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DHEC EMS Division

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DHEC EMS Division Treatment of the Hypoglycemic Patient by the EMT-Intermediate OBJECTIVES The incidence, morbidity and mortality of endocrinologic emergencies ... – PowerPoint PPT presentation

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Title: DHEC EMS Division


1
DHEC EMS Division
  • Treatment of the Hypoglycemic Patient by the
  • EMT-Intermediate

2
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.

3
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.

4
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.

5
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.

6
DIABETES MELLITUS
  • Over 8 million Americans have been diagnosed with
    Diabetes.
  • Researchers believe that the same number may be
    living with undiagnosed diabetes.

7
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.

8
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.

9
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.

10
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.

11
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.

12
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.

13
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.

14
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.

15
ALTERED GLUCOSE LEVELS
  • Levels lower than 80 mg/dL represent
    hypoglycemia.
  • Levels greater than 140 mg/dL represent
    hyperglycemia.

16
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.

17
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.

18
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.

19
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.

20
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)

21
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

22
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.

23
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.

24
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.

25
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.

26
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.

27
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!!

28
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.

29
HYPOGLYCEMIA (INSULIN SHOCK)
  • EVERY SECOND COUNTS WHEN TREATING THE PATIENT
    WITH SEVERE HYPOGLYCEMIA!!

30
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!

31
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.

32
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.

33
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.

34
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!!

35
PHARMACOLOGY
  • DEXTROSE 50 IN WATER
  • D50W

36
THE PATIENTs Rs
  • The RIGHT patient
  • The RIGHT medication
  • The RIGHT dose
  • The RIGHT route
  • The RIGHT expiration date

37
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)
38
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.

39
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.

40
Open here!!! Works MUCH better!!!
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43
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.

44
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.

45
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
46
  • D50W is supplied 25G in 50 mL. Give 14G to a
    patient.
  • 14 Grams
  • 25 Grams

X 50 mL 28 mL
47
DRUG CALULATION FORMULA
  • 14 divided by 25 0.56
  • 0.56 multiplied by 50 28 (mL)
  • Give 28 mL of the solution

48
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!!

49
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 _____________
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