Module 9 Drugs Used to Treat Endocrine Emergencies PDF

Endocrine Emergencies Module 9  Overview of Diabetes Diabetes is a disease manifested by a dysfunc0onal pancreas. Insulin is required to convert sugars into energy for use by the body. Diabetes takes two different forms, type 1 diabetes and type 2 diabetes. Pa0ents wi...

Endocrine Emergencies Module 9  Overview of Diabetes Diabetes is a disease manifested by a dysfunc0onal pancreas. Insulin is required to convert sugars into energy for use by the body. Diabetes takes two different forms, type 1 diabetes and type 2 diabetes. Pa0ents with type 1 diabetes do not produce insulin. Without insulin, the cells of the body are not able to take sugar into the cell to be used for energy by that cell. Sugar is the main fuel of the cells, and like a car without gasoline, the cells of the body are not able to run without sugar.  Overview of Diabetes Pa0ents with type 2 diabetes are capable of making insulin; however, the insulin is not used properly by the body, a condi0on known as insulin resistance. The majority of people with diabetes have type 2. Insulin is used in pa0ents with type 1 diabetes and some pa0ents with type 2 diabetes. Insulin s0mulates the uptake of glucose by the cells of the body and lowers the level of sugar in the blood. Insulin allows glucose to enter cells, and potassium follows in turn. Oral hypoglycemic medica0ons are used to manage most pa0ents with type 2 diabetes.  2diabetes insulin resistance type Acht Tenor treatable only treated by medication can be treated by lifestyle changing i dite changing  Overview of Diabetes These agents act at a receptor on the insulin- producing cells of the pancreas. Some oral hypoglycemic agents also act by improving insulin’s ac0on on cells around the body. Oral hypoglycemic medica0ons have a tendency to contribute to hypoglycemia, especially in certain groups of pa0ents such as older adults and people with liver and kidney disease.  Overview of Diabetes Diabetes is a common disease, and paramedics rou0nely will encounter pa0ents who take various forms of insulin. These various forms differ in their onset and dura0on of ac0on. Although prehospital providers are exposed to several different forms of insulin, if a paramedic administers insulin to a pa0ent, it will most likely be regular insulin. Several types of insulin are on the market. What dis0nguishes these different types are the 0me of onset and the dura0on of ac0on. Some forms of insulin have a fast onset of ac0on that may last only a few hours.  Overview of Diabetes In contrast, other, longer-ac0ng insulins may have a slower onset but last as long as 24 hours. A pa0ent’s blood sugar level changes throughout the day. It may be lower between meals or overnight. AMer a meal or a snack, blood sugar increases. To provide reasonable control of blood sugar, a pa0ent may be taking several different forms of insulin. Diabetes is an increasingly common disease process. These emergencies typically represent complica0ons of a blood sugar level that is too high (hyperglycemia, poten0ally resul0ng in ketoacidosis) or too low (hypoglycemia, resul0ng in seizure or coma).  Hypoglycemia Hypoglycemia (low blood sugar) is the most common complica0on experienced by pa0ents with diabetes and is a life-threatening emergency. It is oMen referred to as insulin shock. Research has shown that diabe0c pa0ents have fewer long- term complica0ons when they maintain 0ght control of their blood sugar. However, with the increased effort toward improved blood glucose control can come an increased risk of hypoglycemia. A careful analysis that balances the poten0al benefits of 0ght blood glucose control and decreased long-term complica0ons of diabetes against the risk of iatrogenic hypoglycemia and its poten0ally lethal consequences is essen0al.  Hypoglycemia Mild hypoglycemia commonly occurs in pa0ents with diabetes and can simply be treated with oral glucose. However, moderate hypoglycemia can lead to serious hypoglycemia—that is, low blood sugar that requires interven0on by someone other than the pa0ent. The cause of hypoglycemia is not always recognized, and the pa0ent can have liVle warning to intervene and prevent worsening of the situa0on. This is par0cularly true for pa0ents who have had diabetes for several years because they can lose the ability to recognize symptoms of hypoglycemia, such as tachycardia, pallor, swea0ng, and anxiety.  Hypoglycemia This condi0on is referred to as hypoglycemic unawareness. In certain popula0ons, 40 to 50% of hypoglycemic episodes go unrecognized. Normally the body has a robust defense system to protect the brain against a significant drop in available blood glucose. When blood glucose drops, a variety of body chemicals, including catecholamines, glucagon, and cor0sol, are released to either increase blood glucose levels or shiM blood glucose toward the brain. These chemicals cause clinical signs and symptoms such as hunger, anxiety, and swea0ng, which normally alert the person that his or her blood sugar has dropped.  Hypoglycemia When hypoglycemic unawareness occurs, pa0ents do not develop or recognize these signs and symptoms before neurologic impairment occurs. In these situa0ons, pa0ents are unable to take steps to correct the hypoglycemia themselves and become largely dependent on assistance or rescue by others. Hypoglycemia is oMen caused by the insufficient intake of sugar from inadequacies in the diet or by excessive insulin from inaccurate dosing or excessive ac0on of the medica0on. Both factors typically contribute to hypoglycemia. Increased use of glucose by the body, such as occurs during and aMer exercise or strenuous physical ac0vity, can cause blood sugar to drop rapidly, resul0ng in hypoglycemia.  Management Hypoglycemia requires prompt treatment. When possible, the treatment of choice is oral glucose. If the pa0ent is conscious, oral glucose can result in an immediate improvement. Oral glucose is available as either a glucose gel or tablet. Glucose gel is easier to tolerate and can prevent the risk of choking in the event of an altered level of consciousness.  Management If the pa0ent has an altered or depressed level of consciousness, or if an adequate airway is not established, parenteral administra0on of glucose is more appropriate. This is achieved by using IV dextrose. Dextrose is available as 50% dextrose solu0on. That means that 100 mL of a solu0on has 50 g of dextrose. The preloaded syringe of 50% dextrose used in most emergency situa0ons is a 50-mL syringe (25 g dextrose in 50 mL solu0on). Twenty-five percent dextrose has 25 g of dextrose in 100 mL of solu0on, and 10% dextrose has 10 g of dextrose in 100 mL of solu0on.  Management Dextrose solu0ons that are more concentrated than 5% solu0ons are considered hypertonic and can cause irrita0on and pain when injected too rapidly. To avoid this irrita0on to the vein, any dextrose solu0on more concentrated than 5% should be slowly injected into a large vein. Concentrated dextrose solu0ons should not be administered intramuscularly (IM) or subcutaneously. Treatment of hypoglycemia depends on the pa0ent’s level of consciousness. If IV access were not possible in the pa0ent in the scenario, the next step would be to administer IM glucagon.  Management This would mobilize glycogen stores from the liver and elevate blood glucose levels rather rapidly. However, a common side effect is vomi0ng because glucagon delays gastric emptying. Pa0ents who have been fas0ng for days may not show a pronounced effect because of low glycogen levels in the liver. Pa0ents with hypoglycemia require close monitoring of the airway, and blood glucose should be checked every 30 minutes. Pa0ents with depressed mental status who are alcoholics or malnourished may have a deficiency of thiamine.  Management If given dextrose before thiamine administra0on, such pa0ents can develop a brain condi0on (Wernicke-Korsakoff syndrome) that manifests itself by amnesia, confabula0on, aVen0on deficit, disorienta0on, and vision impairment. To prevent Wernicke-Korsakoff syndrome, administer thiamine before dextrose in malnourished or alcoholic pa0ents.  Diabe>c Ketoacidosis Diabe0c ketoacidosis (DKA) occurs most commonly in pa0ents with type 1 diabetes, although it can also occur in pa0ents with type 2 diabetes. The key problem in DKA is a lack of insulin. In diabe0c pa0ents, too liVle insulin prevents the cells of the body from using glucose and, consequently, blood glucose rises. The cells cannot use the glucose but s0ll require a source of fuel. Therefore, the glucose-starved cells start to break down fat, producing acid and chemicals known as ketone bodies.  Diabe>c Ketoacidosis Pa0ents with DKA have metabolic acidosis, dehydra0on, and electrolyte abnormali0es. The type of acidosis that these pa0ents have is known as ketoacidosis, which is dis0nct from lac0c acidosis. Ketoacidosis occurs when the body uses alterna0ve fuel sources for energy produc0on because of the inability to burn glucose from the lack of insulin. Conversely, lac0c acidosis occurs in shock states when oxygen is lacking; the cellular machinery uses an inefficient energy- genera0ng process known as anaerobic metabolism. The product of anaerobic metabolism is lactate; hence, pa0ents generate lac0c acidosis. These two forms of acidosis are not related.  Diabe>c Ketoacidosis High blood glucose levels oMen result in loss of glucose in the urine, and pa0ents can become dehydrated due to electrolyte imbalances as the body uses water as a carrier to move electrolytes or remove various electrolytes from the body. Within the kidney, glucose is filtered into the tubules that collect the urine produced. As the fluid passes through the tubules of the kidney, the glucose is reabsorbed. In cases in which the concentra0on of the blood glucose is elevated, the amount of glucose passed into the kidney tubules exceeds the kidney’s ability to reabsorb the glucose back into the bloodstream, and glucose is spilled into the urine.  Diabe>c Ketoacidosis The spilling of glucose into the urine typically occurs at a serum blood glucose of approximately 300 mg/dL. The glucose molecule in the urine also decreases the reabsorp0on of water by the kidney and the pa0ent rapidly becomes dehydrated. In this situa0on, pa0ents have symptoms of increased thirst, increased urina0on, racing of the heart, and vomi0ng. The breath of a pa0ent in DKA is oMen described as “fruity” because of the presence of the ketone bodies.  Management Treatment of DKA includes correc0on of dehydra0on and acidosis with IV fluids and insulin. However, fluid replacement needs to be undertaken slowly. Remember that the pa0ent in the case lost weight and deteriorated over a 3- week period. As such, IV fluid administra0on should not be too rapid or aggressive unless the pa0ent has cardiovascular instability. If a fluid bolus is an0cipated, place a large- bore IV catheter if possible. The recommenda0on for adults is a 15- to 20-mL/kg ini0al normal saline fluid bolus.  Management The IV fluid of choice ini0ally should not include potassium replacement because the presence of ketoacidosis suggests an elevated potassium level. (Once urine output is ensured and electrolyte status can be determined at a hospital, potassium replacement becomes increasingly important.) Treatment of DKA with insulin, as well as correc0on of the acidosis, moves potassium into cells and rapidly lowers blood potassium levels. Prehospital treatment should include an isotonic solu0on such as normal saline or Ringer’s lactate.  Management Many EMS agencies do not carry insulin; simple IV fluid administra0on is oMen sufficient to improve hyperglycemia and help correct the metabolic acidosis un0l the pa0ent can be transported and treated at a medical facility. If insulin is available and appropriate, it can be given as a bolus or drip. The use of IV bolus insulin has been debated and remains a less-desirable method of trea0ng hyperglycemia in DKA than an insulin infusion. IV insulin has been shown to be significantly more effec0ve than IM or subcutaneous administra0on, at least in the ini0al treatment of DKA.  Management In a pa0ent with poor perfusion from hypovolemia or shock, subcutaneous insulin may not absorb appropriately, leading to a slow onset of ac0on. Blood sugar should be monitored every 30 to 60 minutes while the pa0ent is on an insulin drip or aMer a subcutaneous injec0on of insulin. The desired response should be a decrease in blood sugar by 10% per hour, or no faster than approximately 50 mg/dL per hour. Conversely, if the rate of decrease exceeds 50 mg/dL per hour, the insulin infusion may need to be decreased to prevent hypoglycemia.  Rapid-Ac>ng Insulins Insulin lispro (Humalog), insulin aspart (NovoLog), and insulin glulisine (Apidra) are three forms of synthe0c insulin whose molecular structure makes them op0mal for use in the treatment of type 1 diabetes. Onset of ac0on occurs within 10 minutes, and peak ac0on is 90 minutes, with a dura0on of ac0on of 2 to 4 hours in some pa0ents. These insulin products do not require a 30-minute wait when administered subcutaneously before a meal. They can even be administered immediately aMer a meal in some pa0ents. The End