Management of the Acute Diabetic
Developed by:
Institute for Emergency
Medical Education
3/11/2016
Purpose:
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To enhance the EMT's understanding of the
normal physiology as it applies to transportation
and utilization of glucose, and how it fits into the
Krebs' Cycle
Improve the EMT's understanding of the
pathophysiology of Diabetes and how to
appropriately mange an acute Diabetic state
To enhance the EMT’s understanding of
electronic glucose monitoring
3/11/2016
Learning Objectives:
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Student will have a basic understanding of
the normal functioning transport system
for glucose and how it is utilized by the
body and will have a working knowledge
of the Pancreas and the Krebs' Cycle.
Students will understand the
Pathophysiology of the Diabetic disease
process
3/11/2016
Learning Objectives:
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Students will be able to identify the Acute
Hyperglycemic (DKA) patient and
appropriately treat him/her to the EMT's
level of training, utilizing both clinical
judgment and blood glucose testing
devices
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Learning Objectives:
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Students will be able to identify the Acute
Hypoglycemic patient and treat
appropriately to the level of the EMT's
training, utilizing both clinical judgment
and blood glucose testing devices.
The Basic EMT will know how to operate
an electronic glucose monitor
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Overview
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A & P as it pertains to Diabetes and
Glucose metabolism
Pathophysiology of Diabetes as it relates to
Hyperglycemia and Hypoglycemia
Assessment and management of Diabetic
Emergencies
Glucose measurement
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Anatomy and Physiology:
Diabetes
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Pancreas
– Located in the
abdomen attached
to the intestines but
behind the stomach
– Responsible for the
Production of the
hormone Insulin
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Hormone: Insulin
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Secretion by the Pancreas from the Beta Cells on
the Islets of Langerhan
It is required by for the intracellular metabolism
of glucose
Its release is primarily stimulated by glucose
levels
Other stimulus for the its release include
– Amino Acids
– Fatty Acids
– Ketones
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How is Insulin used in Liver
cells?
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Glucose enters Liver cells
Insulin is needed to activate the hormone
Glucokinase
– Glucokinase Promotes phosphorylation of
glucose
– First step in glucose metabolism
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Activates the hormone Glycogen
Synthetase
– Necessary for glycogen formation
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What is Glycogen?
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It is stored sugar
We use it as a reserve energy supply
We only store sugar when insulin is
present
– Insulin doesn’t do the work Glycogen
Synthetase does
– But insulin must start the process off
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How does Insulin used in Muscle
cells?
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Resting muscle
– Insulin is needed to transport glucose across
the cell membrane
– Insulin increases glycogen synthetase
– Insulin inactivates the enzyme Phosphurylase
– Insulin's presence facilitates Amino acid
uptake and protein synthesis while
preventing protein catabolism
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How does Insulin used in Muscle
cells?
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Active muscle
– Glucose can enter without insulin
– Glucose is oxidized to CO2 and H2O for
energy production
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How does Insulin used in
Adipose tissue?
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Insulin is necessary for transport of
glucose across cellular membrane
Promotion of glucose metabolism, fatty
acid synthesis
Insulin will combine with fatty acids
produced in the liver and in fat cells to
form Triglycerides
Insulin presence decreases Lipolysis
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Lets watch a Movie…..
KREB Cycle Video
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General Pathophysiology of
Diabetes Mellitus
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This condition is caused by either
– Absolute or relative lack of Insulin
– Or ineffective utilization of Insulin
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In Insulin Dependent
– Absolute lack of Insulin
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In Noninsulin Dependent
– Normal or near normal levels of Insulin
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When Insulin levels are normal
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It is usually ineffective utilization of
Insulin
– Caused by a decrease number of Insulin
Receptor Cells
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Or Impaired Binding of Insulin to body
cell
– Caused by a receptor defect
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Problems associated with
alterations in metabolism
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The are seen when there is a lack,
deficiency or under utilization of Insulin
These problems are
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Hyperglycemia
Hypoglycemia
Diabetic Ketoacidosis
Nonketonic Hyperosmolar Coma
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Hyperglycemia
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Caused by several factors
Over production of glucose due to an increase
in
– Glucogenesis
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The formation of glycogen from noncarbohydrate sources
such as Amino Acids or Fatty Acid
– Glycogenolysis
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Hydrolysis of glycogen into glucose
– And a decrease in peripheral utilization of glucose
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Hyperglycemia
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Caused by Protein Catabolism and loss of
Amino Acids from muscle.
Caused by impaired Triglycerides
Synthesis
– Which increases the release of Free Fatty
Acids from Adipose Tissue which increases
Beta Oxidation of Fats
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Diabetic Ketoacidosis (DKA)
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Most frequently seen in IDDM (Insulin
Dependent Diabetes Mellitus)
Caused by Acute Insulin Insufficiency and is
usually precipitated in the known Diabetic by
stressors that increase Insulin needs
When there is insufficient Insulin for appropriate
metabolism of glucose, fats, proteins
This causes inappropriate utilization of glucose,
resulting in Hyperglycemia
3/11/2016
What does this mean to us?
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Hyperglycemia increases dehydration and
Lactic Acid build up
Hyperglycemia causes Acidosis
Acidosis results in hypoxia and coma
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Who will we see like this?
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New onset (undiagnosed) Diabetics
– Particularly young kids between 7 and 13
years old
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Noncomplient IDDM patients
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Frequent precipitating factors:
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Infection (serious
local or systemic)
Urinary infections
Respiratory
infections
Major Surgery
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Trauma
Major illness
Therapy with
Steroids
Emotional upset or
excessive stress
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Signs and Symptoms of
DKA/Hyperglycemia
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Are usually associated with acidosis and
the bodies compensatory mechanisms
Of Gradual onset
– Usually greater than 48 hours
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Signs and Symptoms of
DKA/Hyperglycemia by Body Systems
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Respiratory system
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– Body's trying to remove
acid by elimination of
Ketones which causes
– Acetone Breath (fruity)
– Kussmaul's Respiration’s
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– Nausea and Vomiting
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Caused by acidosis
– Polyuria
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Central Nervous System
– Change in mental status
– Caused by Dehydration
Acidosis & lack of glucose
GI & GU Systems
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attempting to remove
ketones
Which causes
dehydration
Circulatory System
– Hypotension
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Other Signs and Symptoms of
DKA/Hyperglycemia
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Loss of skin turgor/dry mucosa
– Dehydration
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Polydipsia
– Dehydration
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Polyphasia
Warm/dry skin
Tachycardia to Normal pulse
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Hypoglycemia
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Major complication for patients treated
with Insulin and Oral Hypoglycemic
agents
Usually caused by too little food or too
much Insulin/Oral Hypoglycemic agents
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Hypoglycemia
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Alterations in mental status and bizarre
behavior are caused by Brain cells being
starved for food
The longer the duration of decrease, or no
glucose, reaching Brain cells, the greater
the chance of/or increasing the amount of
damage sustained
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Signs and Symptoms of
Hypoglycemia
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Quick onset of
symptoms
Headache/blurred
vision
Diaphoresis/Pallor
Tachycardia with
weak
pulse/Palpitations
Numbness of lips and
tongue
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Alteration in mental
status or Coma
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Emotional changes
Confusion
Irritability/Nervous
Bizarre behavior
Weakness/Fatigue
Seizures/Trembling
Incoherent speech
Hunger
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Diabetic Assessment &
Management
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Assessment
– Scene Size Up
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Scene Safety
Body Substance
Isolation
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Interventions
– Scene Size Up
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Make scene safe
Retreat from scene
Take appropriate BSI
precautions
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Diabetic Assessment &
Management
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Assessment
– Initial Assessment
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Nature of Illness
General Impression
AVPU
Airway
Breathing
Circulation
Baseline Vital Signs
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Interventions
– Initial Assessment
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Open Airway
Suction
Insert Adjunct
Intubation if
necessary
Apply High Flow
Oxygen or Ventilate
Transportation
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Diabetic Assessment &
Management
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Assessment
– Rapid/Focused
History & Physical
Exam (BLS & ALS)
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History of Diabetes
Hx of present illness
Onset
Duration
Last Dextrose Stick
by patient
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Interventions
– Rapid/Focused
History & Physical
Exam (BLS & ALS)
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Oral Glucose
– If able to protect
own airway
– May use household
items
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Close monitor of
airway with suction
available
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Diabetic Assessment &
Management
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Assessment
– Rapid/Focused History
& Physical Exam (ALS
Only)
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Obtain current Dextrose
level
Obtain Pre I.V. Blood
Tubes
Cardiac Monitor
Repeat Dextrose 3-5
minutes Post D50W
administration
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Interventions
– Rapid/Focused History &
Physical Exam (ALS Only)
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Initiate IV access 0.9%
Sodium Chloride
Administer Dextrose 50% in
Water if D-Stick is below
100mg/dl
Administer Thiamine 100mg
IV or IM
Administer Glucagon IM if
no IV access
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Note for ALS Providers
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Consult with Medical control for additional
Amp(s) of D50W
The Need for additional dosages of D50W is rare
but should be guided by repeated dextrose
analysis
Post D50W administration
– you can expect a Glycogen Stores release
– This may occur approximately an hour after the
D50W which will raise the blood glucose again, but
only if there are any glycogen stores left
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Diabetic Assessment &
Management
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Assessment
– Detailed Exam
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Take a full SAMPE
history
Look for secondary
problems
– On Going Exam
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Reassess interventions
Revisit Initial &
Focused Assessment
Reassess Vital Signs
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Interventions
– Detailed Exam
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Based upon specific
Findings
– On Going Exam
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Additional or new
Therapies may be
employed
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Electronic Glucose Monitors
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Normal values
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– 60 - 150 mg/dl
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Abnormally low
– Below 60 mg/dl
– Less than 20 is very
dangerous
Abnormally high
– Above 200 mg/dl
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Extremely High
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Above 700 mg/dl
REMEMBER: IT is all Relative to the persons Normal Range
Your patient can show signs of Hypoglycemia with a blood sugar
Of 100mg/dl
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Long Term Complications of
Diabetes
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Vascular changes
– Decreased peripheral circulation (Caused by
atherosclerosis & arteriosclerosis)
– Thickening of capillary walls
– Increase infection potential and severity,
particularly in lower extremities Secondary to
decreased circulation
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Long Term Complications of
Diabetes
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Nervous System damage
– Peripheral
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Degeneration causing tremors
Decreased sensory functions
– Spinal
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Slowed conduction through spinal tracts
– CNS
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Degeneration of brain tissues causing memory
disturbances
Loss of/decrease in fine motor control
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Long Term Complications of
Diabetes
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Cardiovascular
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Coronary Artery Disease
CVA/TIA
MI
Angina
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Long Term Complications of
Diabetes
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Renal
– Changes in structures and function
– Lesions
– Causing
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Hypertension
Edema
Nephrotic Syndrome
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Long Term Complications of
Diabetes
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Vision changes
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Blindness
Cataracts
Caused by prolonged periods Hyperglycemia
Retinopathy
Lesions/Aneurysms on retinal vessels
3/11/2016
Summary
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Diabetes is a disease that effects the bodies
ability to properly use glucose for metabolism
The conditions of Diabetes we see are caused
by the body compensatory mechanism when the
disease is unchecked
Management of a Diabetic in an acute setting is
to stabilize the ABCs and provide sugar
Long term management is designed to prevent
peaks and valleys in blood sugar which are the
causes of long term diabetic problems
3/11/2016