Chapter 20

Acute Diabetic Emergencies

Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich Keith J. Karren

Copyright 2010 by Pearson Education, Inc. All rights reserved.

Objectives
1. 2. Define key terms introduced in this chapter. Describe the following regarding glucose (slides 1213):
a. The function of glucose in the body b. Response of brain cells and other body cells to insufficient glucose levels c. Relationships of glucose and water

3. 4. 5.

Describe how insulin and glucagon function to control blood glucose levels (slides 14-17). Describe how glucose levels are regulated in normal metabolism (slides 20-21). Explain the purposes and process of checking blood glucose levels. (slides 22-26).

Objectives
6. Discuss the pathophysiology of diabetes mellitus (DM) and contrast type 1 insulin-dependent diabetes mellitus (IDDM) with type 2 noninsulin- dependent diabetes mellitus (NIDDM) (slides 27-29). Discuss the pathophysiology, assessment, and emergency medical care of a hypoglycemic emergency (slides 30-36). Identify indications and contraindications to the administration of oral glucose (slides 37-39). Discuss the pathophysiology, assessment, and emergency medical care of diabetic ketoacidosis (DKA) (slides 40-47).

7.

8.

9.

Objectives
10. Compare and contrast the speed of onset and the signs and symptoms of hypoglycemia and hyperglycemia (slides 34, 45). 11. Describe the primary differences between DKA and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) (slides 43, 48, 50). 12. Discuss the pathophysiology, assessment, and emergency medical care of HHNS (slides 48-52). 13. Discuss the assessment-based approach to a patient with an altered mental status in a diabetic emergency (slides 53-63).

Multimedia Directory
Slide 26 Slide 29 Slide 39 How to Use a Blood Glucose Meter Video Information about Diabetes Video The Use of Oral Glucose Animation

Topics
Understanding Diabetes Mellitus Acute Diabetic Emergencies Assessment-Based Approach: Altered Mental Status in a Diabetic Emergency

CASE STUDY

Dispatch

EMS Unit 106

Respond to 514 Chicago Avenue for a 66-yearold male who is disoriented and belligerent. The neighbor placed the call. Time out 1402

Upon Arrival

Neighbor found patient in her garden next door When she approached him, the patient began cursing at her Patient is acting strange and not making sense

How would you proceed to assess and care for this patient?

Understanding Diabetes Mellitus

Back to Topics

Glucose (Sugar)

Back to Objectives

 Sources Roles Brain cells

Hormones That Control Blood Glucose Levels

Insulin

Back to Objectives

Insulin

Main functions How it works

Hormones That Control Blood Glucose Levels

Glucagon

Glucagon

Role Functions

Hormones That Control Blood Glucose Levels

Other Hormones

Epinephrine
Released by the adrenal glands Stops the secretion of insulin Promotes release of stored glucose from the liver Promotes conversion of other substances into glucose

Normal Metabolism and Glucose Regulation

Back to Objectives

Normal Glucose Regulation

Checking the Blood Glucose Level

Back to Objectives

 Glucose meters Hypoglycemia Hyperglycemia

Checking the Blood Glucose Level

Testing the Blood Glucose Level with a Glucose Meter

 Blood sample Equipment needed

How to Use a Blood Glucose Meter

Click here to view a video on how to use a blood glucose meter. Return to Directory

Diabetes Mellitus (DM)

Back to Objectives

 Primary problem Type I diabetes Type II diabetes

Information about Diabetes

Click here to view a video on information about diabetes. Return to Directory

Acute Diabetic Emergencies

Back to Topics

Hypoglycemia

Pathophysiology of Hypoglycemia

Back to Objectives

 Cause Reasons for drop

Pathophysiology

Hypoglycemia

Assessment Findings in Hypoglycemia and Hypoglycemia Unawareness

Assessment Findings

Back to Objectives

Cause Signs and symptoms Hypoglycemia unawareness

Hypoglycemia

Emergency Medical Care for Hypoglycemia

Emergency Medical Care

For a responsive patient For an unresponsive patient

Oral Glucose

Back to Objectives

 Purpose for administration Criteria for administration

Information about the Use of Oral Glucose

Click here to view information about the use of oral glucose. Return to Directory

Hyperglycemia

Back to Objectives

 Hyperglycemia Diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

Hyperglycemic Condition: Diabetic Ketoacidosis (DKA)

Pathophysiology of DKA

Pathophysiology

Cause Results in the body Factors causing hyperglycemia in DKA patients Back to Objectives

Hyperglycemic Condition: Diabetic Ketoacidosis (DKA)

Assessment Findings in DKA

Assessment Findings

Signs and symptoms

Polyuria Polydipsia Polyphagia

Kussmauls respirations
Back to Objectives

Hyperglycemic Condition: Diabetic Ketoacidosis (DKA)

Emergency Medical Care for DKA

Emergency Medical Care

ABCs Provide O2 Assist ventilation Check BGL Contact medical direction

Hyperglycemic Condition: Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

Pathophysiology of HHNS

Back to Objectives

Pathophysiology

Blood glucose level Precipitating factors

Hyperglycemic Condition: Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

Assessment Findings in HHNS

Back to Objectives

Assessment Findings

Signs and symptoms

Emergency Medical Care

ABCs Provide O2 Support respirations Determine BGL Medical direction

Assessment-Based Approach: Altered Mental Status in a Diabetic Emergency

Back to Topics

Scene Size-Up and Primary Assessment

Back to Objectives

Look for scene clues Medic alert tags Insulin pumps

History and Secondary Assessment

 SAMPLE Common medications Questions to ask

History and Secondary Assessment

Signs and Symptoms

Signs and Symptoms

Place redrawn picture 2009 here did not have yet, WDS

Emergency Medical Care

 ABCs Determine if patient can swallow Administer oral glucose Transport

Reassessment

May take 20 minutes to see improvement Recheck BGL Continue O2 Manage airway as needed

CASE STUDY

Follow-Up

CASE STUDY
Primary Assessment
Patient sitting on couch Find Digoxin in kitchen and insulin in refrigerator Patient is pale and sweating profusely Patient speaking in mumbled words

CASE STUDY
Primary Assessment
Partner places a nonrebreather mask at 15 lpm RR: 15; P: 100 and strong

CASE STUDY
Secondary Assessment
Do rapid assessment BP: 102/60 mmHg; P: 108; RR:16; skin pale, cool, and moist; SpO2: 97 percent BGL: 48mg/dL Administer one tube of glucose Place patient in left lateral position

CASE STUDY
Treatment and Reassessment
Becomes oriented to name and place Pulse rate, skin, and SpO2 improve Change over to nasal cannula Alert and oriented upon arrival Transfer care without incident

Critical Thinking Scenario

34-year-old female with an altered mental status Responds to painful stimuli only with moans A neighbor called 911 after finding her on the couch and not responding

Critical Thinking Scenario

S Supine on the couch, not alert A Unknown M Her neighbor brings you the patients medications: Zoloft and Novolin P Her neighbor doesnt know the patients medical history L Unknown E Patient called the neighbor 20 minutes ago and said she wasnt feeling well

Critical Thinking Scenario

Vital signs: BP: 108/62 mmHg HR: 122 bpm RR: 12 per minute with snoring respirations but adequate chest rise Skin is pale, cool, and very diaphoretic

Critical Thinking Questions

1. What emergency care would you provide during the primary assessment? 2. Based on the signs, what condition do you suspect the patient is experiencing? 3. What other assessment procedures would be helpful to you for this patient? 4. What would you expect the blood glucose reading to be in the patient? 5. Why is the onset of the altered mental status significant in this patient?

Reinforce and Review

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