Overview of CBT 450 Diabetic
Emergencies
Complete Course Available at:
www.emsonline.net
Copyright 2006 Seattle/King County EMS
Introduction
Diabetes
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affects 20 million people in US alone (7% of the population)
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considered an epidemic by the Centers for Diseases Control and
Prevention (CDC)
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cause of diabetes continues to be a mystery
© 2006 Seattle/King County EMS
Practical Skills
To receive CBT or OTEP credit, you must perform the following practical
skills:
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indicate the need for ALS and/or immediate transport (SICK)
perform blood glucometry and record findings
provide oral glucose (if indicated)
perform proper "after-care" instructions
Practical Skills Checklist available at EMS Online.
EMS Online
© 2006 Seattle/King County EMS
Terms
diabetic coma — An unconscious state caused by high blood glucose.
Dehydration and acidosis are associated symptoms.
diabetes — A metabolic disorder in which the ability to metabolize
carbohydrates is impaired, usually because of a lack of insulin or
interference with the effects of insulin.
diabetic ketoacidosis — A condition resulting from diabetes
characterized by hyperglycemia and acidosis.
glucose — one of the basic sugars; it is the primary fuel, along with
oxygen, for cellular metabolism.
hyperglycemia — Excess concentration of glucose in the blood.
hypoglycemia — Deficient level of glucose in the blood.
© 2006 Seattle/King County EMS
Terms
insulin — A hormone produced by the pancreas that enables sugar in the
blood to enter the cells of the body; it is used in synthetic form to treat
and control diabetes.
ketoacidosis — A condition resulting from metabolism of fatty acids.
kussmaul respirations — Deep, rapid breathing; usually the result of an
accumulation of certain acids when insulin is not available in the body.
type 1 diabetes — A type of diabetes that usually starts in childhood and
requires insulin injections for treatment. Previously referred to as "juvenile
diabetes."
type 2 diabetes — A type of diabetes that usually starts in later life and
often can be controlled through diet and oral medications. Previously
referred to as "adult onset diabetes."
© 2006 Seattle/King County EMS
Glucose
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body's cells need it to function properly
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body’s major source of energy
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without it, brain cells rapidly suffer permanent damage
Food is digested by the body into three main nutrients:
1. fats
2. carbohydrates
3. proteins
Glucose is a simple carbohydrate and
the first to be absorbed into the blood.
© 2006 Seattle/King County EMS
Insulin
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helps glucose enter cells and produce energy
glucose (sugar)
insulin
cell
energy
In a healthy person, rising blood glucose levels stimulate the
pancreas to secrete insulin. Insulin acts like a funnel that directs
glucose into the cells.
© 2006 Seattle/King County EMS
Type 1
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body does not produce insulin
Left undiagnosed or untreated, lack of insulin causes hyperglycemia and
the Three P's:
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polydipsia (constant thirst)
polyuria (excessive urination)
polyphagia (ravenous appetite)
© 2006 Seattle/King County EMS
Type 2
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body does not produce enough insulin or cells ignore what is produced
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most common form of diabetes (nearly 90% of all cases)
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can be controlled by diet and exercise, oral medication or insulin
© 2006 Seattle/King County EMS
Gestational Diabetes
Form of diabetes that can occur during the 24th-28th weeks of pregnancy.
In some cases:
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blood glucose level returns to normal after delivery
symptoms are usually mild and not life-threatening
increased glucose levels are associated with larger birth weight,
increased rate of prenatal complications, including birth trauma,
hypoglycemia and jaundice
Risk factors include:
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maternal age of more than 25
family history of diabetes
obesity
previous birth of an 9 pound or larger baby
unexplained death of a previous infant or newborn
© 2006 Seattle/King County EMS
Hypoglycemia
Hypoglycemia occurs as a result of:
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too much insulin--accidental or intentional
low food intake
too much exercise
Hypoglycemia is a true life-threatening emergency.
Without sugar to the brain, unconsciousness may occur
and permanent brain damage can quickly follow.
© 2006 Seattle/King County EMS
Hypoglycemia, continued
Signs and symptoms of hypoglycemia develops quickly over a period of
minutes and may include:
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cold, pale, clammy skin
abnormal or hostile, bizarre behavior; patient may appear
intoxicated
shaking, trembling, weakness
full, rapid pulse
normal or elevated blood pressure
normal or rapid respirations
dizziness, headache, blurred vision
extreme hunger
slurred speech
seizures, loss of consciousness
Most of the diabetics in crisis present with hypoglycemia.
© 2006 Seattle/King County EMS
Hyperglycemia
The initial presentation of undiagnosed diabetes is hyperglycemia.
Hyperglycemia is a chemical imbalance:
• cells use other foods for energy
• ketones are produced and blood becomes concentrated
• kidneys respond by excreting glucose and ketones
Hyperglycemia occurs most often when:
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a person is an undiagnosed diabetic (initial presentation)
a diagnosed diabetic becomes ill (flu, vomiting)
a diagnosed diabetic takes too little insulin
© 2006 Seattle/King County EMS
Hyperglycemia, continued
Signs and symptoms of hyperglycemia can develop slowly over a period
of days and may include:
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nausea, vomiting, or abdominal pain
weak, rapid pulse (possibly irregular)
warm dry skin
normal to profoundly decreased blood pressure
altered LOC
fruity odor on breath
kussmaul respirations
© 2006 Seattle/King County EMS
DKA
diabetic ketoacidosis
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the natural progression of profound hyperglycemia
body is burning fat instead of sugar
a serious condition that can lead to diabetic coma, or death
more common in people with type 1 diabetes
Ketoacidosis usually develops slowly. However, if vomiting occurs, this lifethreatening condition can develop in a few hours.
Signs and symptoms of DKA include:
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frequent urination, dehydration and extreme thirst (the 3 P's)
high blood glucose levels
high levels of ketones in the urine
fruity breath from blowing out ketones
© 2006 Seattle/King County EMS
Patient Care
Initial Assessment
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guides the initial path of treatment
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quickly assess a patient
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make a decision
SICK or NOT SICK
A SICK patient is one who can die quickly unless you initiate aggressive
BLS and ALS treatment and rapid transport.
A NOT SICK patient is one who can be ill or injured, but not severely
enough to be life threatening.
© 2006 Seattle/King County EMS
Patient Care, continued
Key clinical indicators
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nature of illness
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glucose value
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mental status (LOC)
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respirations (rate and character)
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pulse (rate and character)
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skin signs and color
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body position
SICK or NOT SICK
The SICK/NOT SICK choice is a very important medical decision.
© 2006 Seattle/King County EMS
Patient Care, continued
Glucometry
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most effective way to determine the level of a diabetic emergency
Good questions to ask:
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When did you eat last?
Have you tested your blood glucose today?
Have you taken your insulin or medication today?
Has there been a change in your health, stress level, or exercise?
When did the symptoms begin?
A low reading of 50 mg/dl for example, may indicate hypoglycemia—
a high reading of 400 mg/dl may indicate hyperglycemia.
© 2006 Seattle/King County EMS
LOC
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common symptom of a diabetic emergency
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untreated hypoglycemia will result in loss of consciousness
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can quickly cause significant brain damage or death
An altered LOC is also a possibility for someone who may be having
a stroke, is drunk or has a head injury. From the moment of
dispatch, keep an open mind about the potential causes of a chief
compliant.
© 2006 Seattle/King County EMS
Airway
Unconscious patients
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are at risk of losing their gag reflex as indicated by the inability to
swallow
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cannot reject foreign materials like vomit
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tongue can relax and block the airway
Airway management includes:
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Appropriate positioning
Maintaining the airway
Have suction device ready
High flow oxygen with appropriate device
Assisting ventilations as needed
© 2006 Seattle/King County EMS
Treatment
The key principles of treatment for a diabetic episode include:
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take necessary BSI precautions
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request medics if indicated—determine SICK or NOT SICK
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perform glucose check
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position upright and give oral glucose (if gag reflex is present as
indicated by the ability to swallow)
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monitor vital signs and LOC
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document times and levels of glucose checks
SICK or NOT SICK
© 2006 Seattle/King County EMS
Summary
Diabetes is a disease that refers to a body's inability to produce
insulin, or use insulin effectively.
Diabetics must balance their medications, food intake, and activity
level. Diabetic emergencies can occur when any of these elements are
out of balance.
Type 1 diabetics do not produce insulin, and type 2 diabetics produce
inadequate amounts, or don't effectively use what they do produce.
© 2006 Seattle/King County EMS
Summary
Glucometry is the best way to determine whether a patient is
hypoglycemic or hyperglycemic. The speed of onset, skin signs, and quality
of respirations are other clinical indicators.
The signs and symptoms of a diabetic emergency include an altered level
of consciousness.
Maintain a high index of suspicion for patients who appear intoxicated,
or show signs of a head injury.
Treatment includes maintaining the airway, providing oral glucose,
and seeking advanced medical treatment.
© 2006 Seattle/King County EMS
Questions
What questions do you have about diabetic emergencies?
Dr. Mickey Eisenberg
Medical Director
EMS Online
Guidelines and Standing Orders
Mike Helbock
Training Division Manager
Three options:
1.
2.
3.
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Ask the Doc: http://www.emsonline.net/doc.asp
Check Guidelines/Standing orders at EMS Online:
http://www.emsonline.net/downloads.asp
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