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Chapter 19Endocrine and Hematologic EmergenciesIntroductionlEndocrine system influences nearly every ____________________ ,
organ, and bodily function.lEndocrine disorders can have many signs and symptoms.lHematologic emergencies
–Difficult to assess and treat–Your actions may save a life.
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Endocrine SystemlA complex message and ____________________ system.lGlands secrete messenger hormones.l____________________ are chemical messengers.lSystem maintains homeostasislEndocrine disorders are caused by an internal communication
problem.Anatomy and PhysiologylGlucose metabolism
–The brain needs glucose and oxygen. –____________________ is necessary for glucose to enter cells. –The pancreas produces glucagon and insulin.lStores and secretes insulin and glucagon in response the blood glucose level
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Diabetes (1 of 2)lDiabetes impairs the body’s ability to use glucose (sugar) for fuel.lComplications include blindness, ____________________ disease,
and kidney failure.lWithout treatment, blood glucose levels become too high.
–In severe cases, may cause life-threatening illness, or coma and death
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Diabetes (2 of 2)lAs an EMT, you need to know signs and symptoms of blood glucose
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Diabetes (2 of 2)lAs an EMT, you need to know signs and symptoms of blood glucose
that is:–High (____________________ )–Low (hypoglycemia)
lCentral problem in diabetes is lack, or ineffective action, of ____________________ .
lHyperglycemia and hypoglycemia can occur with diabetes mellitus type 1 and type 2.
lAll hypoglycemic patients require prompt treatment. Defining Diabetes (1 of 2)lDiabetes mellitus
–Metabolic disorder in which the body cannot ____________________ glucose
–Usually due to a lack of insulin.lGlucose
–One of the basic sugars in the body–Along with oxygen, it is a primary fuel for cellular metabolism
Defining Diabetes (2 of 2)lInsulin
–____________________ produced by the pancreas–Enables glucose to enter the cells–Without insulin, cells starve
lHormone–Chemical substance produced by a gland–Has special ____________________ effects on other body organs and tissues
Diabetes Mellitus Type 1 (1 of 5)l____________________ disorder where the immune system
produces antibodies against the pancreatic beta cellslPatient does not produce any insulinlInsulin injected dailylOnset usually in childhood through the fourth decade of life
–Patient must obtain insulin from an external sourceDiabetes Mellitus Type 1 (2 of 5)lMany people with type 1 diabetes have an implanted insulin pump.
–Continuously measures glucose levels and provides an
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lMany people with type 1 diabetes have an implanted insulin pump.–Continuously measures glucose levels and provides an ____________________ infusion of insulin
–Can malfunction and diabetic emergencies can develop–Always inquire about the presence of an insulin pump.
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Diabetes Mellitus Type 1 (3 of 5)lMost common metabolic disease of childhoodlNew-onset patient symptoms:
–____________________ –Polydipsia –Polyphagia –Weight loss–Fatigue
Diabetes Mellitus Type 1 (4 of 5)lPatient’s blood glucose level is above normal
–Kidney’s filtration system becomes overwhelmed and glucose spills into the ____________________ .
lGlucose is unavailable to cells.–Body turns to burning fat.–Produces acid waste (ketones)–Kidneys cannot maintain acid–base balance.–Kussmaul respirations result
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Diabetes Mellitus Type 1 (5 of 5)lIf fat metabolism and ketone production continue, diabetic
ketoacidosis (DKA) can develop.lMay present as generalized illness lDKA can result in death.
–Obtain patient’s history and presentation.–Obtain a glucose level.lGenerally higher than ____________________ mg/dL
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Diabetes Mellitus Type 2 (1 of 3)lCaused by resistance to the effects of insulin at the cellular level
–An association between obesity and increased resistance to the
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lCaused by resistance to the effects of insulin at the cellular level
–An association between obesity and increased resistance to the effects of insulin
–Pancreas produces more insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors.
–Insulin ____________________ can sometimes be improved by exercise and dietary modification.
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Diabetes Mellitus Type 2 (2 of 3)lOral medications used to treat type 2 diabetes
–Some increase secretion of insulin and pose a high risk of hypoglycemic reaction.
–Some stimulate ____________________ for insulin.
–Others decrease the effects of glucagon and decrease the release of glucose stored in the liver.
lInjectable medications and insulin are also used for type 2 diabetes.
Diabetes Mellitus Type 2 (3 of 3)lOften diagnosed at a yearly medical examination from complaints
related to high blood glucose levels, including:
–Recurrent infection
–Change in ____________________
–Numbness in the feet
Severity of DiabeteslSeverity of diabetic complications depends on patient’s
____________________ blood glucose level and when diabetes began.
lObesity increases the risk of diabetes.
lDiabetes complicates every other medical condition and injuries
Role of Glucose and InsulinlGlucose is the major source of ____________________ for the
body.
lConstant supply of glucose needed for the brain.
lInsulin acts as the key for glucose to enter cells.
lNormal glucose (blood sugar) is ____________________ to ____________________ mg/dL.
Insulin
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Insulin
Classic Symptoms of Uncontrolled Diabetes (3 Ps)lPolyuria: frequent, plentiful ____________________ lPolydipsia: frequent drinking to satisfy continuous thirstlPolyphagia: excessive eatingl
Energy SourceslThe body uses glucose as a principal energy sourcelWhen glucose is not available, the body turns to other sources
–____________________ is most abundant.–Using fat for energy results in buildup of ketones and fatty acids in blood and tissue.
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Symptomatic Hyperglycemia (1 of 4)lOccurs when blood glucose levels are high lPatient is in a state of altered mental status resulting from several
combined problems. –In type 1 diabetes, leads to ____________________ with dehydration from excessive urination
–In type 2 diabetes, leads to a nonketotic hyperosmolar state of dehydration
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Symptomatic Hyperglycemia (2 of 4)lHyperosmolar hyperglycemic nonketotic syndrome (HHNS)
–When blood glucose levels are not controlled in diabetes mellitus type ____________________
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Symptomatic Hyperglycemia (3 of 4)• HHNS key signs and symptomsli. Hyperglycemialii. Altered mental status, drowsiness, lethargyliii. Severe ____________________ , thirst, dark urineliv. Visual or sensory deficitslv. Partial paralysis or muscle weakness
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liv. Visual or sensory deficitslv. Partial paralysis or muscle weaknesslvi. Seizures
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Symptomatic Hyperglycemia (4 of 4)lHigher glucose levels in the blood cause the excretion of glucose in
the urine. –Patient increases fluid intake.–Patient cannot drink enough fluid to keep up with the exceedingly high glucose levels in the blood.
–Urine becomes ____________________ and concentrated. –Patient may become unconscious or have seizure activity due to severe dehydration. l
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Symptomatic Hypoglycemia (1 of 3)lAcute emergency where a patient’s blood glucose level
____________________ and must be corrected swiftly–Can occur in patients who inject insulin or use oral medications–When insulin levels remain high, glucose is rapidly taken out of the blood.
–If glucose levels fall, there may be an insufficient amount to supply the brain.
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Symptomatic Hypoglycemia (2 of 3)lMental status declines.
–Patient may become aggressive or display unusual behavior. –Unconsciousness or permanent brain damage can quickly follow.
lHypoglycemia develops much more ____________________ than hyperglycemia.
lSigns and symptoms of hypoglycemia lPatient needs intravenous (IV) glucose or intramuscular (IM) or
intranasal (IN) glucagon (beyond EMT competencies).ll
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Symptomatic Hypoglycemia (3 of 3)lHypoglycemia is quickly reversed by giving the patient glucose. l
Hyperglycemic EmergenciesDiabetic Ketoacidosis (DKA) (1 of 2)lDecrease in insulin levels.lMost common in type 1 diabetesl____________________ cannot enter cells.lGlucose accumulates in the blood.lBody PH decreaseslPolyuria lPolydipsia
Diabetic Ketoacidosis (DKA) (2 of 2)l____________________ diuresislDehydration lShock lCells metabolize fat, produce ketones as wastelRetention of ____________________ by kidneys which leads to
cardiac arrhythmias
Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) lMore often caused by type 2 diabetesl____________________ , more gradual onset than DKAlNo sweet-smelling breathlOther S/S same as DKAlExcessive urination results in dehydration.l
Hyperglycemic Crisis (Diabetic Coma) (1 of 3)A state of unconsciousness resulting from:l____________________ lHyperglycemialDehydrationlExcess blood glucose
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lExcess blood glucoseHyperglycemic Crisis (Diabetic Coma) (2 of 3)Can occur in diabetic patients:lNot under medical treatmentlWho have taken insufficient insulinlWho have markedly ____________________ lUnder stress due to infection, illness, overexertion, fatigue, or alcoholHyperglycemic Crisis (Diabetic Coma) (3 of 3)lIf untreated, can result in ____________________ lTreatment may take hours in a well-controlled hospital setting.lSuspect for all unconscious patients of unknown etiologyDiabetic ComaS/S of DKAlAir hunger (Kussmaul Respirations)lDehydrationlSweet, ____________________ breath odorlRapid, weak pulselNormal or slightly low blood pressurelVarying degrees of unresponsivenesslGradual onset--over several hours or dayslSkin is normalManagement of DKAlHigh flow oxygenlObtain blood glucose level if authorizedlTransportHypoglycemic Emergencies
Insulin Shock (Hypoglycemic Crisis)
Insulin Shock (Hypoglycemic Crisis)lThree causes of Insulin Shock
–insulin ____________________ –taking insulin but not eating adequately
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–insulin ____________________ –taking insulin but not eating adequately–over exercising
lDecreased blood sugar lBrain is deprived of sugarS/S of Insulin ShocklNormal or rapid breathinglPale, ____________________ skinlSweatinglDizziness, headachelRapid pulselNormal or slightly elevated B/P
–lAggressive or confused behaviorlHungerlFainting, seizure, or comalWeakness on one side of the bodyl____________________ SpeechCare for Insulin ShocklOxygenlObtain sugar level if authorizedlGive sugar if ____________________ (Instant Glucose)lContact ALS backup if unconscious or severe altered LOClRapid Transport
–True emergencyl
Diabetic Conditions
Diabetes and Alcohol AbuselPatients may appear ____________________ .lSuspect hypoglycemia with any altered mental status.lBe alert to the similarity in symptoms of acute alcohol intoxication
and diabetic emergencies.lDiabetics may drink alcohol and become intoxicatedEmergency Medical Care (1 of 2)Ask a patient with known diabetes:lDo you take insulin or any pills to lower blood sugar?
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Ask a patient with known diabetes:lDo you take insulin or any pills to lower blood sugar?lHave you taken your usual dose of ____________________ (or
pills) today?lHave you eaten normally today?lHave you had any illness, unusual amount of activity, or stress
today?Emergency Medical Care (2 of 2)lPerform initial assessment.lObtain baseline vital signs and SAMPLE history.lCheck for emergency medical identification symbol.lAlways do a full, careful assessment. lAsk patient or family about last meal or insulin dose.l____________________ administer anything by mouth to an
unconscious patient. DKA vs. Insulin ShocklPt eaten but has not taken insulin?
-DKAlPt taken insulin and has exercised profusely?
-Insulin shocklPt accidentally took two doses of insulin?
-Insulin shocklPt has been sick and vomiting lately and has been taking insulin?
-Insulin ShockDKA vs. Insulin ShocklPt has taken insulin and has been eating normally?
-?????lPt has not been eating and has not taken insulin?
-?????lWhen in doubt, GIVE SUGAR!!
Administering Glucose (1 of 4)lNames:
–Glutose–Insta-Glucose
lDose equals ____________________ grams (one tube)lGlucose should not be given to a diabetic patient with a decreased
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lDose equals ____________________ grams (one tube)lGlucose should not be given to a diabetic patient with a decreased
level of consciousness.
Administering Glucose (2 of 4)lDO NOT give glucose to a patient with the inability to
____________________ or unconscious.lGive between cheek and gumsl
Administering Glucose (3 of 4)lMake sure the tube is intact and has not ____________________ .lSqueeze a generous amount onto a bite stick.l
Administering Glucose (4 of 4)lOpen the patient’s mouth.lPlace the bite stick on the mucous membranes between the cheek
and the ____________________ with the gel side next to the cheek.lRepeat if neededl
Complications of DiabeteslHeart diseasel____________________ disturbanceslRenal failurelStrokelUlcerslInfections of the feet and toeslSeizureslAltered mental statusSeizureslConsider ____________________ as the cause.lUse appropriate BLS measures for airway management.lObtain blood glucose level if authorizedlCall for ALS backup for IV administration of glucoselProvide prompt transport.Geriatric NeedslPatient may have undiagnosed diabetes.lCertain symptoms suggest poorly controlled or uncontrolled diabetes.
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lPatient may have undiagnosed diabetes.lCertain symptoms suggest poorly controlled or uncontrolled diabetes.
–Nonhealing wounds–Blindness–Renal failure
lObtain a ____________________ history.lCheck blood glucose level if authorizedBlood Glucose MonitorslTest stripslNormal range 80-120 mg/dLl____________________ lThere are numerous different glucometers. You must become
familiar with the one used on your service.l
Hematologic EmergencieslHematology is the study and prevention of blood-related diseases.lBlood is “the fluid of life.”
–Understanding it helps understand disorders.BloodlMade up of cells and ____________________ .lRed blood cells contain hemoglobin, which carries oxygen to the
tissues.lWhite blood cells respond to infection and collect dead cells for their
correct disposal.lPlatelets assist in clot formation.lPlasma transports blood cells.Sickle Cell Disease (1 of 2)lInherited disorder, affects ____________________ blood cellslPredominant in African, Caribbean, and South American ancestry
–People with sickle cell disease have misshapen RBCs that lead to dysfunction in ____________________ binding and unintentional clot formation.lClots may result in a blockage known as vaso-occlusive crisis.
Sickle Cell Disease (2 of 2)lMay cause hypoxia; swelling or rupture of blood vessels or
____________________ ; pain and organ damage, and death
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lMay cause hypoxia; swelling or rupture of blood vessels or ____________________ ; pain and organ damage, and death
lSickle cell disease (cont’d)– Sickled cells have a short life span– Results in more cellular waste products and contributing to
sludging of the blood
Complications of Sickle Cell Disease (1 of 2)lCerebral vascular attacklGallstoneslJaundicelAvascular necrosislSplenic dysfunctionl____________________ tolerancelLeg ulcerslRetinopathylChronic painlPulmonary hypertensionlChronic renal failurelAnemial
Complications of Sickle Cell Disease (1 of 2)lSickle cell disease (cont’d)
–Many of these complications are very ____________________ and potentially life threatening.
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Clotting DisorderslThrombophilialHemophilia l
ThrombophilialTendency to develop blood ____________________ lBlood-thinning medications used to treatlNot common in pediatric patientslRisk factors:
–Recent surgery, impaired mobility, congestive heart failure, cancer,
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lRisk factors: –Recent surgery, impaired mobility, congestive heart failure, cancer, respiratory failure, infectious diseases, over 40 years of age, being overweight/ obesity, smoking, oral contraceptive use
–Hemophilia (1 of 2)lRare: Only about 20,000 Americans have the disorder. lCongenital; impaired ability to ____________________ blood clotslPredominant in males (1 per 5,000–10,000)lHemophilia A most commonlPatients typically have intravenous factor VIII replacement infusions
(which help the blood clot) close at hand.l
Hemophilia (1 of 2)Signs and symptoms:lSpontaneous, acute, chronic bleedingl____________________ bleeding (major cause of death)lDuring assessment, seriously consider injury/illness that can cause
bleeding.Deep Vein ThrombosislClotting disorders—deep vein thrombosis (DVT)
–Common medical problem in sedentary patients and in patients who have had recent injury or ____________________
–Methods designed to prevent blood clot formation, include: lBlood-thinning medicationslCompression stockingslMechanical devices
Deep Vein ThrombosislClotting disorders—DVT (cont’d)
–Risk factors–Treatmentl____________________ therapy lOral medications typically administered for at least 3 months after diagnosis of a DVT
–A clot from the DVT can travel from the patient’s lower extremity to the lung, causing a pulmonary embolus. l
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the lung, causing a pulmonary embolus. l
Emergency Medical Care for Hematologic Disorders lMainly supportive and symptomaticlPatients with inadequate breathing or altered mental status:
–Administer high-flow O2 at 12 to 15 L/min.–Place in a position of ____________________ .–Transport rapidly to hospital.
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