Sugar, Sugar A PreHospital Primer on Diabetic Emergencies

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Sugar, Sugar- A Pre-Hospital Primer on Diabetic
Emergencies

• Paul A. Werfel, MS, NREMT-P
• Director, Paramedic Program
• Asst. Professor of Clinical
• Emergency Medicine
• Stony Brook University

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BACKGROUND

• Diabetes is a chronic disease that requires long
  term care
• Devastating complications
• Disproportionately expensive
• 4.6 of US population but 14.6 of all direct
  care expenses in 1994

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PATHOPHYSIOLOGY Type 1

• Insulin dependent
• Younger, leaner patients
• They produce no insulin due to auto immune
  destruction of beta-cells
• Without insulin, acidosis and ketoacidosis
  develop

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PATHOPHYSIOLOGY Type 2

• Typically gt40 yr.
• Family history
• Low insulin
• 90 are obese
• Do not develop DKA
• May be insulin requiring, not dependent
• Loose weight and no meds

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DEMOGRAPHICSType 1

• Frequency
• 16 million-10are type 1
• Race
• Caucasians more so than blacks (Lowest rate of
  type 1)
• Sex
• Malefemale 11
• Age
• Juvenile onset
• mean age is 8-12 yr.
• peaks in adolescence-girls 1.5 yr. ahead of boys

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DEMOGRAPHICSType 2

• Frequency
• 16 million-90 are type 2
• Race
• Type 2 is more prevalent in Hispanic, Native
  American and African-American demographics
• Sex
• Femalegtmale in Caucasian populations
• Age
• Type 2 is becoming more common because people are
  living longer, young obesity
• HFCS- Implications

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MORTALITY / MORBIDITYType 1 and 2

• Related to short and long term complications
• Infections
• Amputations, renal disease
• MI, CVA
• Micro-vascular
• Neuropathies
• Retinopathy
• Major cause of blindness in 20-74 age group

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HISTORY

• Type of diabetes
• Duration
• Inquire about treatment
• Diet, oral meds, insulin
• Self Monitoring

• Ask About
• Retinopathy
• Nephropathy
• HTN- Meds?
• Coronary Artery disease?
• Meds, Hx,
• Peripheral Artery disease?
• CVA, Infections, diabetic foot, ulcers

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HYPOGLYCEMIA

• Blood glucose lt80mg/dl
• Symptoms commonly occur when levels lt60mg/dl
• Can occur in non-diabetics due to
• Physical exertion
• ETOH, drugs, pregnancy, lactation

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HYPOGLYCEMIACauses

• In diabetics
• Too much insulin
• To much oral hypoglycemic med.
• Decreased dietary intake (missed meal)
• Unusual physical activity
• Emotional stress

INSULIN
SUGAR
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HYPOGLYCEMIALess common causes

• Alcoholism
• Adrenal problems
• Liver disease
• Malnutrition
• Sepsis
• Hypothermia
• Cancer
• Pancreatic tumor

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HYPOGLYCEMIASigns Symptoms

• Rapid onset
• Nervousness
• Irritability
• Combative behavior
• Weakness
• Confusion
• Appearance of intox
• Weak, rapid pulse, cool, clammy skin
• Drowsiness, seizures, coma

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HYPOGLYCEMIAPearls/Pitfalls

• Suspect this in any diabetic with behavioral
  change, confusion or unconsciousness
• TRUE EMERGENCY!
• Dont assume intox!

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DIABETIC KETOACIDOSIS

• Absence of insulin
• Glucose does not enter the cell and accumulates
  in blood
• Cells starve and burn fats, producing ketones and
  acidosis
• These dehydrate the cells and produce massive
  oncotic diuresis
• Results include seizures and dysrhythmias

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DIABETIC KETOACIDOSIS Signs SymptomsSlow in
Onset (12-48 hours)

• Diuresis
• Warm, dry skin
• Dry mucous membranes
• Tachycardia, thready pulse
• Orthostatics
• Polyuria
• Polydipsia

• Acidosis
• Abdominal pain
• Nausea vomiting
• Acetone odor to breath (fruity)
• Kussmauls respiration
• Decreased level of consciousness.

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DIABETIC KETOACIDOSISPearls/Pitfalls

• DKA patients are very seldom deeply comatose. If
  this is the case, assess for a cause of the coma,
  like stroke, head trauma, or drug overdose

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HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC COMA (HHNK)

• Life threatening emergency, occurs in older type
  II or undiagnosed diabetics
• There is residual insulin, enough to prevent
  ketoacidosis, but not enough to permit cellular
  uptake of glucose

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HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC COMA (HHNK)

• Hyperglycemia produces hyperosmolar state, and
  osmotic diuresis, dehydration.
• These folks have greater hyperglycemia because
  they are more dehydrated and are not ketotic

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HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC COMA
(HHNK)Precipitating Causes

• Type II diabetes
• Old age
• Cardiac/renal disease
• Inadequate insulin
• Increased insulin requirements
• Stress,infection, trauma,burns,MI
• Medications
• Steroids,thiazides

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HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC COMA
(HHNK)Signs Symptoms

• Weakness,thirst
• Polyuria
• Weight loss
• Extreme dehydration
• Flushed dry skin
• Dry mucous membranes
• Poor skin turgor
• Orthostatics
• AMS
• Tachycardia
• Hypotension
• Tachypnea

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ASSESSMENT OF THE DIABETIC PATIENT

• High index of suspicion
• Always transport
• Beware of atypical presentation of MI in patients
  with a diabetic history

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TREATMENT

• Airway management
• High concentration of oxygen
• Vent. Support-if needed
• Draw blood
• IV saline

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TREATMENT

• Glucometers
• Whats the deal with them?
• Oral Glucose
• When, and when not

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TREATMENT

• HYPOGLYCEMIA
• Dextrose, if IV access is available
• Glucagon- IM
• DKA/HHNK
• Fluid, Fluid, Fluid

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Questions?
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Thank You!