Objectives / Learning Targets: The learner who successfully completes this course will be able to demonstrate understanding of the following concepts: Insulin s function in the body. The basics of diabetes mellitus including Type 1 and Type 2. Field assessment and management of hypo- and hyperglycemia. Watch this short video on I nsulin function https://www.youtube.com/watch?v=olhez8gwmgw Watch this 9 minute video from Khan Academy on blood sugar levels: https://www.youtube.com/watch?v=jsfiof7xgfe Watch this 5 minute video on diabetes in general http://www.youtube.com/watch?v=stgbvjshcck Further (OPTIONAL) video resources on diabetes: http://www.youtube.com/playlist?list=pl59db53f5c358e5da Diabetes is a disorder of glucose metabolism or difficulty metabolizing carbohydrates, fats, and proteins. There are two types of diabetes. Type 1 diabetes typically develops in childhood and requires daily insulin to control blood glucose. Type 2 diabetes typically develops in middle age and often can be controlled with diet, activity, and oral medications. o Type 1 patients do not produce sufficient (or any) insulin. o Type 2 patients produce insulin but its function is ineffective. Insulin Resistance -Type 2 diabetics may be taking oral medications to assist with their blood glucose control. Glyburide and Glipizide are common medications that act to increase insulin production. Metformin is very commonly encountered medication that increases the action of insulin. Avandia and Actos are newer agents in widespread use that address the insulin resistance directly. Diabetes mellitus is the formal name for the standard type of diabetes that we typically encounter. Diabetes insipidus occurs uncommonly (3 in 100,000) and involves an issue with the kidneys and related hormones and therefore its not part of our discussion at the EMT level.
Both types of diabetes are serious systemic diseases, especially affecting the kidneys, eyes, small arteries, and peripheral nerves. Patients with diabetes have chronic complications that place them at risk for other diseases, such as heart attack, stroke, and infections. Most often, however, you will be called on to treat the acute complications of blood glucose imbalance. These include hyperglycemia (excess blood glucose) and hypoglycemia (insufficient blood glucose). o Most EMS calls for diabetics involve hypoglycemic patients who have taken their insulin but did not eat sufficiently. o Diabetes is a disease of high blood sugar yet most EMS contacts with diabetics are low blood sugar incidents because the patients take their insulin but fail to eat sufficiently or on time. Hyperglycemia is typically characterized by excessive urination and resulting thirst, in conjunction with the deterioration of body tissues. o Hyperglycemic patients may present with flu-like symptoms or other vague o presentations. Usually these patients get sick slowly and the treatment is also not quick. Contrast that with the much more rapid onset of hypoglycemia -and its much more rapid fix in most cases. Hyperglycemia is usually associated with dehydration and ketoacidosis and can result in marked rapid (often deep) respirations; warm, dry skin; a weak pulse; and a fruity breath odor. Hyperglycemia must be treated in the hospital with insulin and IV fluids. Symptoms of hypoglycemia classically include confusion; rapid respirations; pale, moist skin; diaphoresis; dizziness; fainting; and even coma and seizures. This condition is rapidly reversible with the administration of glucose or sugar. Without treatment, however, permanent brain damage and death can occur. Because a blood glucose level that is either too high or too low can result in altered mental status, you must perform a thorough history and patient assessment to determine the nature of the problem. When the problem cannot be determined, it is best to treat the patient for hypoglycemia. Be prepared to give oral glucose to a conscious patient who is confused or has a slightly decreased level of consciousness; however, do not give oral glucose to a patient who is unconscious or otherwise unable to swallow properly or protect his or her own airway. Oral glucose takes time to absorb buccally (through the oral mucosa). Similarly, glucose is absorbed through the gastrointestinal tract relatively slowly. In both cases, expect some improvement in 10 minutes or more. Remember, in all cases, providing emergency medical care and prompt transport is your primary responsibility. ALS providers may administer IV glucose ( Dextrose 50% or D50 ) to reverse hypoglycemia. Improvement in these patients is rapid. ALS providers and some patient s family / caregivers may administer Glucagon IM to reverse hypoglycemia. Glucagon, in this case, releases glucose stored in the body. (assuming there is sufficient storage -mainly in the liver). Improvement in these patients takes much longer than IV therapy (varies -expect 10 minutes or more).
Remember, diabetic patients are statistically more likely to present with some other symptoms besides chest pain when they are having an MI. Diabetes is a disease that may cause decreased peripheral pain sensation. Glucose Difference between finger stick and venous blood may be 15% Food is broken down in the intestines into glucose that enters the bloodstream. Insulin is the key that opens doors in the cell for glucose to enter. Produced in the pancreas. Glucose that is not used immediately is stored in the liver and muscles (75% of it). Glucagon puts stored glucose into the bloodstream. Produced in the pancreas. Glucagon also converts free fatty acids into ketones that are converted by the liver into energy. Epinephrine suppresses insulin and stimulates glucagon so that the net effect is an increase in blood glucose levels. Epinephrine also stimulates ketone production. Hypoglycemia causes epinephrine release which causes cool / pale / moist skin and may vasoconstrict capillaries so inaccurately low fingerstick glucose reading. Patient may be altered, excited, tachycardic and hypertensive and may have chest pain / ACS symptoms or cardiac rhythm issues. Chronic diabetics may not have the epinpehrine release signs. Glucose paste buccally should be used (not orally slower absorption) when patients cannot safely eat and drink to raise their glucose levels.
Blood glucose levels fluctuate between 70 s and 120-140 normally. Maybe a bit higher after a meal (180 s or so). Finger stick glucose level may be even lower than venous blood measurement (as much as 15%) Hyperglycemia thirst and urination increase (glucose acts as a diuretic) or potentially confusion / coma in severe cases. These patients are dehydrated and have electrolyte issues. Diabetes mellitus old terms persist (juvenile or adult onset, insulin-dependent and non-insulin dependent) but are replaced by Type 1 and Type 2 Type 1 pancreas is not producing insulin Patients take a variety of insulin replacements including some short-acting and some long-acting. Some by injections including an insulin pen but others by insulin pump (external and potentially implanted) or by inhalation. Brittle diabetics have short term wide fluctuations and are frequently seen by EMS Type 2 insuin is produced but is not effective to some degree cells develop a resistance to insulin (the key won t open the door) obesity fat cells have fewer insulin receptors diet, exercise and meds some meds decrease glucose absorption from the intestines while others work on the liver or pancreas or more directly on the cells issues pancreas may over-produce insulin to compensate for insulin resistance but insulin can increase atherosclerosis / hypertension / fat storage / cause clots to not be broken down Gestational diabetes placental hormones cause insulin resistance that usually resolves after delivery but may cause hypoglycemia in newborn Risks for diabetics in addition to noted above include peripheral neuropathy which may lead to poor peripheral circulation and thus more likelihood of injury with decreased healing; increased risk for kidney disease and blindness Signs polydipsia (thirst), polyuria (excessive urination), polyphagia (hunger cells need sugar so patient is stimulated to eat even though excess sugar is already circulating but cannot get into the cells) (the terms themselves are Advanced Provider level but the signs and symptoms are for all levels)
DKA diabetic ketoacidosis presents in patients who don t yet know they are diabetic as well as poorly controlled diabetics; hyperglycemia detected in the field but ketones in blood and urine plus acetone / acidosis detected in ER. Frequently triggered by an infection. Dehydrated (dry mouth, poor skin turgor), altered mental status / altered LOC, rapid and deep breathing (to compensate for metabolic acidosis), may be tachycardic or even hypotensive; watch for hypokalemia and low magnesium (long QTc?); may have acetone odor to breath but not all medics can smell it. May have seizures Needs insulin and fluids (lots)
Advanced Providers HONKS or HHNS hyperosmolar non-ketotic syndrome or hyperglycemic hyperosmolar non-ketotic syndrome is not DKA because no acidosis is present yet patients present dehydrated and altered. Probably due to renal failure or insufficiency. Water moves to vascular space in response to hyperglycemia. Watch for electrolyte problems including hypokalemia. Alcoholic ketoacidosis listed as special and strange case involving hypoglycemia yet signs of DKA normally seen with hyperglycemia (dehydration, altered mental status) treat hypoglycemia questionable need for glucose check in cardiac arrest (hypoglycemia is no longer one of the H s and T s) Tx of hypoglycemia D50 is thick syrup and can badly damage skin if the IV infiltrates so dilution makes sense 25 grams should increase patient s blood glucose rapidly and within 10 minutes should be at least in the normal range Glucagon only works if enough stored glucose in liver and muscles; should increase the blood glucose level 100 points in 10 minutes Has positive inotropic and chronotropic effects especially when given IV but why give it IV for hypoglycemia? Has other uses. Thiamine for malnourished patients who are receiving glucose but can be given at the ER so many services no longer carrying this.