WK3 - Lecture 15 - Diabetes-Related Emergencies PDF

DH 410 – EMERGENCIES IN DENTAL PRACTICE Lecture: Diabetes-Related Emergencies Objectives  Understand and differentiate Diabetes Classifications  Explain systemic complications of Diabetes  Describe and recognize oral manifestations of Diabetes  Recognize an...

DH 410 – EMERGENCIES IN DENTAL PRACTICE Lecture: Diabetes-Related Emergencies Objectives  Understand and differentiate Diabetes Classifications  Explain systemic complications of Diabetes  Describe and recognize oral manifestations of Diabetes  Recognize and understand Diabetic Ketoacidosis (DKA), hyperglycemia, hypoglycemia  Understand and prepare for medical emergencies involving the Diabetic patient Diabetes Mellitus  Millions in the United States are affected  Type 2 diabetes – MOST common  obesity  highfat/low fiber diets  sedentary lifestyle  2000 patient dental practice  40 – 70 patients are known to be diabetic  1/3 are unaware of condition American Diabetes Association Data from the 2024 National Diabetes Statistic Report Total prevalence of diabetes:   Total: 38 million Americans in the United States—11.6% of the population—have diabetes 1.6 million with Type I diabetes (including approx. 187,000 children) 27.2 million are 65 years of age and older  Diagnosed: 29.7 million people  Undiagnosed: 8.7 million people  Prediabetes: 98 million adults  New Cases: 1.5 million new cases of diabetes are diagnosed each year Data obtained using HbA1C test instead of Fasting Glucose test https://www.cdc.gov/diabetes/data/statistics/statistics-report.html https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics- report.pdf Diabetes Mellitus  Metabolic disorder characterized by hyperglycemia (too much glucose in the blood)  Etiology:  Occurs either when the beta cells in the pancreas do not produce enough insulin OR  When the body cannot effectively use the insulin it produces  Insulin is a hormone that helps regulate blood sugar levels and allows cells to use sugar for energy General Signs and Symptoms: Diabetes  Classic Diabetic Triad: (diabetic condition) 1. Polydipsia – excessive thirst 2. Polyphagia – excessive hunger 3. Polyuria – excessive urination Diabetes Mellitus  4 types  Type 1  Type 1.5  Type 2  Gestational  5th category pre-diabetes or impaired glucose tolerance Type 1 Diabetes Mellitus  Chronic autoimmune disease  Occurs when the body's immune system destroys the beta cells of the pancreas that produce insulin  Without insulin, blood sugar builds up in the bloodstream  5 – 10% of all Diabetics Treatment – Type 1  Usually some type of INSULIN  Different types based on time of onset, peak effectiveness, effective duration and maximal duration Type 2 Diabetes Mellitus  MOST common  90-95% of all Diabetics  Increase in life span (living longer)  Sedentary lifestyle  Poor diet and exercise of adolescents  Body unable to produce sufficient insulin or the body is not able to use the insulin that is produced Treatment – Type 2  Diet  Exercise  Medication (based on cause and severity of condition)  More common medications:  Metformin (Glucophage)  Rosiglitazone (Avandia)  Tolbutamide (Orinase)  Glyburide (Micronase, DiaBeta, Glynase) Type 1.5 Diabetes Mellitus  latent autoimmune diabetes of adults (LADA)  Has characteristics of both type 1 and type 2 diabetes  Presents like type 2 diabetes  Acts like type 1 diabetes  Body destroys insulin producing cells  An autoimmune disease that usually develops in adults over the age of 30 https://www.ncbi.nlm.nih.gov/books/NBK557897/ https://www.rdhmag.com/patient-care/article/14306075/did-you-know-theres-a-new-type-of-diabetes Gestational Diabetes Mellitus  Glucose intolerance during pregnancy  Most common condition during pregnancy  Can lead to adverse effects for mother and baby  Usually disappears after pregnancy, but may return years later as type 1  Etiology: destruction of insulin by placenta  HbA1C  A blood test that measures average blood sugar levels over the past two to three months  Type 2 diabetics get tested every 3-6months LAB VALUES Normal Results: An HbA1c of 5.6% or less is normal Diagnose Diabetes Results: Normal: Less than 5.7% Pre-diabetes: 5.7% to 6.4% Diabetes: 6.5% or higher  HbA1C FYI ONLY Test results may be incorrect in patients with anemia, hemoglobin disorders, or kidney disease http://www.ngsp.org/factors.asp Kidney disease can lead to vitamin/mineral levels, resulting in anemia Low red blood cell levels, mean Erythrocyte age, and turn over due to bleeding  Certain medications can also result in a false A1C level http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm  Conditions Resulting in skewed A1C FYI ONLY https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401751/  Drugs causing skewed A1C FYI ONLY https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401751/ Systemic Complications  Many – 4 major  Diabetic retinopathy https://diatribe.org/silent-complication-closer-look-diabetic-retinopathy  Diabetic neuropathy https://www.niddk.nih.gov/health- information/diabetes/overview/preventing-problems/nerve-damage- diabetic-neuropathies  Diabetic nephropathy http://www.diabetes.org/living-with-diabetes/complications/kidney-disease- nephropathy.html  Oral Manifestations http://clinical.diabetesjournals.org/content/34/1/54 Diabetic Retinopathy  Damages the retina of the eye  Leading cause of blindness age 20 – 74 Diabetic Neuropathy  Nervous system damage  Affects 60 – 70 % of Diabetics  Pain in feet and hands  Pins and needles  Numbness  Slow digestion Macrovascular / Microvascular Complications  Capillaries thicken  Impairment of normal blood flow  Can cause a blood clot (thrombi)  Increased risk of CVA and MI  Lack of blood flow to peripheral arteries often affect legs  Increased risk of gangrene Bacterial infection Often time amputation is needed Diabetic Nephropathy  Damages small blood vessels in kidneys  Impairs ability to filter impurities from blood  Require transplant or dialysis to cleanse blood  Once occurs 100% morbidity within 10 years  Diabetic Medical Emergencies 1. Diabetic Ketoacidosis (DKA) 2. Hypoglycemia Diabetic Ketoacidosis (DKA)  Etiology: insufficient insulin levels in blood Body cannot convert sugar into glycogen for cell energy Instead, fat is broken down for energy Biproduct are acids called ketones Ketones build up in the blood and urine lower blood pH Body exhales carbon dioxide in an attempt to reverse acidosis Increase heart rate – tachycardia Hyperventilation Unconsciousness and lead to diabetic coma Diabetic Ketoacidosis (DKA)  Not a common occurrence in dental office  Types of patients at risk for DKA  Newly diagnosed Type 1 diabetics  Patients that are not medicating or eating properly  Patients with infections  Alcohol and cocaine induced Signs and Symptoms: DKA  Alteration in mental status  Muscle weakness and severe fatigue  Sweet, fruity breath  Dehydrated – poor skin turgor (see next slide)  Skin and mucous membranes warm and dry  Increased thirst  Hypotension  Tachycardia Skin Turgor  Treatment of DKA  Determine blood glucose level (does the office have this capability?)  Need to lower blood glucose level with insulin  Should only be administered by medical professional to prevent hypoglycemia  Contact EMS  Monitor vital signs  Administer O2 4-6 L/minute  If unsure which diabetic emergency – provide glucose as it will not significantly harm a DKA patient, and it will significantly help a hypoglycemic patient Severe Hypoglycemia  2nd most common complication of diabetes  Blood glucose level below 40 – 50 mg/dL  Normal (without diabetes) 70 – 99 mg/dL  Etiology: missed meal, increased exercise without adjusting insulin dosage Signs and Symptoms - Hypoglycemia MILD - MODERATE SEVERE  Dizziness, Fainting  Sweating  Weakness  Irritability or  Headache aggressive behavior  Hunger  Confusion  Nausea  Seizure  Cold, clammy skin  Eventually coma Treatment of Severe Hypoglycemia CONCSIOUS Patient  Position: Upright, patient’s comfort  C-A-B, BLS as needed Conscious patient should be in control  Definitive care: Administer oral carbohydrates / sugar 20-40grams table sugar, honey, candy bar, OJ glucose tablets/paste  Monitor vital signs  Positive response should occur within 10 – 15 minutes No need to dismiss patient Oral glucose tablets, paste, sugar packets Treatment of Severe Hypoglycemia UNCONSCIOUS Patient  Position: upright, comfortable  Contact EMS  C-A-B, BLS as needed Maintain airway  Definitive care: (1) Administer oral carbohydrates / sugar (2) Administer glucagon 1mg IM or 50mL, 50% dextrose IV  Monitor vital signs  Administer O2 4-6 L/minute Injectable glucagon Role of Dental Professional – Preventative  Questions to ask all diabetic patients 1. What was your most recent HbA1C, and date? 2. How do you manage your diabetes? Do you take medication? 3. What medication? When did you take it last? 4. When was the last time you had a meal or snack? 5. Are you having problems with your eyes, feet, legs? 6. Do you see your physician regularly? 7. Do you see an eye doctor yearly? Role of Dental Professional – Preventative  Strategies to implement:  Frequent recall examinations and prophylaxis  Schedule appointments in early to mid-morning  Keep appointments short  Instruct patients to continue normal dietary intake prior to appointment  Check patient’s blood glucose level prior to any invasive procedure or if patient complains of not feeling well References  Malamed, S. F. (2022). Medical emergencies in the dental office. Elsevier.  Little, J. W., Miller, C., & Rhodus, N. L. (2017). Little and Falace’s dental management of the medically compromised patient. Mosby.  Grimes, E. B. (2014). Medical emergencies: Essentials for the Dental Professional. Prentice Hall  http://www.diabetes.org/assets/pdfs/basics/cdc-statistics-report.pdf  https://www.cdc.gov/diabetes/data/statistics/statistics-report.html  https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf  http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401751/  https://diatribe.org/silent-complication-closer-look-diabetic-retinopathy  https://www.niddk.nih.gov/health-information/diabetes/overview/preventing- problems/nerve-damage-diabetic-neuropathies  http://www.diabetes.org/living-with-diabetes/complications/kidney-disease- nephropathy.html  http://clinical.diabetesjournals.org/content/34/1/54  https://integrateddiabetes.com/continuous-glucose-monitor-comparisons-and-reviews/