Diabetes

Glucose

Required as fuel for cellular metabolism Brain’s need for glucose parallels its

demand for oxygen

Insulin

Hormone Produced by Islets of Langerhans in

pancreas Required for sugar to enter most cells Brain does not require insulin to use

sugar

Pancreas

Located in retroperitoneal space

Produces, releases– Digestive enzymes

into duodenum– Insulin, glucagon into

blood

Islets of Langerhans

Alpha cells– Glucagon– Raises blood sugar

Beta cells– Insulin– Lowers blood sugar

Diabetes Mellitus

Metabolic disease

Characterized by inadequate, absent insulin production

Type I Diabetes

No insulin production Takes insulin injections

Type II Diabetes

Inadequate insulin production Increased tissue resistance to insulin effects Controlled with

– Diet– Oral medications:

• Diabeta, Diabinese, Dymelor, Glucotrol, Micronase, Orinase, Tolinase, Glucophage

– Insulin injections as disease progresses

Problems in Diabetes

Blood Sugar Imbalance

Hyperglycemia– Diabetic ketoacidosis (DKA)– Hyperosmolar coma

Hypoglycemia

Hyperglycemia

Causes– Failure to take insulin– Overeating, eating wrong diet– Stress (fever, infection, emotional stress)

New-onset diabetics usually present with an episode of hyperglycemia

Diabetic Ketoacidosis

Usually Type I diabetic (no insulin) Blood sugar rises Kidneys try to remove excess sugar Urine production increases (polyuria) Patient becomes volume depleted

– Thirst (polydypsia)– Tachycardia– Hypotension– Dry skin, mucous membranes

Diabetic Ketoacidosis

Cells cannot burn sugar; patient experiences hunger (polyphagia)

Cells burn fat as alternative fuel Acidic ketone bodies produced Patient tries to correct acidosis; exhales CO2

Rapid, deep breathing (Kussmaul respirations) Exhaled ketone bodies produce nail-polish

remover or “fruity” breath odor

Diabetic Ketoacidosis

Volume depletion Ketone body production (ketoacidosis)

Hyperosmolar Coma

Usually Type II diabetic (inadequate insulin) Blood sugar rises Kidneys try to remove excess sugar Urine production increases (polyuria) Patient becomes volume depleted

– Thirst (polydypsia)– Tachycardia– Hypotension– Dry skin, mucous membranes

Hyperosmolar Coma

Cells continue to burn sugar Acidic ketone bodies not produced Nail-polish remover or “fruity” breath odor not

present

Hyperosmolar Coma

Severe volume depletion NO ketone body production

Hyperglycemia

Management– Support ABC’s – Treat for hypovolemic shock– Transport– When in doubt, give sugar!

Hypoglycemia

Causes– Insulin overdose– Normal insulin use without eating– Over-exercise

Hypoglycemia

A ltera tions in consc iousness ;S e izures; H ea d a che;

U nusua l B eha v ior

B ra in la ck s a d eq ua te g lucose

P a le ; C ool sk in;S w ea ting ; T achyca rd ia ;Increa sed B P ; N a usea

A d rena l G la nd s re lea se E p inep hr ine

B lood S ug ar F a lls

Pale, cool skin; sweating; nausea; tachycardia

Is that why hypoglycemia sometimes is called “Insulin Shock?”

Hypoglycemia

Insulin shock isn’t really shock Patient just looks “shocky” because of

epinephrine adrenals are releasing

Hypoglycemia

Can occur in non-diabetics Most common cause =

EtOH on empty stomach A patient is never, just drunk

Hypoglycemia Management

Conscious patient– Give sugar orally

Unconscious patient– Support ABC’s– Get ALS back-up for IV glucose

When in doubt, Give Sugar!

Ask All Diabetics

Have you eaten today? Have you taken your medication today? When in doubt, give Sugar!

Other Diabetes Complications

Atherosclerosis– Myocardial infarction– CVA– Peripheral vascular disease– Blindness– Renal failure

Other Diabetes Complications

Diabetic Neuropathy– Gangrene– Increased “silent” myocardial infarction risk

Silent MI

Acute MI in diabetic can present without chest pain

May resemble “flu” Manage “sick” diabetics as if critically ill

until proven otherwise