Exam 3 ch 20 diabetic emergencies

Epinephrine

-released from adrenal glands when BGL decreases to dangerous level -stops secretion of insulin -promotes release of glycogen and conversion of other substances into glucose -causes the pale, cool, clammy skin signs

Glucose in the body

3 major sources of energy: glucose, fats, and proteins - when no sugar is available to cells, can use stored sugar, fats or proteins for energy -Brain cells are only cells that do not store glucose or have other form of energy production -production of energy from fats or proteins produce harmful by products-ketones -glucose is large molecule water will follow sugar into cells if possible stroke or head injury, glucose can worsen by increasing swelling of the cells -sugar spilling into urine will cause water to follow lead to dehydration

Diabetes mellitus/2

A disturbance in the body's ability to metabolize carbohydrates, fats and proteins Main problems: lack of insulin secreted by pancreas or inability of the cell receptors to recognize the insulin and allow sugar into the cells BGL >120 : hyperglycemia BGL >185 : kidneys not able to reabsorb glucose and spills into urine BGL >225 : significant glucose into urine leading to dehydration be/c water follows glucose 4 types of DM - these 2 most common seen in field: IDDM-type I-insulin dependent;no insulin production.Less common then type II. Usual onset age 10-14 yrs old NIDDM- type II - use of meds, diet control, exercise. More common, starts in middle aged or older pts

continued pt assessment of aloc

Baseline vital signs Emergency care: Assure history of diabetes Determine last meal, last medication dose, any related illnesses. Administer oral glucose - must be able to swallow Be responsive If known diabetic who is altered, give glucose

hyperglycemia-DKA

DKA - diabetic ketoacidosis BGL above 350 mg/dl - develop dehydration and ketone production. Ketones produce strong acid, leading to acidosis. Onset may take days. s/s : 3 "p's" : polyuria (urination), polyphagia (hunger), polydipsia (thirsty) • all from the dehydration n/v from electrolyte imbalance poor skin turgor tachycardia Kussmaul respirations (rapid, deep respirations) - from acidosis fruity or acetone odor on breath - from the acidosis positive orthostatic changes muscle cramps - from electrolyte imbalance abdominal pain warm, dry skin - from the acidosis ALOC - from the effects of dehydration and acids on brain cells coma ( late state )

Hyperglycemia/2

Diabetic ketoacidosis (DKA) -typically seen in type I DM pts Hyperglycemia hyperosmolar nonketotic syndrome (HHNS) -commonly seen in type II DM pts

DKA

Factors leading to hyperglycemia/DKA -pt with infection, upsetting insulin, glucose balance -pt taking thiazide, dilantin or steroids -pt under stress from either surgery, trauma, pregnancy or heart attack -pt with diet change with overeating or increase in carb/sugar intake

Glucagon

Function is opposite of insulin - secreted with BGL low, helps increase BGL -3 major functions -Converts glycogen stored in liver back into glucose, released into blood -Converts other noncarbohydrate substances into glucose -Increases/maintains BGL by above actions -Secreted when BGL is approx 70 mg/dl

HHNS

Hyperglycemic hyperosmolar nonketotic syndrome BGL usually 600-1200 mg/dl Glucose in urine - hyperosmolar effect More commonly seen in type II NIDDM pts Because there may still be some insulin production, less amt of ketone production, no acidosis May be first indication of diabetes in pt May be precipitated by trauma, burns, drugs, heart attack, stroke, infection and head injuries High mortality rate More likely to have seizures in HHNS than hypoglycemic pts S/S similar to DKA except for acidosis s/s. No Kussmaul respirations No fruity breath Emergency care is same as for DKA

Emergency care for hyperglycemic patients

Maintain ABC's -high flow O2 or PPV -determine BGL if available or permitted -if unsure about condition, administer oral glucose if patient can swallow -contact medical direction for further instruction -rapid transport -consider ALS assistance

Glucometers

May be available to EMS- use as an adjunct to your treatment plan, normal range 80-120 mg/dl, important to know when last intake was Hypoglycemia- BGL < 60mg/dl if pt has s/s of low sugar, BGL <50 mg/dl with or without s/s of low sugar Hyperglycemia: BGL >120 mg/dl persistently

Assessment of ALOC-unknown medical hx

Scene Size up-medical or trauma, look for meds, how many pts?, manual spinal precautions, if more than one pt with ALOC, may be inhalation poisoning Primary assessment-AVPU, airway, breathing may need quick intervention Rapid medical assessment: DCAP-BTLS, assure there is no possibility of head injury SAMPLE hx: s/s could there be any trauma related signs-recent fall?, possibly medical/illness related-fever? Emergency care: spinal prec. maintain airway, suctioning, O2 therapy, may need PPV, position pt, transport (position of comfort)

assessment of ALOC with known diabetes controlled by meds.

Scene size-up Primary assessment: assure ABC's mental status SAMPLE history s/s rapid onset? Did this come on suddenly? Missed meal after taking insulin? Vomited after taking insulin? Unusual exercise, activity level? Intoxicated looking? Heart rate elevated? cold clammy skin? Seizures? insulin in refrigerator? uncharacteristic behavior? anxious, combative?

Insulin

Secreted when BGL is elevated 3 main functions -Increases movement of glucose from blood into cells -Causes liver to take up glucose in blood and convert it into glycogen -Decreases the BGL by the actions listed above: moving sugar into the cells and liver -Without insulin, sugar uptake by cells is 10X slower, leads to BGL elevation

diabetes mellitus

a disease in which the normal relationship between glucose and insulin is altered type 1: usually child onset, no insulin produced, insulin decreases blood sugars Type 2:usually adult onset, produce little or no insulin

Altered mental status

a pt displaying a change in his normal mental status

glucose

a simple sugar that is the body's main energy source

oral glucose

a sugar gel that is the medicine of choice for a diabetic pt with altered mental status

hypoglycemia

blood sugar <60 mg/dl

hyperglycemia

blood sugar >120 mg/dl,ors Hunger Tachycardia Skin signs: pale, cool, clammy skin warm sensation Sudden onset - brain not able to use alternative sources of energy (fat, proteins) does not need insulin for glucose to pass into brain cells Emergency care: Unresponsive pt: give airway, breathing, provide O2, PPV as needed, contact ALS, assess glucose level if available Responsive pt: assure airway, follow oral glucose protocol, give oral glucose, reassess

oral glucose/2

generic name- Glucose trade name - Glutose, Insta-glucose Indications - pt with altered mental status known history of diabetes controlled by medication Contraindications - -unresponsive -unable to swallow Form: gel,toothpaste-type tube Dose - one tube Side effects - none if administered properly Actions increases blood glucose level increases glucose available to brain cells

insulin

hormone produced in pancreas that allows sugar to enter cells

Common meds taken by diabetic pts

insulin (humulin, novolin, lletin, semilente), diabanese, glucamide, orinase, micronase, diabeta, tolinase, glucotrol, humalog, glucophage, glynase

Hormones regulating blood sugars

insulin- lowers blood sugar levels, attaches to cells and allows for sugar to enter cell, brain cells do NOT need insulin to enter cell Glucagon-raises blood sugar, stored in muscles/liver converts glycogen into glucose Epinephrine- stops secretion of insulin, promotes release of glycogen stores

administration of oral glucose

obtain order from medical control -assure s/s of ALOC with diabetes history -assure pt is conscious -assure pt is able to swallow to protect own airway -administer between cheek and gum with or without a tongue depressor ,perform reassessment of mental status

Conditions that may cause an altered mental status

shock, poisoning/overdose, infection, post seizure (postictal state), traumatic head injury, hypoxia from inadequate airway/breathing, alcohol/drug intoxication, stroke, diabetes-high or low blood sugar