Diabetes Review. October 31, Dr. Don Eby Tracy Gaunt Dwayne Cottel

Transcription

1 Diabetes Review October 31, 2012 Dr. Don Eby Tracy Gaunt Dwayne Cottel

2 Diabetes Review Learning Objectives: Describe the anatomy and physiology of the pancreas Describe the effects of hormones on the maintenance of normal glucose metabolism Compare various diabetic emergencies, and their corresponding signs and symptoms Apply the current medical directives appropriately to various diabetic emergencies 1

3 Presentation Overview Review of pathophysiology Overview of Hypoglycemia Overview of Hyperglycemia Case studies Medical Directives pertaining to Hypoglycemia Summary 2 19-Nov-12 2

4 Case 1 25 year old male IDDM found by family confused with decreased LOA. EMS arrival Family states patient is hypoglycemic. Blood glucose is 3.0mmol All vitals stable with GCS of 13 3

5 Case 2 65 year old female IDDM found by family confused with decreased LOA. EMS arrival Family states patient is diabetic Blood glucose is 1.0mmol All vitals stable with GCS of 13 4

6 Pancreas Located in the retroperitoneal cavity Role of the Pancreas Absorption and use of carbohydrates, fat, and protein Regulation of blood glucose concentration Exocrine and endocrine functions 5

7 Pancreas continued: Islets of Langerhans Beta cells secrete an average of 0.6units/kg of insulin daily Alpha cells secrete glucagon Nerves from both divisions of the autonomic nervous system innervate the pancreatic islets 6

8 Insulin and Glucagon Insulin-Released by the beta cells when blood glucose levels rise Glucagon- Released by the alpha cells when blood glucose levels fall 7

9 Glycogenolysis and Gluconeogenesis Glycogenolysis conversion of glycogen to glucose. Gluconeogenesis breakdown of all other elements (except glycogen) for conversion into glucose for energy. 8

10 Normal Digestion Food is eaten The patient has energy Digestion begins in the stomach Sugar enters the body cells with the aid of insulin Normal Digestion Simple sugars are broken down in the small intestine Insulin is released by the pancreas Simple sugars enter the bloodstream 9

11 Diabetes Mellitus Type I - A decrease or absence of insulin Type II - Lack of cell sensitivity to and production of Insulin 10

12 Diabetic Pathophysiology Sugar doesn t enter body cells - the patient feels tired & weak Metabolism Digestion: Simple sugars are broken down in small intestine and enter bloodstream 11

13 Diabetes Type I vs. Type II Type I Diabetes (insulin dependent) Known as juvenile onset diabetes when it develops in the young Little or no insulin is released by the pancreas The beta cells might have been destroyed by a virus or destroyed by the body s own immune system Patient must take frequent doses of insulin Type II Diabetes (mature onset, non insulin dependent) Primary problem is less sensitivity to insulin effects as well as less insulin released Can be associated with obesity, a decrease in the number of insulin receptors, or a decrease in glucose utilization Controlled by weight reduction and reducing carbohydrate intake with the use of oral diabetic medications 12

14 Gestational Diabetes Diabetes that develops during pregnancy Often treated with insulin Must be controlled with insulin if diet alone cannot control Often disappears post delivery; may remain as Type II 13

15 Management of Diabetes (by patient): Diet and exercise (maintain ideal body weight) Insulin pens and pumps Insulin: human, beef, pork Future management 14

16 Patient Presentations in DM Hypoglycemia vs Hyperglycemia 15

17 Signs and symptoms of Hypoglycemia CNS alteration Fainting Normal blood pressure Pale, cool, diaphoretic skin Normal or rapid pulse Tingling in hands and feet Absence of thirst Normal or shallow breathing Occasional hunger Extreme weakness Tremors General muscle weakness 16

18 Management of Hypoglycemia Primary exam Manage and maintain airway Important history questions Blood glucose exam Needs glucose Cardiac monitor Vitals Oxygen 17

19 Hyperglycemia Signs and symptoms Confusion, disorientation Normal or decreased blood pressure Vomiting Red, hot, dry skin Fever Sunken eyes Sweet or fruity odour on breath (ketone bodies) Intense thirst Rapid, deep breathing Intense abdominal pain Frequent urination 18

20 Management of Hyperglycemia Primary exam Manage and maintain airway Important history questions Blood glucose exam IV fluids Cardiac monitor Vitals Oxygen 19

21 Hypoglycemia Medical Directive A Primary Care Paramedic may provide the treatment prescribed in this medical directive if certified and authorized. Indications Agitation OR altered LOA OR seizure OR symptoms of stroke Conditions Dextrose Glucagon AGE: 2 years AGE: N/A LOA: Altered LOA: Altered HR: N/A HR: N/A RR: N/A RR: N/A SBP: N/A SBP: N/A Other: Hypoglycemia Other: Hypoglycemia Nov-12 20

22 Hypoglycemia Medical Directive Contraindications Dextrose Allergy or sensitivity to dextrose Glucagon Allergy or sensitivity to glucagon Pheochromocytoma Treatment Perform glucometry Nov-12 21

23 Hypoglycemia Medical Directive Consider dextrose (if certified and authorized) or glucagon: Drug Dextrose Age 2 years Drug Glucagon Age N/A Dose Weight Weight Weight N/A <25 kg 25 kg Concentration Concentration Concentration D50W N/A N/A Route Route Route IV IM IM 0.5 g/kg (1 ml/kg) 0.5 mg 1 mg Max. single dose 25 g (50 ml) 0.5 mg 1 mg Dosing interval 10 min. 20 min. 20 min. Max. # of doses Nov-12 22

24 Hypoglycemia Medical Directive Clinical Considerations If the patient responds to dextrose or glucagon, he/she may receive oral glucose or other simple carbohydrates. If only mild signs or symptoms are exhibited, the patient may receive oral glucose or other simple carbohydrates instead of dextrose or glucagon. If a patient initiates an informed refusal of transport, a final set of vital signs including blood glucometry must be attempted and documented. IV administration of dextrose applies only to PCPs certified to the level of PCP Autonomous IV Nov-12 23

25 Case 1 25 yr. old IDDM male found by family confused with decreased LOA. Family states patient is hypoglycemic. Assessment by crew reveals blood glucose is 3.0mmol. All vitals stable with a GCS of 13 IV is established and 25 g of Dextrose is given. Patient responds well to treatment with GCS of 15 and second blood sugar of 15.7 mmol/l several minutes later. Vitals are stable Patient refuses transport to hospital and remains with family at home 24

26 Case 1 Discussion Is this patient at risk for recurrent hypoglycemia? Nov-12 25

27 Case 2 65 yr. old IDDM female found by family confused with decreased LOA. Family states patient is diabetic Assessment by crew reveals blood glucose is 1.0 mmol. All vitals stable with a GCS of 12 No IV is established and 1 mg Glucagon is given. Patient responds well to treatment with GCS of 15 and second blood sugar of 4.7 mmol/l several minutes later. Vitals are stable Patient refuses transport to hospital and remains with family at home 26

28 Case 2 Discussion Is this patient at risk for recurrent hypoglycemia? Nov-12 27

29 Questions? Nov-12 28

30 References Sanders, M. J., McKenna, K., Lawrence, L. M., & Quick, G. (2007). Mosby s Paramedic Textbook. St. Louis, Missouri: Elsevier Mosby. Sanders, M. J., McKenna, K. ( 2000 )Mosby s Paramedic Textbook. 2 nd ed. St. Louis, Missouri: Elsevier Mosby Ministry of Health and Long Term Care. (2012). ALS Advanced Life Support Patient Care Standards. 29