Acute Diabetic Emergencies

Acute Diabetic Emergencies
Chapter 20 Acute Diabetic Emergencies Advance Preparation Review local protocols for assessment and treatment of diabetic patients and altered mental status. Contact a local hospital to arrange for a diabetes educator as a guest speaker on the topic of diabetes. Bring in a sleeve or two of saltine crackers for a class activity. (See slide 10.) Bring several tubes of oral glucose to class. Prehospital Emergency Care, Ninth Edition Joseph J. Mistovich • Keith J. Karren Copyright ©2010 by Pearson Education, Inc. All rights reserved.

Objectives Define key terms introduced in this chapter.
Describe the following regarding glucose (slides 12-13): The function of glucose in the body Response of brain cells and other body cells to insufficient glucose levels Relationships of glucose and water 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). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives 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). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Objectives Compare and contrast the speed of onset and the signs and symptoms of hypoglycemia and hyperglycemia (slides 34, 45). Describe the primary differences between DKA and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) (slides 43, 48, 50). Discuss the pathophysiology, assessment, and emergency medical care of HHNS (slides 48-52). Discuss the assessment-based approach to a patient with an altered mental status in a diabetic emergency (slides 53-63). The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

Multimedia Directory Slide 26 How to Use a Blood Glucose Meter Video
Slide 29 Information about Diabetes Video Slide 39 The Use of Oral Glucose Animation These videos and animations appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Topics Understanding Diabetes Mellitus Acute Diabetic Emergencies
Assessment-Based Approach: Altered Mental Status in a Diabetic Emergency Planning Your Time Plan 120 to 130 minutes for this chapter as follows: Understanding Diabetes Mellitus (30 minutes) Acute Diabetic Emergencies (60 minutes) Assessment-Based Approach: Altered Mental Status in a Diabetic Emergency (30 minutes) Note: The total teaching time recommended is only a guideline.

CASE STUDY Dispatch Case Study Discussion
The following case study is intended to challenge your students to think about caring for a patient with an altered mental status and the likelihood of a diabetic emergency. Present the case in a way that your students will imagine being on the call and feel challenged by the circumstances of the incident. If appropriate, briefly relate a personal experience you’ve had running a similar call and how you managed it.

EMS Unit 106 Case Study Discussion, continued You’re working on EMS Unit 106 this afternoon. You’ve been dispatched to 514 Chicago Avenue. Dispatch reports that a 66-year-old male patient on scene appears to be disoriented and belligerent. Be advised, the neighbor placed the call. Time out is 1402 hours. Respond to 514 Chicago Avenue for a 66-year-old male who is disoriented and belligerent. The neighbor placed the call. Time out 1402

Upon Arrival Neighbor found patient in her garden next door
Case Study Discussion, continued As you and your partner approach the house, a woman walks out of the front door. She says, “It’s Mr. Bennet. I found him in my garden next door. When I asked what he was doing, he began cursing at me. He’s always such a nice man. I can’t believe how he’s acting. Now he isn’t making much sense when I talk to him.” You proceed into the house and find the patient sitting on the edge of the couch mumbling incomprehensible words. 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?
Case Study Discussion, continued What types of problems might cause a sudden change in Mr. Bennet’s behavior? If Mr. Bennet is unable to give you a medical history, how can you find out additional information about him? How would you proceed to assess and care for this patient?

Understanding Diabetes Mellitus
Teaching Time 30 minutes Back to Topics

Glucose (Sugar) Back to Objectives Points to Emphasize
Glucose is the primary sugar used by the body for energy. Brain cells are able to use glucose for energy but cannot store glucose. Brain cells quickly stop functioning when blood glucose levels are low. This results in altered mental status. Class Activity To illustrate the break down of starches into simple sugars, pass out some saltine crackers. Ask students to begin to chew the crackers but not to swallow right away. Enzymes in saliva begin to break down the starches, and the cracker will take on a sweet taste after it is held in the mouth for a short period of time. Discussion Question What happens to the glucose that is not immediately needed by our cells for energy? Back to Objectives

Sources Roles Brain cells Talking Points
The three major food sources for the body’s cells are carbohydrates, fats, and proteins. Carbohydrates are a primary energy source for the cells. One of the most important roles of glucose is as a major source of fuel for the cells. Maintaining the glucose level in the blood is crucial to the normal function of cells. Some cells are able to use fats and proteins as energy sources if little or no glucose is available in the blood; however, the brain cells are not able to use anything but glucose. Brain cells are extremely sensitive to a lack of glucose. They are almost immediately affected and will respond quickly to the decrease in available glucose. The brain cells cannot make glucose, store glucose for more than a few minutes, or collect glucose in a concentration from the blood. The consequences of the lack of glucose to brain cells for a short period of time are brain cell dysfunction leading to an altered mental status. Sources Roles Brain cells

Hormones That Control Blood Glucose Levels
Insulin Talking Points The two hormones primarily responsible for controlling levels of blood sugar are insulin and glucagon, both of which are secreted by the pancreas. Insulin and glucagon have opposite effects on blood sugar level. Point to Emphasize The pancreas secretes insulin when blood glucose levels increase. Insulin helps glucose move from the blood into cells for use as energy or for storage. Teaching Tip Use the analogy of a thermostat’s role in regulating heat to explain the pancreas’s role in regulating blood glucose levels. Back to Objectives

Insulin Main functions How it works Talking Points
Insulin is secreted when the blood sugar level is elevated and has three main functions: – Increases the movement of glucose out of the blood and into the cells. – Causes the liver to take the glucose out of the blood and convert it into glycogen, the stored form of glucose. – Decreases the blood glucose level by facilitating the movement of the glucose into the cells and the liver. Insulin works by: – Attaching to the cell at a receptor site to cause another channel on the cell membrane to open. – Facilitating the movement of glucose into the cell through this channel. The brain does not need insulin to help move glucose into the cells. Glucose will cross the blood-brain barrier readily, whether insulin is present or not. Main functions How it works

Glucagon Point to Emphasize The pancreas secretes glucagon when the blood glucose level is low. Glucagon converts stored glycogen in the liver back into glucose.

Glucagon Role Functions Talking Points
Glucagon’s major role in the body is to raise and maintain the blood glucose level. When the blood glucose level decreases to approximately 70 mg/dL, the pancreas secretes glucagon. Glucagon converts liver glycogen and other substances into glucose to raise and maintain the blood glucose level until the next meal. The function of glucagon is exactly the opposite of insulin’s function. It is secreted when the blood glucose level is low and will work to increase the blood glucose level. The major functions of glucagon are to: – Convert glycogen stored in the liver back into glucose and release it into the blood. – Convert other noncarbohydrate substances into glucose. – Increase and maintain the blood glucose level by converting glycogen and other substances into glucose. Role Functions

Other Hormones Talking Points Many other hormones are also released to help maintain the blood glucose level. One of these hormones is epinephrine (adrenalin).

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 Talking Points The adrenal glands release epinephrine when the blood glucose level decreases to a dangerously low level. Many of the signs you see in a patient with a low blood glucose level are caused by epinephrine. Epinephrine causes the following effects: – Stops the secretion of insulin. – Promotes the release of stored glucose from the liver. – Promotes the conversion of other substances into glucose.

Normal Metabolism and Glucose Regulation
Talking Points The blood glucose level (BGL) of a person who has fasted for eight to 12 hours would normally read 80–90 mg/dL. Because patients are not always in a fasting state when you test their blood glucose level, many sources use much wider ranges of 70–120 mg/dL as a normal blood glucose level. Because the brain is extremely sensitive to alterations in the blood glucose level, the body must maintain the blood glucose level within this very narrow range. Primarily insulin and glucagon accomplish this. Point to Emphasize Normal blood glucose level is between 70 and 120 mg/dL. Discussion Question How is the blood glucose level normally regulated? Back to Objectives

Normal Glucose Regulation
Talking Points Within one hour after a meal, a person’s blood glucose level (BGL) increases to 120–140 mg/dL. When blood glucose rises, it triggers the pancreas to secrete insulin, which immediately begins to increase the movement of the glucose into the cells. The liver takes up about two-thirds of the glucose and converts it to glycogen to be stored by the liver and muscles for later use. The brain takes up as much glucose as it needs without the aid of insulin. Consequently, a few hours after a meal, the blood glucose level drops back to a normal level. Eventually, as the cells continue to require and use insulin in the hours after a meal, the blood glucose level drops near the lower end of the normal range. The pancreas recognizes the decreased blood glucose level and secretes glucagon. The glucagon causes the liver to begin converting the glycogen back into glucose and releasing it into the bloodstream. This raises the blood glucose level and maintains it in that normal range until the next meal. Knowledge Application Ask students to explain what happens to glucose and hormone levels in response to eating and fasting.

Checking the Blood Glucose Level
Point to Emphasize Hypoglycemia is a blood glucose level less than 50 mg/dL or less than 60 mg/dL with symptoms of hypoglycemia, such as altered mental status. Back to Objectives

Glucose meters Hypoglycemia Hyperglycemia Talking Points
Portable blood glucose meters, commonly referred to as glucometers by EMS personnel, are available to both the EMS crew and the diabetic patient. These devices can fairly accurately determine the blood glucose level. Blood glucose is measured in milligrams per deciliter (mg/dL). Hypoglycemia is typically a BGL of 60 mg/dL or less with signs or symptoms of hypoglycemia, or a BGL of less than 50 mg/dL with or without signs or symptoms of hypoglycemia. The primary sign of hypoglycemia is an altered mental status. Hyperglycemia is a BGL persistently greater than 120 mg/dL. Use the blood glucose meter as an adjunct to your assessment and emergency medical care. You could get an inaccurate reading from improper use of the glucose meter, expired test strips, or a poorly calibrated device. Use the blood glucose reading in conjunction with the information collected in the history and the signs found in the physical examination. Glucose meters Hypoglycemia Hyperglycemia

Checking the Blood Glucose Level
Testing the Blood Glucose Level with a Glucose Meter

Blood sample Equipment needed Talking Points
Test the blood glucose level prior to the administration of any oral glucose or sugar-containing solution. Be sure to get a good blood sample. Refer to “Steps for Glucose Measurement” in Chapter 20. In order to test the blood glucose level with a glucose meter, you will need to have the following supplies and equipment: – Glucose meter – Glucose meter test strips – Lancet – Lancet device (optional) – Alcohol swabs Blood sample Equipment needed

How to Use a Blood Glucose Meter
Video Clip How to Use a Blood Glucose Meter Describe how to use a blood glucose meter. Which way should you insert the strip into the blood glucose meter? Where should you obtain a blood glucose reading? Discuss the meaning of the blood glucose meter reading. Click here to view a video on how to use a blood glucose meter. Return to Directory

Diabetes Mellitus (DM)
Points to Emphasize Diabetes mellitus (DM) is a condition in which there is disturbance in the metabolism of carbohydrates, fats, and proteins. Diabetes occurs when there is not enough insulin or the cellular receptors for insulin do not respond normally. Glucose cannot enter cells, so the blood glucose level rises. However, cells cannot get the source of energy they need. Type I diabetics must take insulin, while Type II diabetics generally manage with diet, exercise, and oral medications. Discussion Question What are the similarities and differences between Type I and Type II diabetes? Critical Thinking Discussion What causes the three “Ps” of untreated diabetes mellitus? Back to Objectives

Primary problem Type I diabetes Type II diabetes Talking Points
The primary problem in diabetes mellitus is either (1) a lack of insulin being secreted by the pancreas or (2) the inability of the cell receptors to recognize the insulin and allow the glucose to enter at a normal rate. While body cells may be deprived of glucose, brain cells are not because insulin is not required for glucose to cross over into the brain cells. The brain has more glucose than it needs while the body cells are starving for glucose. Type I diabetes is also referred to as insulin-dependent diabetes mellitus (IDDM) since these patients are required to inject or inhale insulin. The Type I patient’s pancreas usually does not secrete any insulin. These patients are most commonly under the age of 40. They are prone to suffering from diabetic ketoacidosis (DKA). Type I diabetes is less common than Type II diabetes. Type II diabetes is also referred to as noninsulin-dependent diabetes mellitus (NIDDM) because Type II patients usually do not have to take insulin. They do have to regulate their diet, exercise, and take oral drugs to help the pancreas secrete more insulin or to make the insulin that is secreted more effective in facilitating movement of glucose into the cells. Type II diabetic patients are usually middle-aged or older. They are typically overweight. Primary problem Type I diabetes Type II diabetes

Information about Diabetes
Video Clip Information about Diabetes What is diabetes mellitus? What are the different types of diabetes? Discuss how insulin works in the body. What is prediabetes? How many people have Type I diabetes? Click here to view a video on information about diabetes. Return to Directory

Acute Diabetic Emergencies
Teaching Time 60 minutes Points to Emphasize Acute diabetic emergencies include hypoglycemia and hyperglycemia. The patient’s mental status deteriorates as the blood glucose level drops below normal. Back to Topics

Pathophysiology of Hypoglycemia
Talking Points Hypoglycemia is the term for a low blood glucose level. This condition is more common in Type I IDDM patients than in Type II NIDDM patients. Hypoglycemia is the most dangerous acute complication of diabetes mellitus. It is estimated that nine to 120 episodes of hypoglycemia will occur per 100 diabetic patients per year. It is one of the most common causes of coma in the diabetic patient. Point to Emphasize Hypoglycemia is more common in Type I diabetes but also occurs in Type II diabetes. In either case, if normal glucose levels are not restored, brain cells begin to die. Discussion Questions At what point is a patient considered hypoglycemic? What are the likely events leading to an episode of hypoglycemia? Back to Objectives

Pathophysiology Cause Reasons for drop Talking Points
Hypoglycemia occurs when the amount of glucose in the blood falls below the normal lower limit. The most common sign of hypoglycemia is an altered mental status. The brain is very sensitive to a drop in the blood glucose level. As the blood glucose level continues to drop, the mental status of the patient continues to deteriorate. If the blood glucose level is not restored, the brain cells begin to die. Hypoglycemia occurs in Type I IDDM for one of the following reasons: – The patient takes insulin and does not eat a meal. – The patient takes insulin, eats a meal, but drastically increases activity. – The patient takes too much insulin. Type II NIDDM patients can also suffer hypoglycemia. The oral medications that they take can cause the blood glucose level to drop too far, resulting in hypoglycemia. Because these oral medications have long-lasting effects, hypoglycemia can be prolonged or recur if these patients are not monitored. Pathophysiology

Assessment Findings in Hypoglycemia and Hypoglycemia Unawareness
Talking Points Hypoglycemia has commonly been referred to as “insulin shock” because of the shock-like signs and symptoms commonly seen with the condition. Many of these are caused by release of epinephrine.

Assessment Findings Cause Signs and symptoms Hypoglycemia unawareness
Talking Points As the blood glucose level drops, epinephrine is secreted at higher levels. The effect of the epinephrine is to shut down secretion of insulin and to stimulate secretion of glucagon. This, in turn, converts stored glycogen and other noncarbohydrate substances into glucose. Signs and symptoms caused by epinephrine release are diaphoresis; tremors; weakness; hunger; tachycardia; dizziness; pale, cool, and clammy skin; and a warm sensation. Signs and symptoms caused by brain cell dysfunction are confusion, drowsiness, disorientation, unresponsiveness, seizures (in severe cases), and stroke-like symptoms including hemiparesis. The hypoglycemic patient may present with bizarre or even violent behavior, and, for this reason, you may mistake the patient’s condition for a behavioral or psychiatric disorder, drug use, or alcohol intoxication. This is potentially a tragic mistake since hypoglycemia can be fatal if not recognized and treated quickly. These patients are generally unaware of their actions. Look for a medical identification bracelet, anklet, or necklace during your physical examination. Cause Signs and symptoms Hypoglycemia unawareness Back to Objectives

Emergency Medical Care for Hypoglycemia
Talking Points Give sugar to the hypoglycemic patient to increase the blood glucose level as quickly as possible and prevent brain cells from dying. Your management is based on the patient’s mental status. Point to Emphasize Only administer oral glucose if the patient is responsive, able to swallow, and able to obey commands. Discussion Question What are the management priorities for patients with hypoglycemia?

Emergency Medical Care
Talking Points If the patient is responsive, able to swallow, and able to obey your commands: – Ensure the airway is patent. – Assess the blood glucose level if your protocol permits. – Administer one tube of oral glucose. – Continuously reassess airway, breathing, and patient status changes. If the patient is unresponsive, unable to swallow, or unable to obey commands: – Establish an open airway. – Provide oxygen via a nonrebreather mask at 15 lpm if breathing is adequate. – Provide positive pressure ventilation if the breathing is inadequate. – Contact advanced life support. – Assess the blood glucose level. Critical Thinking Discussion Why do patients with hypoglycemia often present with bizarre or aggressive behavior? For a responsive patient For an unresponsive patient

Oral Glucose Back to Objectives Talking Points
Oral glucose is the medication of choice in the emergency medical care of the diabetic patient with an altered mental status. This heavy sugar gel raises the amount of glucose circulating in the blood, which increases the amount of glucose available to the brain. Back to Objectives

Purpose for administration Criteria for administration
Talking Points Oral glucose helps raise blood glucose levels, increasing the amount available to the brain. Oral glucose may be administered only if the patient meets all of the following three criteria: – Altered mental status – History of diabetes controlled by medication or a blood glucose reading less than 60 mg/dL – Ability to swallow In cases where all three criteria are not met, do not administer oral glucose. Instead, provide emergency medical care for a patient with altered mental status and an unknown history. Maintain an open airway, suction as needed, maintain oxygen therapy, be prepared to assist ventilations, place the patient in a lateral recumbent position, and transport. Contact medical direction for further orders. Purpose for administration Criteria for administration

Information about the Use of Oral Glucose
Animation Information about the Use of Oral Glucose In what form does oral glucose usually come? Where is oral glucose usually administered? Discuss the brain’s response to a lack of glucose. Click here to view information about the use of oral glucose. Return to Directory

Hyperglycemia Back to Objectives Teaching Tip
Draw a grid on the board with Hypoglycemia and Hyperglycemia as column headings. Label rows Signs, Symptoms, History, and Management. Have students fill in the grid. Review the grid, emphasizing key points and filling in any gaps. Discussion Questions At what point is a patient considered hyperglycemic? What are the management priorities for patients with hyperglycemia? Back to Objectives

Diabetic ketoacidosis (DKA)
Hyperglycemia Diabetic ketoacidosis (DKA) Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Talking Points Hyperglycemia is the term for a high blood glucose level (hyper = high, glyco = glucose, emia = blood). Extremely hyperglycemic patients may suffer from diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). DKA is more common in the Type I diabetic, whereas HHNS is more common in the Type II diabetic. In both conditions, the blood glucose level increases drastically. Unlike hypoglycemia, which is a lack of glucose in the blood, hyperglycemic conditions mean a lack of insulin and an excessive amount of glucose in the blood. In hyperglycemic conditions, the brain has more glucose than it can handle.

Hyperglycemic Condition: Diabetic Ketoacidosis (DKA)
Pathophysiology of DKA Points to Emphasize The patient without enough insulin to allow glucose to move from the blood into the cells for energy begins using fat for energy. This produces ketones, resulting in DKA. Type II diabetics usually have enough insulin to prevent fats from being used for energy. The result is hyperglycemia and dehydration but without acidosis.

Pathophysiology Cause Results in the body
Factors causing hyperglycemia in DKA patients Talking Points In diabetic ketoacidosis, blood glucose levels are elevated (> 350 mg/dL) because of an inadequate amount of insulin. The brain has plenty of glucose and is not failing from low blood sugar, but other body cells are hypoglycemic because insulin is unavailable to move sugar from the blood into the cells. As an alternative, body cells turn to fat for energy. This creates two problems. First, excess glucose from the blood spills into the urine, drawing large amounts of water with it, and the patient becomes dehydrated. Second, when fat is burned for energy, it produces a strong acid byproduct called ketones. As cells burn more fat, acid levels in the body increase to dangerous levels (acidosis). Factors that may provoke hyperglycemia: – An infection that upsets the insulin and glucose balance – An inadequate dose of insulin – Medications such as Thiazide, Dilantin, or steroids – Stress such as surgery, trauma, pregnancy, or heart attack – Change in diet in which the carbohydrate or sugar intake has changed Back to Objectives

Assessment Findings in DKA Talking Points The signs and symptoms of DKA are produced primarily by the dehydration and acid build-up. The name of the condition itself explains the signs and symptoms one would expect from the condition. The word diabetes means excessive urination. Ketoacidosis refers to the production of ketones, which also produces strong acids from fat cells using them as an energy source. Thus, diabetic ketoacidosis is a condition with excessive urination and a build-up of acid from ketone production. Therefore, look for signs of dehydration and acid build-up. Point to Emphasize Patients with DKA and HHNS are dehydrated and acidotic.

Assessment Findings Signs and symptoms Kussmaul’s respirations
Polyuria Polydipsia Polyphagia Kussmaul’s respirations Talking Points Signs and symptoms of diabetic ketoacidosis (DKA) are: Polyuria (excessive urination) Polyphagia (excessive hunger) Polydipsia (excessive thirst) Nausea and vomiting Poor skin turgor Tachycardia Rapid deep respirations (called Kussmaul’s respirations) Fruity or acetone odor on the breath Positive orthostatic tilt test Blood glucose level (BGL) greater than 350 mg/dL Muscle cramps Abdominal pain (in 50 percent of patients; more common in children with DKA) Warm, dry, and flushed skin Altered mental status Coma (very late) Back to Objectives

Emergency Medical Care for DKA Talking Points As an EMT, you may not be expected to distinguish between hypoglycemic and hyperglycemic conditions unless you are able to use a glucose meter. The patient will typically have a history of diabetes mellitus and will usually be on either an injectable or inhalable form of insulin or an oral hypoglycemic agent to manage the blood glucose. The patient with diabetic ketoacidosis is typically dehydrated and acidotic. Aim treatment at reducing the blood glucose level and rehydrating the patient. It may be prudent to contact an advanced life support unit to begin rehydration in the field. Follow your local protocol. Point to Emphasize It is better to err on the side of hypoglycemia and administer glucose to the patient if the condition is unclear. When brain cells are deprived of glucose, they begin to die. On the other hand, if you administer oral glucose to a hyperglycemic patient, the amount of glucose given is not going to raise the blood glucose drastically and will have no effect on the brain.

Talking Points In the patient with DKA, the prehospital emergency medical care includes: Establish and maintain a patent airway. Provide oxygen via a nonrebreather mask at 15 lpm if breathing is adequate. If breathing is inadequate, provide positive pressure ventilation. If your protocol permits, determine the blood glucose level. If you are unsure about the condition, administer oral glucose if the patient is able to swallow. Contact medical direction for further orders. Note that oral glucose should be considered in any patient who has a history of diabetes and who presents with an altered mental status. You may not know if the patient is suffering from hypoglycemia if a glucose meter is not used. If your protocol allows you to measure the blood glucose, do so to determine if the patient is hypoglycemic or hyperglycemic. ABCs Provide O2 Assist ventilation Check BGL Contact medical direction

Pathophysiology of HHNS
Hyperglycemic Condition: Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) Pathophysiology of HHNS Talking Points HHNS is more common in the Type II NIDDM patient. This is because the Type II patient’s pancreas is able to still produce and secrete some insulin. Therefore, some glucose is still getting into the cells. The glucose entering the cells keeps the amount of fat being burned for energy to a lesser amount than is seen in DKA. If a significant amount of fat is not being used, then less ketones will be produced as a byproduct of fat breakdown. Since a large amount of ketones do not collect and cause acid load in the body, the syndrome is termed nonketotic. Discussion Question How are DKA and HHNS distinguished from one another? Back to Objectives

Pathophysiology Blood glucose level Precipitating factors
Talking Points HHNS is a hyperglycemic condition that causes the blood glucose level to increase drastically (> 600–1,200 mg/dL). Because of the high blood glucose level, the kidneys begin to spill off large amounts of glucose in the urine. This creates a hyperosmolar effect in which the glucose draws large amounts of water with it into the urine. The patient then suffers from significant dehydration. An episode of HHNS may be the first indication that a patient has a diabetic condition. It is most commonly found in Type II NIDDM patients who are elderly. HHNS may also be precipitated by trauma, burns, dialysis, drugs, heart attack, stroke, infection, and head injuries. HHNS carries a fairly high mortality rate. HHNS patients are more likely to have seizures than are hypoglycemic patients. Critical Thinking Discussion Why is the blood glucose level typically higher in HHNS than in DKA? Blood glucose level Precipitating factors

Assessment Findings in HHNS
Hyperglycemic Condition: Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) Assessment Findings in HHNS Point to Emphasize You will not find Kussmaul’s respirations or fruity odor on the breath of HHNS patients because ketones do not significantly build up in the body and cause acid load. Knowledge Application Given several different scenarios, students should be able to identify patients with hypoglycemia and hyperglycemia. Back to Objectives

Assessment Findings Signs and symptoms Talking Points
Signs and symptoms of HHNS are very similar to those of DKA with the exception of those caused by acidosis in DKA: Tachycardia Fever Positive orthostatic tilt test Dehydration Thirst (polydipsia) Dizziness Poor skin turgor Altered mental status Confusion Weakness Dry oral mucosa Dry, warm skin Polyuria (If dehydrated, the urine output will be scanty.) Nausea and vomiting Signs and symptoms

Talking Points Emergency medical care for HHNS includes: Establish and maintain a patent airway. Provide oxygen via a nonrebreather mask at 15 lpm if breathing is adequate. If the breathing is inadequate, provide positive pressure ventilation. If your protocol permits, determine the blood glucose level. If you are unsure about the condition, administer oral glucose if the patient is able to swallow. Contact medical direction for further orders. Like the DKA patient, the HHNS patient needs to be rehydrated with fluids. It may be necessary to call for advanced life support for this purpose. Follow your local protocols. ABCs Provide O2 Support respirations Determine BGL Medical direction

Assessment-Based Approach: Altered Mental Status in a Diabetic Emergency
Teaching Time 30 minutes Back to Topics

Scene Size-Up and Primary Assessment
Back to Objectives

Look for scene clues Medic alert tags Insulin pumps Talking Points
If clues gathered during the scene size-up and primary assessment lead you to suspect that the patient may be diabetic, look for medical alert tags or other medical identification that confirms a diabetic history. Some patients with insulin-dependent diabetes may be found wearing an insulin pump.

History and Secondary Assessment
Points to Emphasize When assessing a patient with altered mental status, the patient’s medications and assessment of the blood glucose level may help you determine if the cause is a diabetic emergency. A variety of medications are used to treat diabetes. Check the name of the medication in a pocket drug reference guide. Discussion Question What medications would indicate to you that your patient is a diabetic? Knowledge Application Given several descriptions of patients with altered mental status, students should be able to obtain a relevant history to determine if the patient is more likely suffering from hypoglycemia or hyperglycemia.

SAMPLE Common medications Questions to ask Talking Points
While asking the SAMPLE history questions, especially remember to ask the “M” question about medications. The presence of some medications will help establish a history of diabetes. Medications often taken by diabetics include: Insulin, Humulin, Novolin, Iletin, Semilente, Actos, Diabanese, Glucamide, Orinase, Micronase, Diabeta, Tolinase, Glucotrol, Humalog, Glucophage, Glynase, Exenatide, Byetta, and Exubra (inhaled insulin). Keep in mind that some medications patients take (beta blockers) may hide the signs of hypoglycemia. Four pertinent questions to ask during the history are: – Did the patient take his medication the day of the episode? – Did the patient eat (or skip any) regular meals on that day? – Did the patient vomit after eating a meal on that day? – Did the patient do any unusual exercise or physical activity on that day?

History and Secondary Assessment
Signs and Symptoms Discussion Question What are some key characteristics to help differentiate between hypoglycemia and hyperglycemia?

Signs and Symptoms Place redrawn picture here – did not have yet, WDS Talking Points Signs and symptoms commonly associated with a patient who has an altered mental status and a history of diabetes are: Rapid onset of an altered mental status after unusual exercise, physical work, or missing or vomiting a meal Intoxicated appearance from staggering, slurred speech to unresponsiveness Tachycardia Cool, moist skin Hunger Seizure activity Uncharacteristic or bizarre behavior; combativeness Anxiousness or restlessness Bruising at insulin injection sites on the abdomen Signs and symptoms that mimic a stroke (weakness or paralysis on one side of the body ) for elderly patients

Talking Point Once you’ve confirmed an altered mental status and suspect a diabetic emergency likely resulting from hypoglycemia, concentrate emergency care on correcting any life-threatening conditions and reversing the low blood sugar. Point to Emphasize Oral glucose may be given to hypoglycemic patients who are responsive, can swallow, and can follow commands. Teaching Tip Pass around tubes of oral glucose for students to see and handle. Class Activity Have pairs of students role play assessing a patient to see if he can swallow and follow commands in order to receive oral glucose.

Determine if patient can swallow Administer oral glucose Transport
ABCs Determine if patient can swallow Administer oral glucose Transport Talking Points Establish and maintain an open airway. If the patient’s mental status is severely altered, suction the airway to clear secretions or vomitus and insert an oropharyngeal or nasopharyngeal airway. Administer oxygen by a nonrebreather mask at 15 lpm. If the breathing rate or depth is inadequate, provide positive pressure ventilation with supplemental oxygen. Determine if the patient is alert enough to swallow. To ensure that the patient is alert enough to swallow, hand him the tube of glucose and instruct him to squeeze the contents into his mouth and swallow. If he is not alert enough to hold onto the tube or squeeze it into his mouth, the patient is probably not a candidate for oral glucose. Administer oral glucose according to the protocols established by your local or state medical direction. If the patient is no longer alert during oral glucose administration, stop administering the medication. Immediately reassess the patient’s airway, breathing, and circulation and prepare to suction. Transport.

Reassessment Point to Emphasize
Reassess for signs of improvement after administering oral glucose. Critical Thinking Discussion Why is it important to err on the side of giving glucose if in doubt about a patient’s blood glucose level?

May take 20 minutes to see improvement Recheck BGL Continue O2
Talking Points Once you have administered the oral glucose, reassess the patient’s mental status to determine if the medication has had an effect. It may take more than 20 minutes before you see any improvement. If local protocol permits, retest the blood glucose level to determine if it is increasing. If the blood glucose level increases and the mental status improves, the patient is likely suffering from a low blood glucose level. If the blood glucose level increases but the patient’s mental status does not improve, the patient may be suffering from another condition in addition to the low blood glucose level, such as a stroke. If the blood glucose level remains low, it may indicate that the oral glucose has not yet reached the bloodstream and is not yet effective. If the patient is still able to swallow and is alert enough to obey your commands, consult with medical direction for an order to administer an additional tube of oral glucose. If the patient’s mental status continues to deteriorate or does not improve, manage the airway and breathing. Continue to oxygenate the patient. Communicate and record any changes in the patient’s condition. May take 20 minutes to see improvement Recheck BGL Continue O2 Manage airway as needed

CASE STUDY Follow-Up Case Study Follow-Up Discussion
This case study is continued from the beginning of the presentation. Briefly remind students that they are on the scene with a 66-year-old male who was found acting oddly by his neighbor. The patient is disoriented and belligerent. The neighbor directs you to the patient, who is sitting on his couch.

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 Follow-Up Discussion, continued You proceed into the house with caution and find the patient in the living room. The scene appears to be in order with no sign of trauma. As you approach the patient to begin the primary assessment, you ask your partner to check the house for medications. Your partner finds Digoxin near the kitchen sink and insulin in the refrigerator. Your general impression is that the patient appears to be pale and perspiring profusely. As you approach, you ask him his name. He responds with mumbled words. 65

CASE STUDY Primary Assessment
Partner places a nonrebreather mask at 15 lpm RR: 15; P: 100 and strong Case Study Follow-Up Discussion, continued You assume the airway is open, and his breathing appears to be adequate. The respirations are at approximately 15 per minute. However, because Mr. Bennet’s mental status appears to be altered, your partner places a nonrebreather mask on him at a liter flow of 15 lpm. You assess the radial pulse, which is approximately 100 and strong. His skin is moist and cool. 66

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 Follow-Up Discussion, continued His pupils are equal and respond sluggishly to light. You note no jugular vein distention in the neck. The breath sounds are equal bilaterally. His abdomen is soft, and you note no tenderness. Pulses are good in all extremities. He is able to obey your commands. The grip strength is equal but weak in both upper extremities. The strength in the lower extremities is equal but weak. You find no evidence of trauma anywhere on the body and no medical alert tag. Blood pressure is 102/60 mmHg. Heart rate is 108 per minute. Respirations are 16 per minute and of normal depth. His skin is pale, cool, and moist. His SpO2 reading is 97 percent on room air. You gather a SAMPLE history. The neighbor states that she found him in her garden about 15 minutes prior to calling EMS. She says, “Mr. Bennet was acting strange and not himself.” The neighbor thinks he has a heart and sugar problem. She doesn’t know much more. Mr. Bennet is disoriented and does not know his name, where he is, who his neighbor is, or what day it is. You’re able to determine that Mr. Bennet has an AMS, is able to swallow adequately, has a history of diabetes, and is taking medication for the diabetes. His blood glucose level is 48 mg/dL on the glucose meter. You administer one tube of oral glucose according to standing orders from medical direction, place the patient so that he is lying on his left side on the ambulance cot, and begin transport. 67

Treatment and Reassessment
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 Case Study Follow-Up Discussion, continued En route to the hospital you notice that Mr. Bennet is beginning to respond more quickly to commands and questions. He can tell you his name and where he is. His airway is clear, and breathing remains adequate. His pulse rate decreases to 86 per minute, and his skin becomes less pale, dryer, and warmer. You reassess the vital signs and record them. The pulse oximeter reading is 99 percent and he is showing no signs of hypoxia, so you switch him over to a nasal cannula at two lpm. As you arrive at the hospital, Mr. Bennet is alert and oriented to person, place, and time. He has no complaints and appears in no distress. You give the hospital an oral report of the change in the patient’s condition and help transfer him to the hospital bed. You and your partner complete a prehospital care report, restock the ambulance, and prepare for another call. Case Study Follow-Up Discussion Questions Why is it important to check the refrigerator for medications? Why was Mr. Bennet placed on his left side after receiving oral glucose? 68

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 Discussion This critical thinking scenario is intended to challenge your students to think about managing a patient with an altered mental status. You know nothing about the patient’s medical history except for the two prescription medications you find on scene. The scenario continues on the next slide.

S – Supine on the couch, not alert A – Unknown M – Her neighbor brings you the patient’s medications: Zoloft and Novolin P – Her neighbor doesn’t know the patient’s medical history L – Unknown E – Patient called the neighbor 20 minutes ago and said she wasn’t feeling well Critical Thinking Discussion, continued The scenario continues on the next slide.

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 Discussion, continued Ask students to briefly discuss the scenario before moving on to the series of questions on the next slide.

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? Critical Thinking Discussion, continued Answers: During the initial assessment of this patient, open the patient’s airway with the head-tilt, chin-lift maneuver and initiate high-flow, high-concentration oxygen therapy. Also consider the use of airway adjuncts. This patient is most likely suffering from hypoglycemia. This field impression is based on information from the history and physical exam findings. The patient’s prescription for Novolin, which is an injectable form of insulin, suggests a medical history of Type I diabetes mellitus. The physical exam reveals pale, cool, and clammy skin; tachycardia; and an altered mental status, all of which are consistent with hypoglycemia. It would be helpful to check the patient’s blood glucose level with a glucose meter. Based on this patient’s presentation, the blood glucose reading might read low, perhaps 60 mg/dL or less. Patients who experience hypoglycemic events typically present with a rapid onset of an altered mental status. We know her onset was less than 20 minutes.

Reinforce and Review Please visit www.bradybooks.com
and follow the myBradykit links to access content for the text. Please visit and follow the MyBradyKit links to access content for this text. Under instructor resources, you will find curriculum information, lessons plans, PowerPoint slides, TestGen, and an electronic version of the instructor’s edition. Under student resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.

Acute Diabetic Emergencies

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