Endocrine Emergencies and Diabetes Overview

Endocrine Emergencies

• Endocrine emergencies involve fast-acting conditions related to the endocrine system, such as diabetes.

Overview of Diabetes

• Diabetes is a disease involving dysfunction in the pancreas.
• Insulin is crucial for converting sugars into energy for the body.
• Diabetes exists in two primary forms: type 1 and type 2.
• Type 1 diabetes patients do not produce insulin, so their cells cannot absorb sugar for energy, much like a car without fuel.
• Type 2 diabetes patients produce insulin but their body's cells do not properly utilize it, leading to insulin resistance.
• The majority of people with diabetes have type 2 diabetes.
• Insulin is used in type 1 diabetes and some type 2 diabetes patients.
• Insulin encourages the uptake of glucose by body cells and reduces blood sugar levels.
• Glucose enters cells, and potassium follows.
• Oral hypoglycemic medications are used for managing most type 2 diabetes cases.

Overview of Diabetes (Continued)

• These medications work on the insulin-producing cells in the pancreas or aid insulin function in the body.
• Some oral hypoglycemic medications increase the tendency towards hypoglycemia in certain groups like the elderly and people with kidney or liver diseases.

Type 1 Diabetes

• The disease is considered chronic.
• It is treatable with medications only.

Type 2 Diabetes

• This disease is considered chronic.
• It can be treated through lifestyle changes and medication.

Hypoglycemia

• Hypoglycemia (low blood sugar) is a potentially life-threatening complication of diabetes and is among the most common complications.
• It is often referred to as insulin shock.
• Research shows that strictly controlling blood sugar levels in diabetic patients can lead to fewer complications.
• Factors affecting the risk of hypoglycemia include diet and the dosage of medications.
• Maintaining appropriate blood sugar is important to prevent long-term complications.
• Mild hypoglycemia can typically be treated with oral glucose.
• More severe cases of hypoglycemia require medical intervention but can often have little to no warning signs.
• A significant drop in blood sugar triggers a defense mechanism in the body through chemicals like catecholamines, glucagon, and cortisol to raise glucose and improve blood sugar toward the brain.
• Hypoglycemic unawareness is a condition where patients do not detect symptoms of hypoglycemia before nerve damage occurs.
• Hypoglycemia can result from inadequate sugar intake or excessive insulin intake.
• Exercise or physical activity can cause blood sugar levels to drop quickly.
• Factors such as poor perfusion and shock can interfere with insulin absorption, potentially leading to slower onset effects.

Hypoglycemia Management

• When possible, oral glucose is the preferred treatment.
• Consciousness should be evaluated before deciding on treatment.
• Oral glucose can be administered as glucose tablets or gel.
• Glucose gel is easier to tolerate and helps prevent choking if consciousness is altered.

Management (Parenteral Glucose)

• When consciousness is altered or an airway is compromised, intravenous (IV) glucose administration is preferred.
• The most common 50% dextrose solution is used for emergency situations. This contains 50 grams of dextrose per 100 mL.
• Pre-filled syringes containing dextrose (50 mL, 25g) are frequently utilized in emergency scenarios.
• Other concentrations include 25% dextrose, which is 25 g/100 ml solution.
• 10% dextrose is 10 g/100 ml.
• Dextrose concentrations of more than 5% can cause pain and irritation on injection. These should be administered slowly and not via intramuscular or subcutaneous routes.
• If IV access is impossible, IM glucagon or IV glucose administration can be necessary.

Diabetes Ketoacidosis (DKA) Management

• DKA treatment involves correcting dehydration and acidosis using IV fluids and insulin.
• Fluid replacement should be gradual, considering potential weight loss and deterioration during the three-week period.
• IV fluid administration should not be overly aggressive unless cardiovascular instability is observed.
• 15 to 20 mL per kilogram initial dosage for normal saline is recommended to adults.
• IV fluid should ideally not include potassium during the early stages, due to high potassium likely already present.
• Once urine output is established, and electrolyte status can be determined at a hospital, potassium replacement becomes increasingly important.
• Prehospital treatment should involve isotonic solution such as normal saline or Ringer's lactate.

Management (Insulin Administration)

• Many EMS agencies do not carry insulin, so IV fluid administration is often sufficient in the early stages to manage hyperglycemia and metabolic acidosis until proper treatment can be provided.
• IV insulin can be administered as a bolus or drip if available.
• IV bolus insulin use is less desirable than continuous insulin infusion.
• IV insulin is more effective than intramuscular or subcutaneous injection, particularly in the initial treatment of DKAT.

Management (Further Considerations)

• In patients with poor hypovolemic or shock-related perfusion, subcutaneous insulin may not be effectively absorbed, leading to a slow onset of action.
• Blood sugar monitoring every 30-60 minutes is crucial during insulin administration.
• The desired response is a 10% blood glucose decrease per hour, or less than 50mg/dL per hour. If exceeding 50 mg/dL decrease, the insulin rate should be reduced.
• If thiamine is administered before dextrose, it can prevent Wernicke-Korsakoff syndrome, an acute brain disorder in those with nutritional deficiencies. This is particularly important in alcoholic or malnourished patients.
• DKA treatment also depends on an adequate airway and circulatory conditions as well as the person's level of consciousness.

Rapid-Acting Insulins

• Insulin lispro (Humalog), insulin aspart (NovoLog), and insulin glulisine (Apidra) are rapid-acting insulins.
• Their structure makes them ideal for type 1 diabetes treatment.
• The onset of action is typically within 10 minutes, and peak action occurs around 90 minutes, with duration around 2-4 hours.
• These insulins can be administered immediately after meals, without a 30-minute delay.