Diabetes Mellitus (DM)
(GA)
is a disease that frequently causes changes in the patients mental status resulting from alterations in the blood glucose level
mental status may range from disoreientation to complete unresponsiveness
what can significant deterioration in the mental status of an acute diabetics lead too?
can lead to serious airway and breathing compromise, brain cell damage and death may occur if the blood glucose reaches a very low level.
Acute diabetic emergencies include:
hypoglycemia, blood glucose too low
diabetic ketoacidosis or hyperglycemia hyperosmolar non kinetic syndrome, in which the blood glucose is excessively high
many times what is a persons first indication of having diabetes ?
change in mental status, such as confusion, disorientation, or even loss of consciousness..
long term complications of diabetes mellitus may include:
vascular disease leading to stroke, heart attack, and peripheral vascular disease, kidney disease, nerve dysfunction and retinal nerve disease leading to blindness.
What are the three major food sources for the bodys cells?
carbohydrates, fats and proteins
carbohydrates are the primary source of energy source for the cells.
What are the three major sources of carbohydrates ?
sucrose (table sugar)
lactose (milk and dairy products)
starches (potatoes, bread)
^^^^
These sugars are called complex sugars because of their structure .
what happens to complex sugars ?
complex sugars are broken down into simple sugars to be absorbed through the digestive tract and into the bloodstream. these sugars are glucose, galactose and fructose.
after carbohydrate digestion how much of the simple sugar is in the form of glucose?
80%
close to 95% of the simple sugar entering the body to be used by the cells in the form of glucose.
glucose is the most important sugar in the body this is why the sugar level is referred to as the blood glucose level.
what is the difference between the brain cells and the rest of the body cells.
brain cells are only able to function with glucose as opposed to the body cells that can break down fats and proteins.
the brain also cannot store glucose, when deprived of glucose the brain will dysfunction shut down and eventually begin to die.
what happens when cells use other energy sources such as fats ?
they produce harmful by-products that eventually affect the cell function adversly
what is the most common sign of brain cell dysfunction?
an altered mental status, as glucose becomes more depleted the mental status deteriorates further.
What is one reason why glucose administration in a head injury or stroke patient is dangerous and proven to be detrimental?
if a large amount of glucose moves across a membrane a large amount of water will follow it.
by giving glucose the brain allows more glucose to cross cells and glucose brings water with it
this causes brain cells to swell, leading to more edema which wors
what is a common complication in diabetic patients?
frequently excess glucose spilled off into the urine and the patient urinates large amounts of glucose, excreting water with it that was not reabsorbed into the body because the glucose molecule drew it into the urine.
The two hormones primarily responsible for controlling levels of blood glucose are:
insulin and glucagon, both which are secreted by the pancreas, insulin and glucagon have opposite effects on the blood glucose level .
Insulin
is secreted when the blood glucose level is elevated
The three main functions of glucose are:
it increases the movement of glucose out of the blood and into the cells
it causes the liver to take glucose out of the blood and convert it into glycogen, the stored form of glucose
it decreases the blood glucose level by actions listed in 1 and 2: facil
How does insulin work?
insulin attaches to the cell at a specific receptor site and causes another channel on the cell membrane to open.
a protein then carries the glucose through the channel, thus the insulin facilitates the movement of glucose into the cell.
if insulin is not available how much slower does glucose move into the cell?
10 times slower
this causes glucose to build up in the blood stream causing the blood glucose level to increase.
what happens to the cells as the blood glucose level is increasing and insulin in low?
the cells begin to starve because they have no fuel or energy source, the cells then begin
an organ that does not need insulin to help move glucose into the cells:
the brain
glucose will cross the blood-brain readily whether insulin is present or not.
a patient with a low blood glucose is :
in a serious condition and requires immediate emergency care.
glucagon
is secreted when the blood glucose level is low and will work to increase the blood glucose level
three major functions of glucagon are:
it converts glycogen stored in the liver back to glucose and releases it into the blood
it converts other non carbohydrate substances into glucose in the liver
it increases and maintains the blood glucose level by the actions listed in 1 &2 converting gly
what is glucagon's major role in the body?
to raise and maintain the blood glucose level.
glucagon begins to convert liver glycogen and other substances into glucose to raise and maintain blood glucose level until the next meal.
at what blood glucose level is glucagon secreted?
70 mg/dl
how does epinephrine help maintain the blood glucose level?
Epinephrine is released by the adrenal glands when the blood glucose level decreases to a dangerously low level
Epinephrine stops the secretion of insulin and promotes the release of stored glucose from the liver as well as the conversion of other substan
the blood glucose level of a person who has fasted for 8-12 hours would normally read
80-90 mg/dl
becasue the patient is not always in a fasting state when you check there blood glucose level what does the wider range consist of?
70-120 mg/dl
within 1 hour of a meal what does the blood glucose increase to?
120-140 mg/dl
when the blood glucose increases, what secretes insulin and increases the movement of glucose into the the cells?
the pancreas
approx how much glucose is taken up by the liver?
two-thirds of the glucose, which is converted to glycogen to be stored by the liver and muscles for use later.
how long does glycogen store in the liver?
24-48 hours after that there is typically no more glycogen left and the blood glucose may drop drastically.
while fats and proteins will begin to be used by the bodys cells at a high rate for energy.
what is blood glucose measured in?
milligrams per deciliter (mg/dl)
what is a normal level of glucose in the blood?
80-120 mg/dL
a reading less than 80 mg/dL may indicate:
a lower than normal level of glucose
in a diabetic patient what would the blood glucose level be after an 8-12 hour fast?
blood glucose reading as high as 120 mg/dl
blood glucose readings as high as what may be normal in a diabetic patient?
blood glucose readings as high as 200 mg/dl may be normal
steps for glucose measurement:
1.) prepare the lancet and lancet device
2.) let the arm hang down at the patients side if possible allowing for better blood flow to the fingers
3.) remove a new test strip from the vial ( glucose meter turns on automatically, the steps may vary)
4.)matc
hypoglycemia
is typically defined as a BGL of 60 ml/dL or less with signs and symptoms of hypoglycemia
or a BGL of less than 50 mg/dL without signs and symptoms of hypoglycemia
The primary sign of hypoglycemia is an altered mental status
more common is type 1 IDDM tha
Hyperglycemia
can be defined as a persistent BGL greater than 120 mg/dL
unlike hypoglycemia which is a lack of glucose in the blood, in hyperglycemic conditions there is a lack of insulin and excessive amounts of glucose in the blood
in hyperglycemic conditions the bra
how is it possible to get an inaccurate reading from a glucose meter?
improper use of glucose meter, expired test strips, or poorly calibrated device
In order to test the blood glucose level with a glucose meter you will need the following supplies ans equipment:
glucose meter
glucose meter test strips
lancet
lancet device (optional)
alcohol swabs
Diabetes Mellitus
MD
is a condition in which there is a disturbance in the matbolism of carbohydrates, fats, and proteins
primary problems:
1.) a lack of insulin being secreted by the pancreas
2.) the inability of the cell receptors to recognize the insulin and allow the gluc
at what number does the BGL have to increase until the kidneys are no longer able to reabsorb the high amount of glucose and to spill out into the urine?
185 mg/dL
once the patient reaches 225 mg/dL a significant amount of glucose will be lost in the urine.
because of the higher than normal loss of body water, diabetes mellitus patients typically complain of:
Three P's
polydispia = frequent thirst
polyuria = frequent urination
polyphagia = hungry because the cells are starving for energy
how many types of diabetes are there?
4 types
the two most likely seen in the prehospital environment are type 1 diabetes and type 2 diabetes
Type 1 diabetes
is also referred to as insulin-dependent diabetes mellitus (IDDM) since these patients require to inject insulin to regulate their blood glucose level.
type 1 patient's pancreas usually does not secrete any insulin
typically younger when diabetes occur
pe
Type 1 diabetics suffer from what type of conditions involving their BGL?
diabetic ketoacidosis (hyperglycemia condition)
hypoglycemia (low blood glucose)
Type 2 diabetes
is also referred to as non-insulin dependent diabetes mellitus (NIDDM) because type 2 patients usually do not have to take insulin
typically middle-ages or older they are typically overweight
they suffer from high blood glucose levels if untreated they ma
what hyperglycemic condition are type 2 diabetes patients prone too?
hyperglycemic hyperosmolar nonkeotic syndrome
what percent of the population suffers from diabetes mellitus?
1-2 percent of the population has a true form of diabetes mellitus
approx 25% suffer from type 1 (IDDM)
approx 75% remaining suffer from type 2 (NIDDM)
more common in Caucasians than non-Caucasians
the patient with diabetes mellitus is more prone to a wide variety of diseases and disorders involving blood vessels including:
heart attack, stroke, and kidney failure - from blockage of the vessels by fat deposits
what is hypoglycemia?
The most DANGEROUS ACUTE COMPLICATION of diabetes mellitus it is estimated that 9-120 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
the patient that takes insulin but his blood glucose may drop for one of the following reasons:
that patient takes his insulin but does not eat a meal
the patient takes his insulin, eats a meal, but drastically increases his activity beyond normal
the patient takes to much insulin_ either takes too much at one time or forgets and takes an extra dose
how can a type 2 diabetic patient suffer from hypoglycemia?
the oral medications they take can cause the blood glucose level to drop too far, resulting in hypoglycemia
because theses oral medications have long lasting effects hypoglycemia can be prolonged or can recur if these patients are not monitored
what will deplete the blood of glucose and cause the brain ells to begin to fail?
either of these imbalances- too much insulin or too much exercise
how long does it take for the onset of the signs and symptoms of hypoglycemia?
from a few minutes to about 20 minutes in most patients who become hypoglycemic
this is due to the rapid decline of brain function and secretion of epinephrine associated with the lack of glucose
signs and symptoms caused by epinephrine release in a hypoglycemic patient:
diaphoresis (sweating)
tremors
weakness
hunger
tachycardia
dizziness
pale cool, clammy skin
warm sensation
signs and symptoms caused by brain cell dysfunction:
confusion
drowsiness
disorientation
unresponsiveness
seizures (may occur in severe cases)
stroke-like symptoms including hemiparesis
hypoglycemic patient may present violent behavior and may be mistaken for behavioral or psychiatric condition, drug use, o
what type of patients should be assessed for hypoglycemia
any patient who presents with an altered mental status, bizzare behavior, violence, or intoxicated appearence, even if alcohol is smelled on breath, must be assessed for possible hypoglycemia
what does alcohol do to the body?
it will inhibit the body's ability to convert other noncarbphydrate sunstances into glucose during hypoglycemia allowing blood glucose level to decrease more rapidly
so a diabetic who has been drinking may as a consequence also be hypoglycemic
overtime what happens to the signs and symptoms of hypoglycemia?
they may begin to change and the patient may not recognize the change and continue to look for the old signs and symptoms
this may cause them to allow their blood glucose levels to drop significantly without any intervention as the signs and symptoms go u
oral glucose
is the medication of choice in emergency medical care of the diabetic patient with an altered mental status
oral glucose may be administered only if the patient meets all of the following three criteria:
has an altered mental status
has a history of diabetes controlled by medication or blood glucose reading less than 60 mg/dL
has the ability to swallow
this medical care should be provided to a patient with an altered mental status and unknown history:
maintain an open airway
suction as needed
maintain oxygen therapy
be prepared to assist ventilation's
place the patient in a lateral recumbent position
and transport
contact medical direction for further orders
Two conditions that may result from hyperglycemia
diabetic keoacidosis (DKA) and hyperglycemic hyperosmolar nonkeotic syndrome (HHNS)
as noted ealier DKA is more commonly seen in type 1 diabetic where as HHNS is more common in type 2 diabetic
Diabetic keoacidosis
the blood glucose level is elevated typically greater than 350 mg/dL because if an inadequate amount of insulin
the brain is not suffering from a low blood glucose because it does not need insulin
however the other cells in the body are starving for gluco
what two problems does diabetic keoacidosis cause in the body
dehydration and acidosis
excess glucose begins to spill into the urine drawing large amounts of water with it, the patient begins to frequently urinate, this leads to dehydration
second the cells other than the brain need insulin to move glucose across th
what do keotones produce?
produce a form of a strong acid
as the liver metabolizes more fat, acid levels in the body increase to dangerous levels (acidosis)
in addition to dehydration and acidosis what occurs?
an electrolyte imbalance develops which may lead to cardiac disturbances
since it takes quite a bit of time for the effects of acid and dehydration to occur the signs and symptoms of DKA usually do not occur for up to ?
several days
factors causing hyperglycemia in the diabetic ketoacidosis patient (DKA)
the patient is suffering from an infection that has upset the insulin and glucose balance
the patient takes an inadequate dose of insulin
the patient is taking medications such as thiazide, dilantin, or steroids
the patient has suffered some type of stres
polyuria means ?
frequent urination
ketoacidosis refers to?
the production of keotones, which also produce strong acids from the cells' use of fat as an energy source
signs and symptoms of diabetic ketoacidosis:
polyuria (excessive urination)
polyphagia (excessive hunger)
polydispia (excessive thirst)
nausea and vomiting
poor skin turgor
tachycardia
rapid deep respiration ( called kussmaul respiration)
fruity or acetone odor on the breath
positive orthostatic til
the signs and symptoms related to dehydration:
polyuria
polydispia
poor skin turgor
tachycardia
positive orthostatic tilt test
the nausea vomiting and muscle cramps are typically due to:
electrolyte disturbances from the loss of sodium, potassium and magnesium
the acid in the body will produce:
kassmaul respiration's, warm dry skin, and the odor of the breath
kassmaul respiration's are a pattern of very deep and rapid breathing that is commonly seen in a patient with DKA, it is an attempt by the body blow off carbon dioxide and reduce the carbon
what happens when the keotone acid in the body increases?
the patient will breathe deeper and faster in an attempt to keep the acid load under control, the fruity odor which smells like juicy fruit gum or acetone is from the keotones building up in the body
treatment for DKA
the treatment is aimed st reducing the blood glucose level and re-hydrating the patient
it may be prudent to contact an ALS unit to begin re-hydration in the field, follow your local protocol
hyperglycemic hyperosmolar nonkeotic syndrome (HHNS):
a hyperglycemic condition that causes the blood glucose level to increase drastically
the blood glucose level will typically rise from 600-1,200 mg/dL
because of the high blood glucose level the kidneys begin to spill of large amounts of glucose into the
what occurs in HHNS
there is still insulin being produced which means there is not a collection of keotones that would cause an acid load on the body
the patient will have significant dehydration but not because of acidosis or a lack of glucose
an episode of HHNS may be the
who may have HHNS
it is most commonly found in type two NIDDM patients who are elderly
HHNS may also be precipitated by trauma, burns, dialysis, drugs, heart attack, stroke, infection, head injuries and other endocrine disorders
HHNS carries a very high mortality rate
HHNS
signs and symptoms of HHNS hyperglycemic hyperosmolar nonketotic syndrome:
tachycardia
fever
positive orthostatic tilt test
dehydration
thirst
dizziness
poor skin turgor
altered mental status
confusion
weakness
dry oral mucosa
dry, warm skin
polyuria
nausea
Note there are no Kussmal respiration's or fruity odor on the breath wit
if you are unable to assess the blood glucose level with a glucose meter what should you rely on?
you have to rely solely on your assessment findings to determine whether the patient is experiencing an acute diabetic emergency and what kind of diabetic emergency he is experiencing
if you are unsure and cannot confirm the condition with a glucose reading what should you do?
it is better to err on the side of caution and administer oral glucose
medications taken by diabetics may include:
insulin (humilin, novolin, iletin, semilente
actos
diabinese, glucamide
orinase
micronase, DiaBeta
tolinase
glucotrol
humalog
glucophage
glynase
exenatide (byetta)
lantus
It is particularly important to determine from the patient, family, or any bystanders- the answers to the following questions :
did the patient take his medication the day of the episode?
did the patient eat or skip any regular meal on that day?
did the patient vomit after eating a meal on that day?
did the patient do any unusual exercise or physical activity?
an altered mental status from hypoglycemia will:
typically have a sudden onset, the signs and symptoms may progress rapidly over 5 to 30 mins
signs and symptoms commonly associated with a patient who has an altered mental status and has a history of diabetes are:
rapid of an altered mental status after missing or vomiting a meal, unusual exercise, or physical work
intoxicated appearance - from staggering or slurred speech to complete unresponsiveness
tachycardia
cool, moist skin
hunger
seizure activity
uncharacter
elderly patients with a diabetic condition frequently suffer signs and symptoms that mimic what?
stroke, such as weakness or paralysis on one side of the body
keep in mind that some medications (beta blockers) may hide signs of hypoglycemia
emergency medical care for a patient with hypoglycemia:
establish and maintain an open airway
determine if the patient is alert enough to swallow
administer oral glucose
transport
how long may it take for oral glucose to take affect ?
20 minutes