An Electricians Guide to Diabetic Emergencies

Presence Regional EMS System

November CE 2014

Objectives Discuss the pathophysiology of Diabetes Mellitus

List the assessment findings for a patient who has hyperglycemia and the rational for these findings.

List the assessment findings for a patient who has hypoglycemia and the rational for these findings

Outline the management for a patient who has hyperglycemia

Outline the management for a patient who has hypoglycemia

Describe the science behind insulin pumps and their use by the diabetic population.

Glucose’s path into the cell

Glucose

• Glucose is carried by the blood to the cells, much like electricity is carried by the wiring in your house.

• Cells need Glucose for energy like our electronics need electricity

• Hypoglycemia or low blood glucose is like too little electricity in your house. Your electronics don’t run properly and stop, much like your cells.

• Hyperglycemia is like a power surge and can damage the electronics in your home.

Insulin

• Insulin is a hormone that interlocks with insulin receptors in the cell walls. Each molecule of insulin fits perfectly with a receptor.

• The connection enables glucose to be carried from the blood stream into the cell for energy production.

• Some cells (like brain cells) may rely completely on glucose for energy.

• Insulin resistance is like a problem with the outlet. Electricity is available in the wiring, and the electronics need it, but they don’t get any when connections are attempted between the plug and outlet.

Insulin receptors and glucose transporters

• Insulin receptors interlock with insulin to enable glucose transport into the cell

• Glucose transporters carry glucose into the cell for energy production once signaled by the receptor.

The Cell

• Cells utilize Glucose and O2 for energy production

• Because of the brain’s reliance on glucose for energy, neurological symptoms occur quickly from hypoglycemia:• Altered mental status• Slurred speech• Irritability• Inability to concentrate

**The brain also releases Epinephrine to trigger stored glucose release, causing shock like conditions

What Happens in the Body With Glucose and Insulin Normally

If someone eats ice cream, their glucose level in the blood (golden hexagons) will go up.

When blood glucose goes up, cells in the pancreas are stimulated

When the pancreas is stimulated it releases a hormone called insulin into the blood (blue hash marks)

The insulin travels in the blood to an insulin receptor on a cell wall (green). The insulin plugs into the insulin receptor triggering the opening of glucose gates/transporters (purple) allowing glucose into the cells.

Once inside the cell the glucose combines with oxygen in a chemical reaction releasing the energy needed by the body to survive.

Once the glucose is in the cell creating energy and is no longer in the blood stream, the blood glucose level drops and the insulin production shuts off until it is needed again to allow glucose into the cells.

This is an example of a negative feedback loop, that once a process is no longer needed it shuts itself off.

In addition

If more glucose is taken into the body that is needed by the cells for energy (a double scoop of ice cream), insulin helps distribute the extra glucose in a variety of storage areas in the body.

Some of the glucose will be transformed to glycogen (brown strand) that is stored in the muscle and liver for easy access of more glucose is needed quickly. Insulin is needed to open the glucose transporters in the liver enabling glucose to be transformed to glycogen.

In addition to glycogen, some of the extra glucose in the liver is converted to protein (pink strand)

Also in the liver, some of the glucose is converted to fatty acids (dark green squares)

With the help of insulin, more glucose is admitted into fat cells and converted to glycerol which combines with the fatty acids from the liver to make tri-glycerides which are stored fat. (green and yellow E shaped structures)

Without insulin, none of the uses of glucose can happen: Energy production

Storing glucose as glycogen

Storing fuel as proteins

Storing fuel as fats

Diabetes Mellitus

Diabetes is a disease that affects the body’s ability to use glucose (sugar) for fuel.

Occurs in about 7% of the population

Complications include blindness, cardiovascular disease, and kidney failure.

Type 1 Diabetes Mellitus

Type 1 patients do not produce insulin.

Need daily injections of insulin

Typically develops during childhood

Patients more likely to have metabolic problems and organ damage

Considered an autoimmune problem

Type 2 Diabetes Mellitus

Type 2 patients produce inadequate amounts of insulin, or normal amount that does not function effectively.

Sometimes the problem is that there is Insulin Resistance. Insulin resistance is like a problem with the electrical outlet. Electricity is available in the wiring, and the electronics need it, but they don’t get any when connections are attempted between the plug and outlet.

Usually appears later in life

Treatment may be diet, exercise, oral medications, or insulin.

Type 1 and type 2 diabetes both:

Are equally serious

Affect many tissues and functions

Require life-long management.

How Does Someone Know They Have Diabetes?

The signs and systems of new onset or uncontrolled diabetes are as a result of no insulin or poor insulin being produced in the pancreas.

The person is still eating and taking in glucose, but there is no insulin to plug into the insulin receptors to open the glucose gate/transporter

The cell is deprived of its usual source of energy as the glucose level in the blood continues to rise.

Even if there is no glucose getting from the blood into the cell, the body still needs to create energy.

The body will first use up the stored glucose in glycogen (brown)

Then the body will use the stored fat (yellow) and proteins (pink) for energy.

Without insulin, none of these sources of energy are very efficient, so the patient will complain of feeling tired and weak.

In addition, the body senses that there is not enough good fuel so the person will feel very hungry and continue to eat. (Hyperphagia)

Although the person is eating, no glucose is getting into the cells, so while the blood glucose rises, the person’s body stores of fat and protein are being depleted.

Not only is breaking down fat and protein for energy not efficient, the byproduct of this breakdown is ketone (gray).

Ketone is an acid. The body does not tolerate high levels of acid.

If the acid builds up in the blood this is called ketosis. Ketosis can lead to coma and death.

If someone is creating ketones their body will try to get rid of the extra acid by breathing faster to eliminate the acid by exhaling through the lungs.

This results in rapid deep breathing called Kussmauls Respirations. This is not “hyperventilation” but a protective mechanism to help the body rapidly get rid of extra acid.

When assessing the patient with high ketones, the EMT can smell the ketone on the patient’s breath. Ketones smell like acetone or nail polish remover.

To get rid of the extra glucose in the blood, the person with new onset or uncontrolled diabetes depends on the kidneys.

When the blood glucose level is too high, the kidney removes some of the excess glucose and eliminates in urine, resulting in glucosuria.

The kidney can also eliminate some of the extra ketones in the blood resulting in ketonuria.

Because so much extra material is being sent out in urine, the body needs more water for elimination. The person feels thirsty all the time and becomes dehydrated because more water is needed for urine production that the patient is able to take in.

Excessive thirst is polydipsia. Excessive urination is polyuria.

Hyperglycemia

Uncontrolled Diabetes Mellitus Undiagnosed Diabetes Mellitus Too high blood sugar If untreated leads to:

Developing ketones and acidosisIncreased Kidney workload with

resulting damage

Signs and Symptoms of Hyperglycemia

High blood glucose (> 400 mg/dl)

Polyuria: frequent, plentiful urination

Polydipsia: frequent drinking to satisfy continuous thirst

Polyphagia: excessive eating with weight loss

Feeling weak and fatigued

Weak, rapid pulse

Rapid deep breathing --Kussmaul respirations

Smell of acetone on the breath

Dehydration – dry lips, dry tongue, poor skin turgor

Hyperglycemia

Dehydration can be so severe that the patient goes into hypovolemic shock

May progress to coma and death Death from dehydration Death from acid accumulation

Hyperglycemic Crisis

Can occur in diabetic patients:

Who are not under medical treatment

Who have taken insufficient insulin

Who have markedly overeaten

Under stress due to infection, illness, overexertion, fatigue, or alcohol

Management of Hyperglycemia (high blood glucose)

Support Airway, Breathing and Circulation

Oxygen to maintain 94% pulse oximetry

Check Blood glucose level.

ALS

Correct dehydration with IV fluid boluses of 0.9% saline at 20 ml/kg

Management

Hyperglycemia takes hours or days to develop into a crisis

Treatment may take hours in a well-controlled hospital setting.

The patient requires insulin adjustment and

Correction of blood glucose levels

Correction of dehydration

Correction of acid levels

Hypoglycemia (low blood glucose) Hypoglycemic crisis (insulin shock) is caused by

insufficient levels of glucose in the blood.

Can occur in insulin-dependent patients:

Who have taken too much insulin

Who have taken a regular dose of insulin but have not eaten enough food

Who have engaged in vigorous activity and used up all available glucose

Who have vomited a meal after taking insulin

Signs and Symptoms of Hypoglycemia

Low blood glucose (< 60 mg/dl) Feels weak and shaky Epinephrine release with pale, cool sweaty skin

Fast pulse Normal Blood pressure

Insufficient glucose supply to the brain

Altered mental state

Confusion

Loss of consciousness

Seizures

Management of Hypoglycemia (low blood glucose)

Support Airway, Breathing and Circulation

Oxygen to maintain 94% pulse oximetry

Check Blood glucose level.

Management of Hypoglycemia

If the blood glucose less than 60mg/dL

If still able to swallow (protect airway) “feed the meter”

Foods rich in simple sugars will keep the electricity flowing more quickly

Glucose paste

Follow up with complex carbs to sustain the electricity flow.

ALS Management for Hypoglycemia

If unable to swallow:

Initiate large bore IV, administer 50% glucose IVP, and high flow O2.

If unable to initiate a large bore IV

give glucagon 1 mg IM

Follow up with complex carbs

once able to swallow

Hypoglycemia Is a Crisis!!

Low blood sugar can occur very fast.

If untreated, it can produce unconscious-ness and death.

Hypoglycemia is quickly reversed by giving glucose

Insulin Pumps

Insulin pumps are small, computerized devices

(about the size of a small cell phone)

Insulin pumps are worn on the belt or put in a

pocket and allow for a continuous flow

of a rapid-acting insulin to be released

into the body.

The pumps have a small, flexible tube

(called a catheter), which is inserted under

the skin of the abdomen and taped in place.

Insulin Pumps

Some diabetics use an insulin pump because its slow release of insulin mimics how a normally working pancreas would release insulin.

Studies vary on whether the pump provides better blood sugar control than multiple daily injections.

An advantage of the insulin pump is that it frees the diabetic from having to measure insulin into a syringe.

Insulin Pumps The insulin pump is designed to deliver a continuous

amount of insulin, 24 hours a day according to a programmed plan unique to each pump wearer. The amount of insulin delivered can be changed by the user.

Between meals and overnights, a small amount of insulin is constantly delivered to keep the blood sugar in the target range. This is called the basal rate. When food is eaten, a bolus dose of insulin can be programmed into the pump.

Patients using an insulin pump can measure how much of a bolus is needed using calculations based on the grams of carbohydrates consumed.

When using an insulin pump, patients must monitor blood sugar levels at least four times a day.

Insulin Pumps and EMS Providers

Machines can malfunction

If a patient has an insulin pump manage the patient the same way you would one without an insulin pump.

Assess the blood glucose level and proceed accordingly

Summary

Telling the Difference Between High Blood Glucose and Low Blood Glucose

Glucose’s path into the cell

Review

If doing this CE individually, please e-mail your answers to:

Shelley.Peelman@presencehealth.org Use “November 2014 CE” in subject box. IDPH site code: 06-7100-E-1214 You will receive an e-mail confirmation.

Print this confirmation for your records and document in your PREMSS CE record book.

Case Study ReviewANSWER THE QUESTIONS ASKED IN THE CASE STUDY AS THEY ARE ASKED AND THEN CONSULT THE ANSWERS IN THE NEXT SLIDE

Case 1

Dispatch: 1845 hours

24 year old unconscious male

The apartment manger will let you in.

What could be going on?

What could be going on? (answers)

IntoxicatedDrug overdoseSeizureStrokeDeadBlood glucose issue

Scene Size Up

You find Tim lying on a couch He appears to be asleep Good rise and fall of the chest From condition of his clothing and the

smell he has been incontinent of both urine and stool.

The apartment is a mess. Piles of clothing and newspapers Dirty dishes and moldy food on the

coffee table The smell is overpowering There is an empty bottle of insulin on

the table What does this environment tell you?

What does this environment tell you? (answers)

Confirm unconscious Deeply unconscious because he is

incontinent The apartment mess is old, so the

problem has been going on for a while Insulin is involved in the situation, Tim

may be diabetic.

Initial Assessment

Mental status: Opens eyes to voice, no verbal response

Airway: Open and clear Breathing: Rapid rate 46 Good breath

sounds bilaterally Circulation: Pale, warm dry skin, poor

turgor, radial pulse weak 110 All mucus membranes dry

SAMPLE History

Allergies – unknown Medications – Insulin Past Hx: Insulin dependent diabetic, he

has had the flu for a week Last meal – unknown Events– Tim’s sister was worried and

called the manager

Focused Exam

VS – BP 80/68 P 110 R 46Pulse oximetry – 100%Blood sugar reads HIGH

What is going on?

What is significant about Tim’s history?

What is significant about Tim’s breathing?

What is significant about Tim’s history?

Tim is known to be diabetic He has been sick for a while and may not

be eating and/or taking his insulin

What is significant about Tim’s breathing?

Tim is breathing rapid and deep suggesting Kussmaul’s breathing

Kussmaul’s breathing occurs with ketone production from hyperglycemia

What is significant about Tim’s blood pressure and skin condition?

Where did his body water go?

What is significant about Tim’s blood pressure and skin condition?

Tim is dehydrated Tim is in hypovolemic shock from the

dehydration Where did his body water go? Tim’s body water has been depleted by the

kidney using the water to eliminate glucose and ketones from the blood in to his urine.

Why hasn’t anyone noticed a ketone “fruity” smell?

What is the relationship between Tim’s condition and his mental status?

Why hasn’t anyone noticed a ketone “fruity” smell?

Tim’s incontinence and other odors in the apartment have masked any “fruity” Ketone smell Tim might have.

What is the relationship between Tim’s condition and his mental status?

Tim is in hypovolemic shock and not perfusing has brain well enough to remain conscious.

How serious is Tim’s condition?

How do you want to manage Tim?

Does Tim need dextrose ?

How serious is Tim’s condition?

Tim is in critical condition.

How do you want to manage Tim?High flow oxygen

Support A, B, Cs

Call for ALS transport for IV fluids

Does Tim need dextrose ?

NO, he has too much glucose in his blood now.

Case 2

Dispatch: 1030 hours warm June day

34 year old confused male

Scene Size Up

You arrive at the scene of a 10 K race. It is warm and sunny with a cool breeze.

The patient, Bob is one of the participants in the race. He stopped running and sat down under a tree a the 8 K marker.

Bob is pale, ashen, and diaphoretic. His eyes are closed.

What might have happened?

What might have happened?

Heat exhaustion/heat stroke Heart attack Stoke Shock Blood glucose issues

Initial Assessment

Mental Status: Able to speak to you in short sentences. Confused as to what is going on.

Airway: Open and clear Breathing: Rate 30 and shallow, Lung

sounds clear Circulation: Cold wet skin, gray and

slightly cyanotic, Rapid weak radial pulse

SAMPLE History

No identification or tags. Bob is an unknown runner from out of town. Officials have only his name and address.

Bob had been running well to the 7 K marker when he began to fall behind before he staggered off the course and sat down under a tree

Focused Exam

VS– 98/42, P 122, RR 30 Pupils dilated and sluggish Pulse oximetry will not register Blood sugar reads LOW He denies chest pain He is able to move all extremities equally

What is significant about Bob’s history?

Could more than 1 problem be going on?

What is significant about Bob’s history?

Bob is a runner and in good physical condition.

Bob developed problems at the 7 km

point of a 10 Km race, so he just

developed a problems during the race.

Could more than 1 problem be going on?

Yes, he could have heat exhaustion He could be dehydrated He has hypoglycemia

What is the reason for Bob’s level of consciousness?

How do you want to manage Bob?

How might you treat him differently from other diabetic emergencies?

What is the reason for Bob’s level of consciousness?

He has poor perfusion of the brainDue to heat

Due to dehydration

Due to low blood glucose levels

How do you want to manage Bob?

High flow oxygen Support A, B, Cs Oral glucose or other high sugar food to

raise his blood glucose level Call for ALS support for IV fluids and

further evaluation

How might you treat him differently from other diabetic emergencies?

Bob needs to be treated for dehydration/heat illness with fluid replacement in addition to replacing glucose.