Diabetes and Blood Sugar Issues

1. Diabetes and Blood Sugar Issues Will/Grundy EMS System Continuing Medical Education June 2010 Sources: elsevierhealth, bryanking.com, diabetescare.info,

2. Introduction – Some Anatomy and Physiology review • Endocrine system has 8 glands • Hormones send chemical messages through these glands to maintain homeostasis • Hypothalamus • Pituitary • Thyroid • Parathyroid • Thymus • Pancreas • Adrenal • Gonads

3. Anatomy & Physiology Endocrine Glands Source: us.elsevierhealth.com

4. Anatomy & Physiology • Pancreas – the one we care about for diabetes • In the pancrease, Islets of Langerhans • Alpha cells produce glucagon • Beta cells produce insulin • Delta cells produce somatostatin • F cells produce pancreatic polypeptide • Insulin decreases blood glucose levels by increasing glucose transport into cells and increasing glucose metabolism by cells • Glucagon increases blood glucose levels by stimulating liver to release glucose stores • Glycogenolysis - takes place in the muscle and liver tissues, breakdown of glycogen to glucose • Gluconeogenesis – formation of glycogen from fatty acids and proteins instead of carbohydrates

5. Type 1 diabetes • In Type 1 diabetes, beta cells have ceased producing insulin. • Usually diagnosed in teenagers or young adults, but can occur any time after birth. • Heredity a factor. • Requires daily insulin.

6. Type II diabetes • Insulin production diminished, no longer meets metabolic demands • Cellular receptor sites decreased sensitivity, no longer respond effectively to current insulin levels • Occurs most often in adults over 40, overweight adults or teenagers, Native Americans, Hispanics, African-Americans • Usually treated with medication and diet, although insulin used sometimes as well.

7. Life-long complications of diabetes • Microvascular complications • Blindness • Renal dysfunction, hypertension • Neuropathy • Autonomic neuropathy • Macrovascular complications • Peripheral vascular disease • Cerebrovascular disease • Coronary artery disease

8. American Diabetes Association Stats As of 2007: 23.6 million children and adults in the United States—7.8% of the population—have diabetes. 6.6% of non-Hispanic whites 7.5% of Asian Americans 11.8% of non-Hispanic blacks 10.4% of Hispanics Diabetes seventh leading cause of death listed in US in 2006. • Adults with diabetes have heart disease death rates 2 to 4 times higher.• Risk for stroke is 2 to 4 times higher among people with diabetes. • Diabetes leading cause of new cases of blindness among adults aged 20–74 years.• Diabetes leading cause of kidney failure, accounting for 44% of new cases in 2005.• 60% to 70% of diabetics have mild to severe forms of nervous system damage. • More than 60% of nontraumatic lower-limb amputations are in people with diabetes. $174 billion: Total costs of diagnosed diabetes in the United States in 2007  $18 billion for the 6.3 million people with undiagnosed diabetes • $25 billion for the 57 million American adults with pre-diabetes

9. Hypoglycemia – low blood sugar • Region VII SMO requires sugar below 60 mg/dL, but definitions change depending on source. • Symptoms - Hunger, agitation, altered mentation, nausea, weakness, confusion, tachycardia, cool/clammy skin, seizures • These patients will be very sweaty and confused. Can easily be mistaken for intoxication and other problems. • Symptoms may vary – some patients seem fine with really low number, while others get loopy at 59.

10. Source: bryanking.net

11. Hypoglycemia - treatment Goal - Increase blood glucose level Oral glucose if patient is awake and able to swallow IV glucose if patient cannot swallow IM Glucagon if unable to get an IV

12. “Breakfast in Bed” Patient with hypoglycemia wakes up early in the morning with symptoms. Family calls 911, medics arrive to find patient nearly unconscious in bed. Paramedics give glucose, patient then insists on signing refusal once symptoms disappear. EMS phenomenon known as “Breakfast in Bed” It’s really easy for providers to fall into the refusal trap with hypoglycemic patients. Hypoglycemia is a life-threatening emergency. Even if the patient is magically “cured” by your IV, you should still encourage transport in case the low blood sugar was caused by an unknown medical problem. If patient insists on a refusal, document with call to medical control. Also encourage patient to eat a complex carbohydrate before you leave, as your IV glucose will not last in their blood for long (peanut butter on high-fiber toast is a great choice). FYI, a can of Pepsi is NOT a complex carbohydrate.

13. Hyperglycemia – high blood sugar • Diabetic ketoacidosis – cause • Caused by lack of insulin or resistance to insulin • Body cannot manage glucose, accumulates in blood • Body starts to use fat for energy, which results in buildup of acids (ketones) in blood. • Ketones cause acidosis, resulting in loss of potassium and severe sodium/electrolyte imbalance. • Ketoacidosis/hyperglycemia is slow in onset, 12-48 hours, unlike low blood sugar/hypoglycemia, which can affect a patient very quickly.

14. Diabetic Ketoacidosis • Symptoms include: Dry mucous membranes, orthostatic hypotention, supine hypotension, fatigue, increased thirst, increased urination, increased hunger, tachycardia, abdominal pain, vomiting from acidosis, altered mental status. • Late stages – coma, death • Kussmaul Respirations - Respiratory rate, tidal volume elevated, as patient tries to blow off carbon dioxide and ketones/acids . • Breath may smell sweet , fruity or metallic

15. Source: diabetescaregroup.info

16. Diabetic Ketoacidosis • Treatment: Fluids, insulin • Region VII SMO – 200 ml bolus for dehydration, repeat at physician discretion • Monitor for pulmonary edema, cerebral edema • Monitor vital signs and retake blood sugar measurement if necessary • Can’t give insulin in field because it requires refrigeration, plus hard to determine what level is needed without doctor review

17. HHNK • Hyperosmolar hyperglycemic nonketotic coma • Rare, life-threatening emergency • Typically in Type 2 diabetes and in the elderly • Elevated glucose from poor insulin action • Develops over several days • Fewer ketones in urine then ketoacidosis, but higher blood sugar levels • Blood glucose level increase • Severe volume depletion, CNS symptoms, coma • Treatment,: Fluid therapy, insulin

18. HHNK Signs/Symptoms • Severe volume depletion • Warm, dry skin • Dry mucous membranes • Poor skin turgor • Tachycardia • Weakness • Polyuria – increased urination • Polydipsia – increased thirst • Orthostatic hypotension • Supine hypostension • Altered mental status • Lethargy • Coma

19. How will you know the difference between ketoacidosis and HHNK in the field? You probably won’t. So when in doubt, stick to the SMO – if blood sugar is over 180, and there are signs/symptoms of Ketoacidosis, pull out the fluid. Be sure to monitor lung sounds, as many people with Type 2 diabetes have co-morbid breathing problems like CHF. And FYI: there are some diabetics who have been told by their doctors to maintain a higher blood sugar level or who feel fine with hyperglycemia. When in doubt, contact medical control.

20. There are other kinds of diabetes besides the “classics”. Gestational Diabetes Diabetes Insipidus

21. Gestational Diabetes • Diabetes caused by pregnancy. Can end when the pregnancy ends, or may continue after birth • Impaired glucose tolerance, elevated • If untreated, fetal death risk Risk Factors: • 25+ years • Obese • Impaired insulin secretion • Prior delivery of 9+ lbs. • 1st-degree relative with diabetes • Recurrent infections • African/Hispanic ancestry • Treatment - Dietary modification, insulin therapy, medication

22. Diabetes Insipidus • Rare • Diabetes insipidus (DI) is characterized by excessive thirst and excessive urination. • Drinking less doesn’t reduce the amount of urine excreted. • The most common type is neurogenic DI, caused by a deficiency of antidiuretic hormone (ADH), which is secreted by the pituitary gland. • Usually a result of posterior pituitary deficiencies