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INTRODUCTION

Optimal patient care requires that the EMT-I understand the signs/symptoms and field treatment of diabetic emergencies. The following topics will be discussed during this session:

· Pathophysiology of diabetes mellitus

· Types of diabetes mellitus

· Acute complications of diabetes mellitus

· Pathophysiology, signs and symptoms, and field management of hypoglycemia

· Pathophysiology, signs and symptoms, and field management of hyperglycemia

· Chronic complications of diabetes

· Transport decisions relevant to the diabetic patient

LESSON OBJECTIVES

At the end of this lesson the participants will be able to:

1. Understand the pathophysiology of diabetes mellitus.

2. Differentiate between type I and type II diabetes mellitus

3. List 3 acute complications of diabetes

4. Discuss the pathophysiology, signs and symptoms, and field management of hypoglycemia

5. Identify at least 3 chronic complications related to diabetes mellitus.

6. Discuss transport decisions relevant to the diabetic patient.

SKILLS

Administration of oral glucose

KEY VOCABULARY

The following terms will be used during this lesson:

· Conscious - patient is awake and responds to stimuli appropriately

· Coma - patient is not aroused by external stimuli

· Diabetes mellitus - endocrine disorder characterized by inadequate insulin production by beta cells in the islets of Langerhans in the pancreas

· Endocrine Glands - glands that secrete hormones directly into the blood stream

· Glucose – source of energy required by cells for normal functioning

· Hyperglycemia - abnormally high levels of glucose in the blood

· Hypoglycemia - abnormally low levels of glucose in the blood

· Hormones - chemical substances released by a gland that control or affect other glands or body systems

· Insulin – hormone secreted by pancreas which allows cells to use glucose

· Ketoacidosis - complication of diabetes that occurs from too little insulin production or secretion

· Oriented - responds appropriately to questions regarding person, place, time, and events (purpose)

KEY CONCEPTS

The following section provides information and space for taking notes on the key concepts discussed

by the instructor.

DIABETES MELLITUS – OVERVIEW

Pathophysiology

· All cells require glucose for survival

· Glucose is primarily acquired from the digestion of carbohydrates

· Starches and complex sugars are converted to the simple sugar glucose

· If glucose is not available from the ingestion of carbohydrates the body will break down glycogen (a sugar stored in the liver) or protein in the liver

· Insulin (a hormone secreted by the beta cells in the pancreas) is necessary to allow glucose to pass from the blood stream into the cells.

Classifications of diabetes:

Type I:

· Insulin dependent (IDDM)

· Onset is usually in adolescence or early adulthood

· Cause is thought to be a virus that damages the pancreas resulting in an inadequate production of insulin

· Usually “brittle” diabetics (hard to control)

· Diabetic ketoacidosis is common

Type II:

· Non-insulin dependent (NIDDM)

· Use oral hypoglycemic agents

Orinase

Tolinase

Diabinese

Diabeta

Dymelor

· Onset is in older adults

· Often associated with obesity

· The cells do respond to the insulin that is available

Complications of diabetes

Acute:

· Hypoglycemia

· Diabetic ketoacidosis

· Hyposmolar, hyperglycemic, nonketotic coma

Chronic:

· Infections

· Vascular disease

· Coronary artery disease

· Stroke

· Neuropathies

· Blindness

PATHOPHYSIOLOGY, SIGNS AND SYMPTOMS, AND FIELD MANAGEMENT OF COMMON DIABETIC EMERGENCIES

Hypoglycemia (insulin shock)

Pathophysiology:

· Occurs when there is too much insulin in the blood stream.

· Usually occurs when the diabetic patient takes their insulin and does not eat.

· Can occur if the diabetic patient eats but is vomiting and the nutrients are not absorbed.

Signs and symptoms:

· Dizziness/headache

· Pale, cool, clammy

· Mental confusion

· Abnormal behavior

· Altered LOC

· Tachycardia is common

· Strong or bounding pulse

· Normal BP

· Shallow respirations

Field management of hypoglycemia

BLS procedures:

· Maintain airway

· High flow O₂ by mask

· Left lateral position if unconscious

· Thorough history to determine to determine possible cause

· Oral hypoglycemic agent if patient is conscious and has a gag reflex

· Transport

· Assist with ALS procedures

ALS procedures:

· Advanced airway management prn

· Venous access

· Monitor

· Glucometer

· Dextrose 50% if blood glucose < 80

· Glucagon 1 mg. May be ordered if unable to obtain venous access and glucose <80

· Transport

Hyperglycemia (Diabetic Coma)

Pathophysiology:

· Insulin levels are inadequate to meet the body’s needs.

· Glucose cannot be utilized by the cells and it accumulates in the bloodstream.

· The excess sugar begins to spill over into the urine.

· As the sugar is excreted it takes excessive amounts of water with it resulting in serious dehydration.

· Ketones and acids are produced as cellular glucose depletion continues.

· Ketoacidosis is a serious complication that can result in coma and death.

Signs and symptoms:

· Increased hunger

· Increased thirst

· Altered LOC

· Kussmauls respirations

· Hypotension

· Weak, rapid pulse

· Fruity odor on breath

· Frequent urination

Field management of hyperglycemia

BLS Procedures

• Maintain Airway
• High flow O₂ by mask
• Left lateral position if comatose
• Shock position if hypotensive
• Thorough history to determine possible causes
• Assist with ALS Procedures

ALS Procedures

• Advanced airway prn
• Venous access (large bore)
• Glucometer
• Fluid challenge if hypotensive
• Transport

INITIAL ASSESSMENT AND FOCUSED HISTORY AND DETAILED PHYSICAL EXAMINATION OF DIABETIC PATIENTS

Initial Assessment

1). Assess environment: (may need to manipulate the environment)

· Safety of rescuers and environment

• Environmental factors
• Medications (may offer clues to past medical history)
• Witnesses (may help to explain circumstances)

2). Airway: determine responsiveness and patency of airway

• Unconscious patients may need assistance to maintain and protect their airway

3). Breathing: assess the rate and quality of respirations

• Rapid shallow breathing may be indicative of hypoglycemia
• Rapid deep (Kussmauls) breathing may be indicative of hyperglycemia

4). Circulation: palpate for pulse noting rate/rhythm/quality

• Rapid bounding pulses may indicate hypoglycemia
• Weak thready pulses may indicate hyperglycemia

5). Skin signs: assess color, temperature and moisture

• Pale, cool, moist skin and delayed capillary refill are due to peripheral vasoconstriction
• If signs of poor perfusion, consider placing patient supine

6). Assess Neurological Status:

· Assess level of consciousness using the GCS, and neuro deficits

· Hyperglycemia and hypoglycemia both result in altered LOC

· Assess thoroughly for “AEIOUTIPS”

7). Determine chief complaint:

Focused History and Detailed Physical Examination