DIABETIC EMERGENCIES STUDY GUIDE

WHAT HAPPENS WHEN THE BODY REGULATES ITS OWN BLOOD SUGAR LEVELS NORMALLY?

Glucose is used in the human body for energy to perform all essential functions for a neuron all the way to a cellular level. Normally, the pancreas is the major organ responsible for regulating blood sugar levels in the body. When somebody eats a meal, glucose is transported in the blood stream which signals the pancreas to releases insulin, helping glucose move into the cells to be used as energy. If blood sugar levels become too high, the body will signal the pancreas to release insulin and the liver to convert glucose to glycogen. If blood sugars are too low, signals will be sent to the pancreas to stop releasing insulin, and secrete glucagon which is produced by alpha cells. The liver stops converting glucose to glycogen due to the release of glucagon from the pancreas. These are all counter regulations to maintain blood sugar levels. Not everyone has the ability to regulate blood sugar levels normally. These will be discussed in detail later on.

HYPOGLYCEMIA EXPLAINED (LOW BLOOD SUGAR)

TYPE 1 DIABETES

Hypoglycemia is experienced in people with both type one and type two diabetes. People with type one diabetes do not produce insulin. Hypoglycemia experienced by people with type one diabetes is usually a result of elevated exogenous (def. taken in from outside) insulin from inaccurate dosing, intentional overdose, or a mismatch between carbohydrate intake and insulin dosing.

TYPE 2 DIABETES

People with type two diabetes are able to make insulin, but their body either does not secrete enough to lower blood sugar levels, or their body is resistant to it. Medications given to people with type 2 diabetes either stimulate the body to secrete insulin or improve insulin action. These medications can cause hypoglycemia. An adult patient with a blood glucose level below 60 mg/dl is considered to be hypoglycemic. The signs and symptoms of a patient experiencing hypoglycemia are; hunger, agitation or unusual combative behavior, altered mentation, nausea, weakness, confusion, tachycardia, cool/clammy skin, and seizures. As you can see, the symptoms mainly reflect neurologic changes. The reason for this is; most of the body’s cells can withstand low blood sugar levels for some time. The brain is the most sensitive to the decrease in glucose levels which is why neurologic deficiencies are noted in the signs and symptoms. The brain needs three things to make it happy, oxygen, glucose, and a pump to transport those items.

TREATING HYPOGLYCEMIA

Treatment for patients experiencing a hypoglycemic emergency is dependent on their mental status. The first and least invasive treatment is to have the patient ingest glucose. This can be done by having them ingest oral glucose paste, or tablets depending on what your agency uses. This treatment is dependent on the patient’s ability to swallow and maintain their own airway. Placing anything in the mouth of an altered patient carries a high risk of aspiration. Always follow your local protocols but EMS providers should highly consider NEVER placing glucose tabs or paste in an unconscious person’s mouth. If the patient is unconscious or cannot maintain their airway, the best treatment is IV dextrose. It is important to have a patent IV because D50% is hypertonic and will cause tissue necrosis if extravasation occurs. If IV access is inaccessible, and oral glucose is not an option, IM glucagon is the last option. Glucagon initiates the breakdown of glycogen from stores in the liver. Chronic alcoholics, younger patient populations, illness, recent trauma or a history of seizures could cause the patient to not have adequate glycogen liver stores.

HYPERGLYCEMIA EXPLAINED (HIGH BLOOD SUGAR)

Hyperglycemia at its lower level is represented by blood glucose levels of approximately 250 mg/dl or higher. At this level it represents no immediate life threats, but over time can cause strain on the cardiovascular system, kidneys, and other organs. Simple hyperglycemia may present with mild symptoms such as; blurred vision, polyuria, polydipsia, polyphagia, orthostatic syncope, frequent infections, and skin ulcerations. Treatment for this is mainly supportive.

DIABETIC KETOACIDOSIS

If blood sugar levels rise above 350 mg/dl, this results in a condition known as diabetic ketoacidosis. This is a life threatening emergency that is caused by either a complete lack of or too little insulin. This frequently occurs in newly diagnosed type one diabetic patient who has a stressful event in which glycogen is released but insulin intake is not adjusted accordingly. This results in elevated blood sugar levels, excessive break down of energy stores, which causes increased accumulation of acids in the body that cause dehydration. The signs and symptoms are; fruity odor to breath, dry mucous membranes, orthostatic hypotension, supine hypotension, fatigue, increased thirst, increased urination, increased hunger, tachycardia, abdominal pain, vomiting from the acidosis, altered mental status. You may notice Kussmaul’s respirations due to the body’s attempt to relieve excess CO2 from the acidosis. Patients with type 2 diabetes rarely experience DKA. This is because insulin is still secreted from the pancreas and is enough to prevent uncontrolled breakdown of glycogen.

TREATING HYPERGLYCEMIA

Treatment for DKA is fluids and insulin. Patients will most likely be very dehydrated. Unless the patient is hypotensive, fluid replacement should be gradual to prevent complications secondary to overaggressive treatment. 1 to 1.5 L of normal saline is usually given within the first hour. Monitor patient closely to prevent pulmonary edema and transport to the hospital. Usually fluids replacement is efficient treatment in the prehospital setting. Once patient arrives at the ER, insulin can be administered either through a drip or IM injections.

HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC COMA (HHNC)

HHNC is the result of elevated glucose levels in patents with type two diabetes. This results when blood glucose levels reach in access of 600 mg/dl. They signs and symptoms are similar to DKA except onset of symptoms are more insidious compared to DKA. Treatment revolves around ABCs, oxygen, ventilatory support and fluid resuscitation.

PRESCRIPTION MEDICATIONS

For patients with type one diabetes, there are many prescription drugs that may be encountered in the field. These are both long and short acting drugs. Short acting drugs that may be encountered are; Lispro (Humalog), Aspart (Novolog), and Glulisine (apidra). Long acting insulins that may be encountered are; Glargine (Lantus) and Detemir (Levemir). For type two diabetes some prescriptions that may be encountered by patients are; Metformin, Actos, Glucophage, and Glipizide.

Need some humor in your day? Check out the “Frequent Flyers” cartoon by Lenwood Brown III. He does excellent cartoons that hit home what we as EMS providers deal with everyday. You can view his work on diabetic calls HERE, an EMS1 article.

In EMS, routine auscultation of heart tones is largely ignored. Often times this is due to a lack of education on what to listen for. The goal of this study guide is to equip the EMS provider with the tools necessary to add routine heart tone auscultation to their patient assessment.

Heart tones are often times difficult to hear as they require a very quiet environment to hear through our stethoscopes. Due to the loud noises that are often going on during our treatment of patients, routine auscultation of heart tones can be very difficult. The time to auscultate heart tones is usually on scene where road noise and/or lights & sirens are not likely to be heard.

When a heart valve opens and closes, it gives off vibrations that are picked up by our stethoscopes during auscultation. These vibrations occur as the blood flow inside the hearts chambers, rapidly accelerates or slows through the valve as it opens or closes. The ability to auscultate these sounds can vary patient to patient. If you have a morbidly obese patient with excess tissue on their chest wall, auscultation will obviously be more challenging. If you are auscultating heart tones on a frail elderly patient, the sounds will be heard much more clearly.

What is a normal heart tone?

• S1 and S2 are the names given to normal heart tones.
• S1: This heart tone is described as a “lubb” sound. The sound itself is low-pitched and dull. This sound is auscultated during the contraction of the ventricles, which is also when the tricuspid and mitral valves are closing.
• S2: This heart tone is described as a “dupp” sound. The sound itself is high-pitched and shorter in length that S1. S2 is also louder than S1. S2 can be auscultated when the ventricles have relaxed, which is also when the pulmonic and aortic valves are closing.

What is an abnormal heart tone?

• S3 is the name given to abnormal heart tones. Often called a “Gallop,” the S3 sound can be heard in healthy children and adolescents. In adults however, it is a negative sign that is often associated with heart failure. The S3 sound is called a gallop because it comes at the end of the S1-S2 sequence and sounds like a horse galloping. S3 occurs because of the vibrations created from rapid ventricular filling on the walls of the ventricles.

How to Auscultate the 4 Heart Valves

• Mitral Valve

• Pulmonary Valve

• Aortic Valve

• Tricuspid Valve

Feel free to check out our video on Heart Tones on our YouTube page.

THE START TRIAGE METHOD

S.T.A.R.T. = SIMPLE TRIAGE AND RAPID TREATMENT

• Developed by Hoag Memorial Hospital in Newport Beach, California.
• This type of triage has quickly become one of the most popular forms.

RPM = RESPIRATIONS, PULSE AND MENTATION

This is the way EMS professionals are taught to rapidly assess patient’s airway, respiration, pulse and mental status while at the scene of a MCI, or multiple casualty incident. After the assessment has been completed, the patient is placed in one of the following four categories:

• Immediate: RED
• Delayed: Yellow
• Minor: Green
• Dead/Dying: Black

It is estimated that when working in pairs of two, EMS professionals can effectively triage 1 patient in 30 seconds. One thing that tends to get EMS professionals in trouble at the scene of MCI’s, is they get sucked into treatment. With the START triage method, EMS professionals are very limited to the type of treatment they can provide. The treatment they can provide includes:

• Open an airway via the H-T/C-L method
• Insertion of an OPA
• Application of direct pressure to stop bleeding

WHAT CONSTITUTES A “IMMEDIATE” PATIENT CLASSIFICATION?

A patient who is critically injured and must be transported as soon as resources allow.

• Respirations: greater than 30 per minute
• Perfusion: No radial pulse or a capillary refill time >2 seconds
• Mental Status: Unable to follow simple commands

WHAT CONSTITUTES A “DELAYED” PATIENT CLASSIFICATION?

A severely injured patient who needs evaluation and treatment but may not require immediate transport

• Any patient who cannot walk, but has respiratory drive, and are within normal limits with RPM

WHAT CONSTITUTES A “MINOR” PATIENT CLASSIFICATION?

Patients requiring minor treatment or prophylactic evaluation

• Any ambulatory patient.
• It is important to remember that this can be an initial classification and could be changed later on.

WHAT CONSTITUTES A “DECEASED” PATIENT CLASSIFICATION?

• Any patient who does not have respiratory effort after attempting to open the airway
• Any patient who will die before appropriate treatment is available

REMEMBER THIS SIMPLE SAYING…

• 30 : 2 : CAN DO

• Are the respirations greater or less than 30/minute?
• Is the cap refill time greater or less than 2 seconds?
• Can the patient follow simple command?
• Asking yourself these questions during each rapid assessment of patients at an MCI will help assure they’re initially placed in the correct area.

SEPSIS & SEPTIC SHOCK STUDY GUIDE

When EMS providers are called to treat someone experiencing signs and symptoms of sepsis, the disease process is already well on its way to negatively affecting the individual. More and more studies are showing that sepsis requires rapid identification and intervention to ensure positive outcomes with our patients. Knowing this, we should be asking ourselves, what can I do to better my abilities to recognize sepsis and how can I treat it quickly?

Septic shock, is a type of shock that begins with an infection in the bloodstream. This infection eventually overloads the compensatory mechanisms in the body and when left untreated, leads to shock, and eventually MODS, or multiple organ dysfunction syndrome. Much like the ways in which ischemia can cause a cascade of issues in the cardiac patient, the signs and symptoms of septic shock are progressive.

HOW DOES A PATIENT’S BLOOD PRESSURE DROP BECAUSE OF A BAD INFECTION?

• In the early stages of the infection, the patient may look and act normally. They may not even be aware something is wrong. By the late stages, these patients can drop their blood pressures dramatically. The toxins that have been released into the system increase the permeability of the blood vessels. When this happens the patient’s fluid levels drop out of the vasculature in rapid succession. This loss of fluid, causes their pressure to subsequently drop.

These patients will present with a wide array of symptoms based on the stage of septicemia they’re experiencing. To give an example, their skin could be flushed and hot in the early stages, as their body tries to kill off the infection, or it could be cold and cyanotic towards the later stages. The organ system that is the most susceptible to these types of infections are the lungs and respiratory systems. It is very common for these patients to present with shortness of breath, abnormal lung sounds, and/or mild to moderate hypoxia.

When sepsis is suspected, you should let the nurses at the receiving facility know as soon as possible. We as EMS providers have the opportunity to set the tone on our arrival at the ED. Cueing the receiving facility into our suspicions can be the trigger they use to order certain tests to either confirm or deny what everyone is suspecting.

Treatment in the field will depend on your local protocols. Nationally, high-flow oxygen, large-bore IV’s, and Dopamine to maintain a healthy blood pressure can help. Some departments are taking things one step further, they’re creating “sepsis alert” protocols to notify the receiving facilities of their patient’s potential septic conditions. To do this, crews are using sepsis meters that measure the lactic acid in the patient’s blood stream. When your body is fighting a nasty infection, the immune system kicks into action. With sepsis, the immune system overreacts and ends up fighting itself. This releases a lot of lactate. Serial measurements of the lactate levels can help providers notify hospitals of their patient’s status, and ultimately get them definitive treatment quicker.