DHEC EMS Division

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DHEC EMS Division

• Treatment of the Hypoglycemic Patient by the
• EMT-Intermediate

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OBJECTIVES
TO UNDERSTAND..

• The incidence, morbidity and mortality of
  endocrinologic emergencies related to Diabetes
  Mellitus and Glucose metabolism.
• Risk factors associated with Diabetes.
• Anatomy and physiology of structures involved
  with Diabetes and the normal metabolism and use
  of Glucose.

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OBJECTIVES

• Formation of ketone bodies and its relationship
  to ketoacidosis.
• How the kidneys excrete potassium and ketone
  bodies.
• How insulin in the body works.
• Assessment findings in the patient with Diabetic
  emergency.
• The need for rapid intervention of the patient
  with abnormal blood glucose levels.

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OBJECTIVES

• Pathophysiology of Type I and Type II Diabetes.
• The effects of increased and decreased insulin
  levels on the body.
• Management of the Diabetic emergency.

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DIABETES MELLITUS

• A condition when there is inadequate insulin
  activity in the body.
• Insulin is important for maintaining a normal
  glucose level.
• Glucose is the ONLY substance that brain cells
  can use readily and efficiently use as an energy
  source.

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DIABETES MELLITUS

• Over 8 million Americans have been diagnosed with
  Diabetes.
• Researchers believe that the same number may be
  living with undiagnosed diabetes.

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Anabolism vs- Catabolism

• When a person eats, glucose is stored as
  glycogen, protein, and fat. This is called
  anabolism.
• Insulin is responsible for this build-up of
  stored glucose.
• The process of Anabolism uses energy.

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Anabolism vs- Catabolism

• If there is too much insulin, or too little food
  (glucose), the blood glucose level will drop to a
  level not sufficient to maintain energy for
  cells, specifically the brain cells.
• There may be sufficient glucose stored as
  glycogen, but it is not in the bloodstream.

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Anabolism vs- Catabolism

• Glucagon is the dominant hormone that allows for
  the breakdown of stored glycogen for use as
  glucose.
• In severe hypoglycemic states, glucagon may not
  work fast enough to restore adequate glucose
  levels in the blood for immediate use.
• RESULT?? Brain cells do not have adequate energy,
  the patient may have an altered mental status.

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TRANSPORT OF GLUCOSE

• Insulin is the hormone responsible for the
  transport of glucose.
• The diffusion process is considered a
  mediated or facilitated transport.
• Insulin must bind with the glucose molecule and
  taxi it across the cell membrane out of the
  bloodstream.

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TRANSPORT OF GLUCOSE

• The elevation of insulin in the bloodstream may
  increase the rate of glucose transport out of the
  vascular system by 10 times, causing a rapid
  decrease of blood glucose levels.
• Not having enough intake of glucose will lead to
  the same result.

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TRANSPORT OF GLUCOSE

• Excessive use of energy (heavy work or exercise),
  or vomiting soon after eating, will also lead to
  a decrease of blood glucose levels.
• The result in ANY case will lead to hypoglycemic
  states.

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USE of GLUCOSE vs- FAT

• If enough insulin is not present to transport the
  glucose, then the body catabolizes (breaks down)
  fat instead of glucose.
• When this happens, the body produces ketone
  bodies in abundant quantities.
• This is called ketosis.

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GLUCOSE REGULATION

• If a person had a BGL of 80 mg/dL.
• A meal is ingested.
• In the first hour, the BGL may increase to 120
  140 mg/dL.
• The alpha and beta tissues of the islets of
  Langerhans and the liver produce glucagon and
  insulin.
• Liver disease, or Pancreas insufficiency may lead
  to poor regulation of glucose.

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ALTERED GLUCOSE LEVELS

• Levels lower than 80 mg/dL represent
  hypoglycemia.
• Levels greater than 140 mg/dL represent
  hyperglycemia.

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THE ROLE OF THE KIDNEY

• When blood passes through the tubules of the
  kidney, many substances are reabsorbed into the
  blood, and the waste is excreted.
• Reabsorption of glucose depends on the amount
  present in the blood.
• Reabsorption is essentially complete for levels
  up to 180 mg/dL.

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THE ROLE OF THE KIDNEY

• When baseline BGL levels are above 180 mg/dL,
  some of the glucose is lost in the urine.
• The urine is sweet with sugar, hence the name
  mellitus.
• Glucose in urine is called glycosuria.
• When glucose is in the urine, the osmotic
  pressure causes water to be excreted in excessive
  quantities.

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THE ROLE OF THE KIDNEY

• This leads to dehydration. It is called osmotic
  diuresis.
• As the water (fluid or plasma) leaves the
  vascular system, potassium is excreted also,
  causing hypokalemia.
• This result may lead to effects such as cardiac
  dysrhythmias.

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TYPE I DIABETES

• Characterized by very low production of insulin
  by the pancreas.
• Insulin may not be produced at all.
• Commonly called
• Juvenile Diabetes
• Insulin Dependent Diabetes Mellitus
• IDDM
• Less common than Type II Diabetes.
• Accounts for most Diabetic related deaths.

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TYPE I DIABETES

• This type is hereditary.
• Before diagnosis and treatment, BGL levels of 300
  to 500 mg/dL is not uncommon.
• As the osmotic diuresis occurs, it accounts for
  the
• Polydipsia (constant thirst)
• Polyuria (excessive urination)
• Polyphagia (weakness and weight loss)

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TYPE II DIABETES

• Associated with a moderate decline in insulin
  production.
• A deficient response to insulin may be present.
• Also called
• Adult onset Diabetes Mellitus.
• Non insulin dependant Diabetes Mellitus.
• NIDDM

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TYPE II DIABETES

• Heredity may play a role.
• Obesity is more likely to be the cause.
• Much more common than Type I.
• Accounts for about 90 of Diabetics.
• Less serious than Type I Diabetes.
• Ketoacidosis is not likely to occur.
• Controlled diet is the usual treatment.
• May require oral medications.
• Only a few cases lead to insulin use.

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DIABETIC KETOACIDOSIS

• Associated with Type I Diabetes.
• Occurs with profound insulin deficiency coupled
  with increased glucagon activity.
• Could be the result of
• Non-compliance with insulin injections.
• Physiologic stress such as surgery or serious
  infection.

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DIABETIC KETOACIDOSIS

• Glucose levels elevate in the vascular system,
  but are decreased in the cells due to the insulin
  deficiency.
• Glucagon is released causing catabolism of fats,
  leading to ketone body production and
  accumulation.
• Glucose is lost in the urine, and osmotic
  diuresis occurs.
• Dehydration occurs because of fluid loss.

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DIABETIC KETOACIDOSIS

• Blood pH decreases to dangerous levels because of
  the acidic nature of the ketone bodies.
• The patient becomes comatosed and may die if the
  acidosis is not treated.
• REMEMBER? the patient may have a fruity odor on
  their breath. This odor resembles the odor of
  ETOH.

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DKA SIGNS SYMPTOMS

• Onset is slow (12 24 hours)
• Increased urine production.
• Excessive hunger and thirst.
• Feeling weak, general malaise.
• Tachycardia
• Tachypnea Hyperpnea
• KUSSMAULs respirations.
• Acetone fruity odor on breath.

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DKA SIGNS SYMPTOMS

• May have cardiac dysrhythmias caused by low
  potassium levels.
• Warm/dry skin.
• Fever is not caused by DKA, and is usually a sign
  of infection.
• ALS TREATMENT NEEDED IF FEASIBLE!!

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HYPOGLYCEMIA (INSULIN SHOCK)

• This is a medical emergency!
• It can occur when
• The patient takes too much insulin.
• Eats too little for the insulin dose.
• Overexerts or over-exercises.
• Vomits soon after a meal.
• Glucagon may take HOURS to work, so it is less
  effective in compensating.

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HYPOGLYCEMIA (INSULIN SHOCK)

• EVERY SECOND COUNTS WHEN TREATING THE PATIENT
  WITH SEVERE HYPOGLYCEMIA!!

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HYPOGLYCEMIA (INSULIN SHOCK)SIGNS SYMPTOMS

• Altered Mental Status (AMS)
• Restlessness and Impatience
• Inherent HUNGER
• Anger or Rage
• Bizarre behavior
• Diaphoresis
• Cool clammy skin
• HYPOGLYCEMIA (INSULIN SHOCK)SIGNS SYMPTOMS
• Tachycardia
• Seizure
• Coma
• Sudden onset
• S/S may be similar to CVA!!!!!
• IF UNRESPONSIVE
• CALL FOR ALS BACK-UP!

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HYPOGLYCEMIA (INSULIN SHOCK)ASSESSMENT

• SAMPLE history.
• Take and record vital signs.
• Administer high concentration O2.
• Look for medical alert indicators
• Bracelet
• Necklace
• Pocket card
• Tattoo
• Look in the refrigerator for insulin.
• Look for insulin syringes.

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HYPOGLYCEMIA (INSULIN SHOCK)TREATMENT

• Call for ALS back-up!!
• Perform blood glucose check.
• If patient has S/S of hypoglycemia, (and/or) if
  the BGL is lt 70 mg/dL, start an IV with 0.9 NaCl
  (Normal Saline) and administer D50W 25 Grams, 50
  ml.
• NOTE if patient is alert enough to swallow, you
  may administer 1 to 2 tubes Instant Glucose (12
  25 Grams).
• Re-check BGL after 2-3 minutes.

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HYPOGLYCEMIA (INSULIN SHOCK)TREATMENT

• If the patient awakes to a fully alert status,
  the EMT-I may cancel the Paramedic and transport
  the patient if none of the following are present.
• Symptomatic bradycardia.
• Symptomatic tachycardia.
• Irregular pulse that is not normal.
• Chest pain, or any other complaint that should be
  evaluated by a Paramedic.

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WHICH PATIENTS CAN YOU TREAT?

• The S.C. EMT-Intermediate MAY ONLY administer
  D50W to a patient who is
• at least 12 years of age!!

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PHARMACOLOGY

• DEXTROSE 50 IN WATER
• D50W

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THE PATIENTs Rs

• The RIGHT patient
• The RIGHT medication
• The RIGHT dose
• The RIGHT route
• The RIGHT expiration date

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DEXTROSE 50 D50W, 50 Dextrose----------------
--------------------------------------------------
-------------INDICATIONS Suspected or
documented hypoglycemia. Altered LOC, or
Coma/Seizure of unknown etiology.ADMINISTRATION
IO, IV through a free flowing line.DOSAGEADULT
25.0 grams slow administration initial dose.
May repeat doses based upon Medical Control Order
or Protocols/Standing Orders for persistent
hypoglycemia.PEDIATRIC May be used for
patients at least 12 years old, or weighing at
least 55 kg. (120 pounds)
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CONTRAINDICATIONS

• The ONLY actual contraindication to
  administering D50W is known hyperglycemia and
  infiltration or a noticed hematoma at the IV
  site.
• Suspected CVA or TIA is a relative
  contraindication. Consider if the patient will
  suffer or die from the additional brain necrosis
  or from the hypoglycemia. Consult with Medical
  Control if CVA/TIA is suspected.

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COMPLICATIONS

• The most dangerous complication is infiltration.
  It causes local tissue necrosis and could lead to
  cellular death.
• Seek advise from MCP before D50W administration
  if CVA suspected.
• Thick fluid, you should use at least an 18 ga.
  catheter if possible.

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Open here!!! Works MUCH better!!!
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ADMINISTRATION

• Determine the need for the medication.
• Select suitable site, start IV (medium bore or
  large bore).
• Make sure the IV is PATENT!!
• Verify the medication and expiration date.
• Open and assemble the medication syringe. Expel
  the air from the syringe.
• Attach the syringe to the injection port closest
  to the patient.

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ADMINISTRATION

• Pinch the line, or cut the flow regulator off.
• Begin the injection.
• Periodically pull the syringe back (every 10ml)
  to ensure that the catheter is still inside the
  vein (you should aspirate blood each time).
• Continue until the desired dose is given.
• Document the dose and time.
• Monitor for patient improvement.
• Reassess Blood Glucose Level.
• Cancel Paramedic response if patient improves.

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DRUG CALULATION FORMULA

• Desired dose divided by the dose on hand,
  multiplied by the volume supplied in, will give
  you the amount of volume you should administer.
• Desired Dose
• Dose on Hand

X Volume Amount
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• D50W is supplied 25G in 50 mL. Give 14G to a
  patient.
• 14 Grams
• 25 Grams

X 50 mL 28 mL
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DRUG CALULATION FORMULA

• 14 divided by 25 0.56
• 0.56 multiplied by 50 28 (mL)
• Give 28 mL of the solution

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REPORTING

• You are administering medication that is allowed
  by prescription ONLY.
• This could be a standing order by your Medical
  Control Physician, or by on-line orders from the
  ED Physician.
• The receiving physician MUST sign the report!!

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DHEC, Division of EMS D50W Administration by the
EMT-I Skills Assessment Score Sheet     Name
_______________________ Date __________
Evaluator ______________________  
      Determines AMS, applies high flow
oxygen _____   Performs patient assessment to
include BGL test _____   Calls for Paramedic
back-up _____   Determines need for the
medication _____   Prepares IV
equipment _____   Selects suitable
site _____   Attaches tourniquet _____  
Start IV using aseptic technique _____   Sec
ures IV, runs W/O to check for infiltration _____
  Prepare D50W for injection (check exp date,
etc) _____   Pinch or clamp line, or run wide
open _____   Administer desired dose using
push-pull method _____   Runs IV W/O to
flush line _____   Reassesses mental
status _____   Reassesses BGL _____      
Evaluator signature ____________________________
________ Date _____________