Diabetic Emergencies. Christopher J. Bosche, MD FACEP

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1 Diabetic Emergencies Christopher J. Bosche, MD FACEP

2 Diabetes! American Diabetes Association estimates that over 5 million people have diabetes and are unaware of it! Diabetes is the 7 th leading cause of death in the United States! Affects 8% of the population! Predisposes the patient to several kinds of medical emergencies

3 Pancreas! Principle regulator of blood glucose concentrations! Produces the hormones insulin and glucagon

4 Insulin! Protein released when blood glucose levels rise! Increases glucose transport into cells! Increases liver glycogen levels

5 Glucagon! Released when blood glucose levels fall! Stimulates the liver to release glucose stores from glycogen

6 Diabetes Mellitus (DM)! Systemic disease of the Endocrine System! Characterized by a deficiency of insulin or an inability of the body to respond to insulin

7 Type 1 Diabetes Mellitus! Inadequate production of biologically effective insulin by the pancreas! Insulin producing cells are absent or are destroyed by an autoimmune response.! Over 95% of Type 1 diabetics develop the disease before the age of 25! Linked to heredity! Lifelong treatment required

8 Symptoms of Type 1! Abrupt onset! Polyuria! Thirst! Dizziness! Blurred vision! Rapid, unexplained weight loss! DKA

9 Type 2 Diabetes Mellitus! Insulin resistance in peripheral tissue requires additional insulin that the pancreas can t produce.! Most common form of DM, highly associated with family history, older age, obesity, and lack of

10 Symptoms of Type 2! Gradual! Blurred vision! Polyuria! Thirst! Fatigue! Infections! Tingling, numbness, and pain in extremities

11 Gestational Diabetes! Insulin resistance develops as pregnancy advances.! Diabetes develops if pancreas can t increase production of insulin enough to compensate.! May resolve after delivery but associated with increased risk of developing Type 2 DM later in life

12 Long Term Complications of Diabetes

13 Types of Insulin

14 Insulin Pumps! Provide a small basal rate of insulin. The pt gives themselves boluses when needed.! Pt should stay connected to device whenever possible.! To stop device, suspend it or disconnect tubing. Do not shut it off.! Contact Medical Control with questions.

15 Oral Hypoglycemic Agents!!!! Sulfonylureas: stimulate insulin secretion Metformin: increases insulin action Thiazolidinediones:reverse insulin resistance Alpha-Glucosidase Inhibitors:decrease the absorption of glucose after meals.

16 Diabetic Emergencies! Hypoglycemia! Diabetic Ketoacidosis (DKA)! Hyperosmolar Hyperglycemic Nonketotic Coma (HHNK)

17 Hypoglycemia! Blood Glucose levels below 60 mg/dl! May occur in non-diabetic patients as well (ex: sepsis)! In diabetics usually caused by:! Too much insulin (or oral hypoglycemic medication)! Decreased dietary intake! Unusual or vigorous physical activity

18 Signs & Symptoms of Hypoglycemia! Nervousness, trembling! Sweating! Psychotic (combative) behavior! Weakness & incoordination! Confusion! Appearance of intoxication! Weak, rapid pulse! Cold, clammy skin! Drowsiness! Seizures! Coma Altered Mental Status

19 Hypoglycemia Treatment! If level is < 60 mg/dl, administer dextrose IV! May give oral glucose if patient A&O x3! Glucagon 1 mg IM if unable to obtain IV! Consider causes! Contact medical control if patient refuses transport.! The patient should monitor their BS frequently if not transported. 10% Dextrose

20 Is it a Stroke?! 78 y/o diabetic male with multiple medical problems presents with altered mental status.! Blood glucose for EMS was 345.

21 Diabetic Ketoacidosis! If the body can t get the glucose it needs, it begins metabolizing reserves.! The by products of this are ketones and metabolic acidosis.! As blood glucose levels rise, the patient undergoes massive osmotic diuresis, causing dehydration & shock! May cause cardiac dysrhythmias, altered mental status, seizures

22 Signs & Symptoms of DKA! Diuresis! Warm, dry skin! Dry mucous membranes! Tachycardia, thready pulse! Postural hypotension! Weight loss! Polyuria! Polydipsia! Acidosis! Abdominal pain! Anorexia, nausea, vomiting! Acetone breath odor! Kussmaul s respirations! Decreased level of consciousness

23 DKA Treatment! EMS should give fluids and antiemetics.! Metabolic acidosis will be resolved slowly in the hospital.! End tidal CO2 will be low and BS will be high

24 Hyperosmolar Hyperglycemic Nonketotic Coma! Life-threatening emergency! Hyperglycemic, hyperosmolarity, and dehydration without significant ketoacidosis.! Most present with dehydration and altered mental status.! Blood sugars can be greater than 1000 mg/dl.

25 Precipitating Factors HHNK Coma! Advanced age! Type 2 diabetes! Illness that leads to reduced fluid intake.

26 Signs & Symptoms of HHNK Coma! Weakness! Thirst! Frequent urination! Weight loss! Extreme dehydration! Flushed, dry skin! Dry mucous membranes! Decreased skin turgor! Postural hypotension! Altered level of consciousness! Tachycardia! Hypotension! Tachypnea

27 EMS HHNK Treatment! EMS should give fluids and supportive care.! Hyperglycemia will be resolved slowly in the hospital.

28 Questions?

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