1. Diabetic Emergencies Not too Sweet – Not too Sour

2. What is Diabetes?  Diabetes Mellitus – a disorder of Insulin

3. Diabetes Mellitus  Type I – insulin dependent  Usually starts at an early age  Caused by autoimmune destruction of Beta cells  No insulin production at all  No Insulin = Death  1922 – first successful use of insulin to treat kids with DKA – always fatal up until that point.  Currently – insulin pumps and various types of insulin are state of the art in treatment for Type I DM.

4. Diabetes Mellitus Type II – insulin resistant  Obesity, sedentary lifestyle  Beta blockers, glucocorticoids, thiazides  90% of all diabetes in US  Insulin is unable to do its work  Dietary changes, medications or insulin may be needed  Usually does not cause DKA

5. Diabetes Mellitus  Gestational Diabetes  Occurs during pregnancy  Resolves with delivery most of the time.  Due to hormone levels and obesity

6. Diabetes

9. Insulin  What is Insulin?  A hormone made by Beta cells in the Pancreas  Insulin works on multiple cells to regulate blood Glucose levels  Muscle – prevents protein breakdown  Adipose tissue – increases fat production  Liver – increased glycogen synthesis  Increased glucose and amino acid uptake  Inhibits Glucagon production

10. Effects  Vasculopathy - Vascular damage

11. Effects  Nephropathy - Kidney Damage

12. Effects  Neuropathy – nerve damage

13. Effects  Retinopathy – eye damage

14. Effects  Diabetic Ketoacidosis

15. Effects  Hypoglycemia – caused by treatment

17. Medications used in Treating Diabetes  Antihyperglycemics – stimulate insulin production  Sulfunylureas – Diabinese, Glucotrol, Diabeta, Amaryl  Meglitinides – Prandin, Starlix  Antihyperglycemics – do not stimulate insulin  Biguanide – Metformin – Lactic acidosis  Thiazolidinediones – Avandia, Actos  Alpha-glucosidase inhibitor – Precose, Glyset  DPP-4 Inhibit – Januvia, Onglyza

18. Hypoglycemia  The brain MUST have glucose to function  Brain is not affected by insulin.  Normal blood sugar levels range from 70-100  Low blood sugar can be caused by  Taking insulin when you cannot eat or forget to eat  Intentionally overdosing on insulin  Taking the wrong type  Exercising more than normal and not adjusting diet  Certain diabetes medications, but not all  Infections/illness which prevent eating

19. Hypoglycemia  Clinical symptoms  Lethargy  Unconsciousness  Stroke-like symptoms (especially in those with prior strokes)  Seizures  Trouble speaking  Confusion  Cardiac Arrest

20. Hypoglycemia  Testing  Fingerstick blood sugar  Make sure machine gets calibrated regularly  Make sure you have the right test strips that are not expired  Clean finger off with alcohol  Prick side of finger with lancet  Squeeze finger (milk it) to get enough to cover testing area  Read machine when test is complete

21. DEMO TIME…

22. Hypoglycemia  Treatment – Glucose!  IV Dextrose – AEMTs/Paramedics  Adults – 50% 1 ampule (50ml = 25gm)  Children – 25% 2ml/kg  Neonates – 12.5% - 1ml/kg  Oral Glucose – EMR/EMTs  Must have gag reflex and be alert to avoid aspiration/choking  Glucagon – for adults  1-2 mg IM if cannot get an IV

23. Dextrose  Class – carbohydrate  Mechanism – provides metabolic substrate  Contraindications  Absolute – None  Relative – hyperglycemia  Dosage – 50ml of D50, repeat x1 if needed  Peds – 2ml/kg of D25  Neonates – 1ml/kg of D12.5

24. Glucagon  Class – hormone  Mechanism – stimulates glycogen breakdown in the liver and muscle, increasing glucose levels  Contraindications  Absolute - sensitivity  Relavtive – starvation, fasting, adrenal insufficiency  Uses – hypoglycemia, beta-blocker overdose, calcium channel overdose, anaphylaxis (for folks on beta-blockers)  Dosage – hypoglycemia – 1mg IV/IM Q20 min; beta-antagonist OD – 3-5mg IV; anaphylaxis 1-2mg IV  Kids - 20mg – 1mg IV/IM  Side effects – Nausea, vomiting, diaphoresis, hypotension, rash

25. Meter is broken…  Get as much history as possible.  Smell for ketones (only half of us can)  Are there empty insulin bottles on scene? Recent exercise or illness?  Err on the side of treating for hypoglycemia

26. DKA  No insulin activity = high blood sugar levels  Can’t make glycogen, fatty acids and cannot move glucose into cells  Cells starve  Fatty Acid breakdown  Ketosis  High blood sugar  sugar in urine  peeing a lot  dehydration  acidosis  Diabetic Ketoacidosis!  Fruity odor to breath  Increased respiratory rate  Abdominal pain  Nausea/Vomiting  Tachycardia / hypotension

27. Hyperglycemia  Low Insulin activity = high blood sugars  Still able to get some glucose in cells = no starvation = no ketosis  Acidosis also less likely  No fruity odor  Generalized weakness  Less nausea/vomiting  Death very rare

28. Hyperglycemia  Treatment  ABC’s  IV fluids!  Adults – 500ml – 1 liter WO  Children – 20ml/kg fluid boluses  May repeat if needed for hypotension or tachycardia

29. What about Insulin Pumps  If hypoglycemia – have patient turn off pump after you wake them up with D50  If hyperglycemia – don’t touch it  May not be working  Patient may be able to do a bolus on their own based on their sliding scale  If infected, leave in place, but do not use.

30. Alcoholic Ketoacidosis  Chronic Alcoholics are malnourished  Few glycogen stores  After a binge, their glucose levels can drop, stimulating fatty acid breakdown  Treatment is glucose with Thiamine  Don’t withhold glucose if level is abnormal!

31. You wanna refuse?  While people have a right to make their own decisions, it must be an INFORMED decision  They must:  Be alert, oriented to person, place, time, and situation  Know of the risk for relapse  Have recovered within 10 minutes. FSBS >80  They should  Have test strips available or have someone there to call back if they get hypoglycemic again.  Have adequate follow-up.

32. Questions  A diabetic’s family calls 911 for sudden onset of left sided weakness that started 10 minutes prior to arrival. After ABCs, what is your next step?

33. Questions  A Diabetic teen-ager decides to say “f&^% you” to his diet, and eats an ice cream sundae. A day later, he calls 911 for vomiting and abdominal pain. His Glucose on fingerstick reads “Hi” What should you give?

34. Questions  You come across a “local regular” beside the bar. He smells of alcohol, and is lethargic. He looks like he hasn’t been eating regularly for quite some time. You consider _____ as a possible diagnosis, and _________