9/11/2012. Chapter 11. Learning Objectives. Learning Objectives. Endocrine Emergencies. Differentiate type 1 and type 2 diabetes

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1 Chapter 11 Endocrine Emergencies Learning Objectives Differentiate type 1 and type 2 diabetes Explain roles of glucagon, glycogen, and glucose in hypoglycemia Learning Objectives Discuss following medications for treatment of hypoglycemia: Dextrose (50% dextrose, 25% dextrose) Thiamin (vitamin B1) Glucagon Define diabetic ketoacidosis and complications associated with this condition for patients with diabetes 1

2 Learning Objectives Discuss effect of insulin in diabetic ketoacidosis Identify causes of acute adrenal insufficiency, and discuss how hydrocortisone (Cortef, Solu-Cortef) is used to treat this condition Learning Objectives Discuss medications used in the treatment of thyrotoxicosis: Esmolol (Brevibloc) Labetalol (Trandate, Normodyne) Metoprolol (Lopressor) Introduction Most common endocrine emergencies Diabetic Hyperglycemia Diabetic ketoacidosis Thyroid and adrenal Thyrotoxicosis Adrenal insufficiency 2

3 Disease manifested by a dysfunctional pancreas Insulin is required to convert sugars into energy for use by the body Type 1 Does not produce insulin Without insulin, cells of the body are not able to take sugar into the cell to be used for energy by that cell Sugar is main fuel of cells; body is not able to run without sugar Type 2 Capable of making insulin Insulin is not used properly by the body Majority have type 2 3

4 Insulin Used in patients with type 1 and some with type 2 Stimulates uptake of glucose by cells of the body Lowers level of sugar in blood Allows glucose to enter cells, potassium follows Oral hypoglycemic medications Used to manage most type 2 Agents act at receptor on insulin-producing cells of the pancreas Some also act by improving insulin s action on cells around the body May contribute to hypoglycemia 4

5 Paramedics will encounter patients who take various forms of insulin Differ in onset and duration of action Some fast with short duration Some slow with 24-hour duration Blood sugar level changes throughout the day Lower between meals and overnight After food, blood sugar level increases Low blood sugar Most common complication of diabetes Life-threatening emergency Insulin shock As a patient s average blood sugar approaches 120 mg/dl, incidence of hypoglycemia increases 3x If mild, treated with oral glucose 5

6 Hypoglycemic unawareness Patients lose ability to recognize symptoms of hypoglycemia Tachycardia Pallor Sweating Anxiety Often caused by: Insufficient intake of sugar in diet Excessive insulin from inaccurate dosing Excessive action of medication Exercise and strenuous activity Glucagon Is secreted by pancreas in response to low blood sugar Mobilizes glucose stored in the liver and muscle in form of glycogen When body needs additional glucose, pancreas releases glucagon Stimulates breakdown of glycogen, producing glucose 6

7 Epinephrine stimulates increase in blood sugar Produces increase in BP, tachycardia, diaphoresis, and anxiety Beta blockers can mask symptoms of hypoglycemia Patient is more prone to hypoglycemic unawareness Management Requires prompt treatment Oral glucose is treatment of choice If conscious, can result in immediate improvement Oral glucose gel can prevent risk for choking in case of altered level of consciousness Administration of oral glucose Equipment needed: Medicine Gloves Tongue depressor Other appropriate applicator PPE 7

8 Administration of oral glucose Procedure: Observe universal precautions Verify drug order Confirm right patient, right medication, right dose, right route, right time Confirm that patient has no allergies to medication When possible, explain to patient what medication is being administered and why Administration of oral glucose Procedure: Ensure patient is responsive and able to swallow Place glucose on tongue depressor and administer the full tube between patient s cheek and gum Record time of drug administration in PCR Evaluate patient for desired effects of medication and any adverse effects If patient has altered or depressed level of consciousness, parenteral administration of glucose is needed Use IV dextrose Available as 50% dextrose solution 100 ml of a solution has 50 g of dextrose Preloaded syringe of 50% dextrose is a 50 ml syringe (25 g dextrose in 50 ml solution) 8

9 Dextrose solutions more concentrated than 5% solutions are considered hypertonic Can cause irritation and pain when injected too rapidly Any dextrose solution more concentrated than 5% should be slowly injected into a large vein Concentrated dextrose solutions should not be administered IM or Sub-Q If IV access not possible, administer IM glucagon Mobilizes glycogen stores from liver Elevates blood glucose levels rapidly Common side effect: vomiting because glucagon delays gastric emptying Patients require close monitoring of airway, and blood glucose should be checked every 30 min Glucose levels can potentially be lowered to hypoglycemic levels 9

10 Patients with depressed mental status who are alcoholics or malnourished may have deficiency of thiamine If given dextrose before thiamine administration, patient can develop brain condition (Wernicke-Korsakoff syndrome) that manifests by: Amnesia Confabulation Attention deficit Disorientation Vision impairment Diabetic ketoacidosis (DKA) Occurs with type 1 diabetes Lack of insulin Too little insulin prevents cells of the body from using glucose Blood glucose rises Cells cannot use glucose but still require source of fuel Glucose-starved cells start to break down fat, producing ketone bodies Patients with DKA have: Metabolic acidosis Dehydration Electrolyte abnormalities 10

11 Ketoacidosis Occurs when body uses alternative fuel sources for energy production Inability to burn glucose from lack of insulin Lactic acidosis Occurs in shock states when O 2 is lacking Uses anaerobic metabolism for energy High blood glucose levels result in loss of glucose in urine Become dehydrated Within kidney, glucose is filtered into tubules that collect the urine produced As fluid passes through tubules, glucose is reabsorbed When blood glucose is elevated, amount of glucose passed into kidney tubules exceeds kidney s ability to reabsorb glucose back into the bloodstream Glucose is spilled into the urine Occurs at a serum blood glucose of 300 mg/dl High blood glucose levels result in loss of glucose in urine Glucose molecule in urine also decreases reabsorption of water by the kidney, and patient becomes rapidly dehydrated Increased thirst Increased urination Racing of the heart Vomiting Breath is fruity 11

12 Management Correct dehydration and acidosis with IV fluids and insulin Fluid replacement must be done slowly IV fluids administered at maintenance to 1.5x the maintenance rate are adequate for initial stabilization with initial fluid bolus IV fluid should not include potassium replacement Management Use isotonic solution Normal saline Ringer lactate Bicarbonate should be avoided unless ordered by medical direction Management Ketonemia Results in rapid breathing Body s attempt to relieve itself of CO 2 Fruity breath odor indicates ketones 12

13 Management Patients with hyperkalemia must be monitored for peaked T waves on ECG Monitor cardiovascular status If cardiovascular condition requires IV bolus, volume resuscitation should be conservative Management Monitor vital signs Assess neurologic status If hypovolemic patient with DKA is resuscitated too quickly, can develop cerebral edema Management Insulin Can be given as bolus or drip IV bolus less desirable than insulin infusion IV insulin is more effective than IM or Sub-Q Blood sugar should be monitored every 30 to 60 min while patient is on insulin drip or after Sub-Q injection Should have decrease in blood sugar by 10% per hour No faster than 50 mg/dl per hour If rate decrease exceeds 50 mg/dl per hour, infusion must be decreased to prevent hypoglycemia 13

14 Overview of Acute Renal Insufficiency Life-threatening emergency Treatment cannot be delayed Cardiovascular and metabolic status will rapidly deteriorate Adrenal glands are located on top of each of the kidneys Responsible for production and secretion of important hormones Overview of Acute Renal Insufficiency Adrenal medulla produces catecholamines Epinephrine Norepinephrine Overview of Acute Renal Insufficiency Adrenal cortex produces steroid hormones: Mineralocorticoids Glucocorticoids Cortisol Responsible for electrolyte stability Antiinflammatory stress hormones Contributes to body s stress response Affects BP, heart rate, blood glucose 14

15 Overview of Acute Renal Insufficiency Adrenal insufficiency can result from: Lack of an enzyme, renders them unable to produce cortisol sufficiently Congenital adrenal hyperplasia (CAH) Infection Injury Autoimmune reaction of the gland Overview of Acute Renal Insufficiency Sometimes adrenal glands are unable to produce adequate stress hormones because of lack of central input from the pituitary gland Pituitary gland secretes adrenocorticotropin (ACTH) Stimulates necessary signaling at adrenal gland Results in production and release of cortisol and other adrenal hormones Overview of Acute Renal Insufficiency Management Usually treated with cortisone (Cortone) Solu-Cortef Parenteral form of hydrocortisone Cortef Enteral form of hydrocortisone Many patients have emergency kit of IM hydrocortisone to administer when tablets cannot be taken 15

16 Overview of Acute Renal Insufficiency Management During times of stress, hydrocortisone should be increased to stimulate body s needs Oral increase is limited during vomiting Intravascular volume is depleted, contributes to hypotension If IV access cannot be obtained, use IM hydrocortisone Overview of Thyrotoxicosis Thyroid Small gland found in the neck over the voice box Produces hormones Regulates body s metabolic rate When the body produces excessive amounts of thyroid hormones, metabolic rate is increased Elevated thyroid hormone levels can result in thyrotoxicosis Overview of Thyrotoxicosis Caused by: Autoimmune disease Infections Cancer 16

17 Overview of Thyrotoxicosis Symptoms: Tachycardia Tremor Diaphoresis Weight loss Intolerance to warmth Overview of Thyrotoxicosis Management Thioamide agents (propylthiouracil and methimazole) Oral antithyroid medications Used for long-term management of hyperthyroidism Inhibit synthesis not release of thyroid hormone Other medications should be used for short-term treatment Thyroid hormone affects cardiovascular system by sensitizing it to catecholamines Results in elevations of BP and heart rate Overview of Thyrotoxicosis Management Beta blockers are used for treating hypertension and tachycardia Inhibit binding of catecholamines to receptor site Improves symptoms of: Tremulousness Anxiety Palpitations Sweating Eyelid retraction Tachycardia 17

18 Overview of Thyrotoxicosis Management Beta blockers Esmolol (Brevibloc) Labetalol (Trandate, Normodyne) Metoprolol (Lopressor) Questions? 18