Diabetic Emergencies

1. Diabetic Emergencies Not too Sweet – Not too Sour

2. What is Diabetes? • Diabetes Mellitus – a disorder of Insulin

3. Diabetes Mellitus • Type I – insulin dependent • Usually starts at an early age • Caused by autoimmune destruction of Beta cells • No insulin production at all • No Insulin = Death • 1922 – first successful use of insulin to treat kids with DKA – always fatal up until that point. • Currently – insulin pumps and various types of insulin are state of the art in treatment for Type I DM.

4. Diabetes Mellitus Type II – insulin resistant • Obesity, sedentary lifestyle • Beta blockers, glucocorticoids, thiazides • 90% of all diabetes in US • Insulin is unable to do its work • Dietary changes, medications or insulin may be needed • Usually does not cause DKA

5. Diabetes Mellitus • Gestational Diabetes • Occurs during pregnancy • Resolves with delivery most of the time. • Due to hormone levels and obesity

6. Diabetes

9. Insulin • What is Insulin? • A hormone made by Beta cells in the Pancreas • Insulin works on multiple cells to regulate blood Glucose levels • Muscle – prevents protein breakdown • Adipose tissue – increases fat production • Liver – increased glycogen synthesis • Increased glucose and amino acid uptake • Inhibits Glucagon production

10. Effects • Vasculopathy- Vascular damage

11. Effects • Nephropathy - Kidney Damage

12. Effects • Neuropathy – nerve damage

13. Effects • Retinopathy – eye damage

14. Effects • Diabetic Ketoacidosis

15. Effects • Hypoglycemia – caused by treatment

17. Medications used in Treating Diabetes • Antihyperglycemics – stimulate insulin production • Sulfunylureas – Diabinese, Glucotrol, Diabeta, Amaryl • Meglitinides – Prandin, Starlix • Antihyperglycemics – do not stimulate insulin • Biguanide – Metformin – Lactic acidosis • Thiazolidinediones – Avandia, Actos • Alpha-glucosidase inhibitor – Precose, Glyset • DPP-4 Inhibit – Januvia, Onglyza

18. Hypoglycemia • The brain MUST have glucose to function • Brain is not affected by insulin. • Normal blood sugar levels range from 70-100 • Low blood sugar can be caused by • Taking insulin when you cannot eat or forget to eat • Intentionally overdosing on insulin • Taking the wrong type • Exercising more than normal and not adjusting diet • Certain diabetes medications, but not all • Infections/illness which prevent eating

19. Hypoglycemia • Clinical symptoms • Lethargy • Unconsciousness • Stroke-like symptoms (especially in those with prior strokes) • Seizures • Trouble speaking • Confusion • Cardiac Arrest

20. Hypoglycemia • Testing • Fingerstick blood sugar • Make sure machine gets calibrated regularly • Make sure you have the right test strips that are not expired • Clean finger off with alcohol • Prick side of finger with lancet • Squeeze finger (milk it) to get enough to cover testing area • Read machine when test is complete

21. DEMO TIME…

22. Hypoglycemia • Treatment – Glucose! • IV Dextrose – AEMTs/Paramedics • Adults – 50% 1 ampule (50ml = 25gm) • Children – 25% 2ml/kg • Neonates – 12.5% - 1ml/kg • Oral Glucose – EMR/EMTs • Must have gag reflex and be alert to avoid aspiration/choking • Glucagon – for adults • 1-2 mg IM if cannot get an IV

23. Dextrose • Class – carbohydrate • Mechanism – provides metabolic substrate • Contraindications • Absolute – None • Relative – hyperglycemia • Dosage – 50ml of D50, repeat x1 if needed • Peds – 2ml/kg of D25 • Neonates – 1ml/kg of D12.5

24. Glucagon • Class – hormone • Mechanism – stimulates glycogen breakdown in the liver and muscle, increasing glucose levels • Contraindications • Absolute - sensitivity • Relavtive – starvation, fasting, adrenal insufficiency • Uses – hypoglycemia, beta-blocker overdose, calcium channel overdose, anaphylaxis (for folks on beta-blockers) • Dosage – hypoglycemia – 1mg IV/IM Q20 min; beta-antagonist OD – 3-5mg IV; anaphylaxis 1-2mg IV • Kids - <20kg – 0.5mg IV/IM; >20mg – 1mg IV/IM • Side effects – Nausea, vomiting, diaphoresis, hypotension, rash

25. Meter is broken… • Get as much history as possible. • Smell for ketones (only half of us can) • Are there empty insulin bottles on scene? Recent exercise or illness? • Err on the side of treating for hypoglycemia

26. DKA • No insulin activity = high blood sugar levels • Can’t make glycogen, fatty acids and cannot move glucose into cells  Cells starve  Fatty Acid breakdown  Ketosis • High blood sugar  sugar in urine  peeing a lot  dehydration  acidosis • Diabetic Ketoacidosis! • Fruity odor to breath • Increased respiratory rate • Abdominal pain • Nausea/Vomiting • Tachycardia / hypotension

27. Hyperglycemia • Low Insulin activity = high blood sugars • Still able to get some glucose in cells = no starvation = no ketosis • Acidosis also less likely • No fruity odor • Generalized weakness • Less nausea/vomiting • Death very rare

28. Hyperglycemia • Treatment • ABC’s • IV fluids! • Adults – 500ml – 1 liter WO • Children – 20ml/kg fluid boluses • May repeat if needed for hypotension or tachycardia

29. What about Insulin Pumps • If hypoglycemia – have patient turn off pump after you wake them up with D50 • If hyperglycemia – don’t touch it • May not be working • Patient may be able to do a bolus on their own based on their sliding scale • If infected, leave in place, but do not use.

30. Alcoholic Ketoacidosis • Chronic Alcoholics are malnourished • Few glycogen stores • After a binge, their glucose levels can drop, stimulating fatty acid breakdown • Treatment is glucose with Thiamine • Don’t withhold glucose if level is abnormal!

31. You wanna refuse? • While people have a right to make their own decisions, it must be an INFORMED decision • They must: • Be alert, oriented to person, place, time, and situation • Know of the risk for relapse • Have recovered within 10 minutes. FSBS >80 • They should • Have test strips available or have someone there to call back if they get hypoglycemic again. • Have adequate follow-up.

32. Questions • A diabetic’s family calls 911 for sudden onset of left sided weakness that started 10 minutes prior to arrival. After ABCs, what is your next step?

33. Questions • A Diabetic teen-ager decides to say “f&^% you” to his diet, and eats an ice cream sundae. A day later, he calls 911 for vomiting and abdominal pain. His Glucose on fingerstick reads “Hi” What should you give?

34. Questions • You come across a “local regular” beside the bar. He smells of alcohol, and is lethargic. He looks like he hasn’t been eating regularly for quite some time. You consider _____ as a possible diagnosis, and _________