last night, and skipped his bedtime snack. Last night his blood sugar was 4.1 mmol/l. On Exam: No evidence of trauma Loc—Groans to painful stimulus Airway—Inadequate, snoring-will not take an airway positioned ¾ prone—airway clears Breathing—Adequate Circulation—Easily felt radial pulse/rapid RBS—unremarkable

4. Should you initiate your Diabetic emergencies Protocol or should you load and go? What are the 4 things required to initiate your protocol?

5. On further Exam: IDDM since the age of 8 years old, sick for 2 days, infrequent episodes of hypoglycemia that are usually resolved with food. The patient has never required an ambulance before. Vitals—108/64, Pulse 96 regular and easily felt, respirations are 20 regular and adequate, skin is pale, cool and clammy, GCS 1,2,4 = 7, O2 sat on high flow o2 is 99% Blood glucose is 1.7 mmol/l

6. Patient takes Humulin N and R on a sliding scale in the morning and evening. He has also been taking Ibuprofen for the last 2 days. The Patient has no drug allergies.

7. Types of Insulin

9. What are the S/S of hyperglycemia? What are the S/S of Hypoglycemia? What are the common causes of Hyperglycemia? What are the common causes of Hypoglycemia?

10. Taking too much insulin Excessive exercise Inadequate food intake Oral Hypoglycemic Agents Common causes of hypoglycemia include:

11. Failing to take insulin Taking inadequate amounts of insulin Infection Excessive food intake Pregnancy Increased stress (both emotional and physical; E.G., Surgery Common causes of hyperglycemia include:

12. You start administering gluco-gel….. If IV endorsed what do you do? If you miss the IV or are not IV endorsed what do you do? What is the first choice, an IV or glucagon?

13. Drug Monograph: Classification: Hyperglycemic Agent (antihypoglycemic) Mechanism: Pancreatic Hormone, which acts on the glycogen in the liver, converting it to glucose. Producing a temporary rise in blood glucose. (Glycogenolysis) Indication: Hypoglycemia (if unable to establish an IV for ALS and EMA II, P1 hypoglycemia when patient is unable to obey commands) Contraindications: Known allergy to Glucagon Pheochromocytoma (an adrenal gland tumor, can cause sudden and marked increase in BP) So we are now into the Glucagon!!!!!!!

14. Drug Monograph: Route and Method: IM (ACP/CCP only) SC (ACP/CCP/ PCP) Onset/Duration: IM 8-15 minutes, 10-30 minutes SC—similar to IM (a little slower) Elimination: rapidly degraded by the liver, kidneys and in the plasma. Half life 3-6 minutes in plasma

15. Dose: Patients > 20 kg—1.0 mg Patients < 20 kg—0.5 mg Side Effects: Nausea and Vomiting (common) (infrequent) Hypokalemia, Generalized allergic reaction Hypertension, Hypo tension Diarrhea Increased pulse and BP (rare) Hypoglycemia

16. So back to the patient: IV attempts are unsuccessful (or if you are not licensed to that level…) Lets give Glucagon: How much Glucagon do we give to this patient? What are the doses and weight guidelines?

17. We give the glucagon—What route and what is the preferred site? What do we do next? We initiate transport, it has been about 5 minutes after Glucagon administration, we do another set of Vitals and find: BP-105/68 Pulse-92 Resp-20 Skin-Pale, cool, clammy GCS-1,2,4 = 7 Pt is unable to follow instructions, O2 saturation is 99% on high flow O2

18. Another 5 minutes goes by: Current Vitals: 110/70, pulse 88, resp 18, skin is pale cool and dry, GCS is now 4,4,6 = 14, o2 sat 99% Patient is now able to follow instructions, what do you do now?

19. Commercial Break!!!!!

20. So back to the patient: You have given gluco-gel and you are well on the way to the hospital…current vitals are now: BP-110/72 Pulse-82 Resp-18 Skin-Normal, Cool, Dry GCS- 4,5,6 = 15, O2 sat 99 % on high flow The patient is able to follow instructions, things are looking pretty good! The rest of the trip to the hospital is uneventful….

21. What is Type I Diabetes and describe the typical patient? What is Type II Diabetes and describe the typical patient?

22. Oral Hypoglycemic Drugs: There are a number of medications taken orally to control blood sugars. These drugs are grouped into a number of categories and are prescribed to target certain areas of the body, such as the liver or muscle cells.

23. Oral Hypoglycemics: • Stimulating Insulin production: • Diabeta, Glyburide • Decreasing Glucose Release from the Liver: • Glucophage, Metformin • Slowing down the absorption of sugars from the Gut: • Prandase, Acarbose • Increasing glucose Uptake by fat and muscle cells: • Pigoglitazone, Avandia

24. Questions: Can glucagon be repeated if the patient doesn’t respond to the first dose? Do we give thiamine after administering Glucagon? What are the chances of an overdose? If a patient doesn’t respond to IV glucose do we give Glucagon? Can an IV be started on a patient after Glucagon has been given? Can Glucagon be used in the NYD protocol?

25. Can we “Code X” a patient that we’ve given Glucagon to? Glucagon is only effective if the patient has adequate stores of glycogen, what conditions cause depleted glycogen stores? What else is in the glucagon solution that we are giving? Will glucagon be effective if a patient has had a hypoglycemic reaction in the last 24-48 hours?