Endocrine Emergencies - Module 9

Endocrine Emergencies

• Endocrine emergencies are a serious concern, particularly those involving diabetes and thyroid issues.
• Module 9 in the curriculum focuses on these emergencies.

Overview of Diabetes

• Diabetes is a condition caused by a malfunctioning pancreas.
• Insulin is needed to convert sugars into energy for the body's cells.
• Two common types are Type 1 and Type 2 diabetes.
• Type 1 diabetics do not produce insulin, rendering their cells unable to utilize sugars for energy.
• Type 2 diabetes results in the body's ineffective use of insulin, a condition called insulin resistance.
• Insulin promotes the uptake of glucose by cells and regulates blood sugar levels.
• Oral hypoglycemic medications are used to manage Type 2 diabetes, while in Type 1 diabetes insulin is essential.

Overview of Diabetes (continued)

• Most diabetic patients have Type 2 diabetes.
• Insulin use is common in both Type 1 and some Type 2 diabetes cases.
• Insulin facilitates glucose entry into cells and influences potassium movement.

Overview of Diabetes (continued)

• Some oral hypoglycemic medications work on receptors in insulin-producing cells of the pancreas.

• Other oral hypoglycemic agents enhance insulin's effect on cells in the body.

• These medications can contribute to hypoglycemia, particularly for older adults and people with liver/kidney issues.

• Different types of insulin have varying onset and duration of action.

• Some insulins have rapid onset of action, lasting only a few hours.

• Longer-acting insulins have a slower onset, lasting up to 24 hours.

• Blood sugar levels fluctuate throughout the day, changing after meals or during periods of fasting or sleep.

Hypoglycemia

• Hypoglycemia, low blood sugar, is the most common complication for people with diabetes, also called insulin shock.

• Low blood sugars require intervention (by others, usually).

• Hypoglycemia can stem from inadequate sugar intake or excessive insulin dosage/action.

• Hypoglycemia incidence increases during and after physical exertion.

• Mild cases of hypoglycemia can often be resolved by administering oral glucose.

• In severe cases, hypoglycemic unawareness occurs, where symptoms of low blood sugar are not recognized.

• Hypoglycemia can lead to serious neurological issues in these cases.

• Glucose levels should be monitored regularly during treatment, aiming for a decrease of 10% per hour or a maximum of 50 mg/dL per hour.

Hypoglycemia (continued)

• Hypoglycemic episodes could go unnoticed, a condition referred to as hypoglycemic unawareness, in some cases approximately 40-50% of episodes are unrecognized.
• The body's defense mechanisms include releasing chemicals like catecholamines, glucagon, and cortisol to help raise blood sugar levels.
• These chemicals trigger symptoms such as hunger, anxiety, and sweating, which alert the individual to low blood sugar.

Management

• Hypoglycemia requires immediate treatment with oral glucose, when possible.
• Oral glucose is available as gels or tablets and could prevent choking.
• If the patient has an impaired or no airway or is unconscious, parenteral administration of dextrose is necessary.
• Common dextrose solutions include 50%, 25%, and 10% concentrations, differing in the strength of glucose they contain.
• Dextrose solutions, if not 5% or less, are given slowly to avoid vein irritation.
• Dextrose should not be injected intramuscularly or subcutaneously, as these routes are not appropriate for these high-concentration dextrose solutions.
• Treatment varies based on the patient's level of consciousness.

Management (continued)

• If IV access is unavailable, immediately administer glucagon intramuscularly.

• In managing hypoglycemia, glycogen stores in the liver are mobilized to rapidly raise blood glucose.

• Vomiting is a possible side effect of glucagon administration because it can delay stomach emptying.

• Patients in DKA are treated with IV fluids and insulin to correct dehydration and acidosis.

• The fluid replacement must be administered slowly, without aggressive intervention unless cardiovascular instability is noted.

• The initial normal saline fluid bolus is usually 15 to 20 mL per kg in adults.

• IV fluids for DKA management should initially exclude potassium, since ketoacidosis generally suggests higher potassium levels.

• Once urine output and electrolytes are stable, potassium supplementation may become essential.

• Prehospital treatment should ideally include isotonic fluids such as normal saline or Ringer's lactate along with insulin bolus or drip if available/appropriate.

Management (continued)

• Many EMS services don't carry insulin while some may use simple IV fluids to manage high blood sugar and acidosis in the initial stages.
• The use of IV bolus insulin is sometimes less effective compared to continuous intravenous insulin infusion for severe cases of Diabetic Keotacidosis (DKA).
• In patients with weak perfusion, subcutaneous insulin absorption might be poor.
• Blood glucose needs to be monitored regularly every 30-to-60 minutes during treatment.

Rapid-Acting Insulins

• Insulin lispro (Humalog), insulin aspart (NovoLog), and insulin glulisine (Apidra) are three rapid-acting synthetic insulin types.
• These insulins have a quick onset (around 10 minutes), peaking around 90 minutes, and lasting up to 4 hours.
• Patients can receive these insulins immediately after meals or when appropriate.

Diabetic Ketoacidosis (DKA)

• DKA is most frequent in type 1 diabetes, though it can occur with type 2 diabetes.

• A critical factor in DKA is insufficient insulin supply.

• Insufficient insulin prevents cells from using glucose, causing blood sugar to increase significantly.

• Glucose-starved cells start breaking down fats, producing ketone bodies, which are acids.

• This process, termed ketoacidosis, leads to metabolic acidosis, dehydration, and electrolyte imbalances.

• As glucose levels exceed the kidney's reabsorptive capacity, glucose spills out in the urine, causing water loss and dehydration.

• The breath of a DKA patient is often described as 'fruity' due to the presence of ketone bodies.

Thiamine administration

• Giving dextrose before thiamine can lead to Wernicke-Korsakoff syndrome (a neurological disorder) in malnourished or alcoholic patients.
• Thiamine should be given prior to administering dextrose to patients in such conditions.

Insulin, Regular

• Regular insulin, often labelled Humulin R or Novolin R, is hormonally classified.
• Its action involves binding to cell receptors to facilitate glucose uptake into cells.
• Adverse effects can include hypoglycemia (low blood sugar) and other symptoms depending on usage.