EMT Chapter 20/21*63 Endocrine/ Hematologic Emergencies and Allergy/ Anaphylaxis

Acidosis

the buildup of excess acid in the blood or body tissues that results from a primary illness

diabetes mellitus

A metabolic disorder in which the ability to metabolize carbohydrates (sugars) is impaired, usually because of a lack of insulin; impairs body’s ability to use glucose for fuel - Cannot get glucose into the cells (glucose levels get too high)

Diabetic Ketoacidosis (DKA)

A form of hyperglycemia in uncontrolled diabetes in which certain acids accumulate when insulin is not available; *weight loss is very very unhealthy

endocriene glands

secrete or release chemicals that used inside the body

Endocrine system

The complex message and control/communications system that integrates many body functions, including the release of hormones.

Glucose

One of the basic sugars; it is the primary fuel, in conjunction with oxygen - needed for cellular metabolism in brain; Insulin is necessary for glucose to enter cells for metabolism

Hematology

The study and prevention of blood-related disorders.

Hemophilia

A hereditary condition in which the patient lacks one or more of the blood's normal clotting factors (Type A - mostly affects males); Decreased ability to create a clot after an injury

Hormones

chemical substances produced in specialized organs or glands and carried to another organ or group of cells in the same organism. Help regulate many body functions, including metabolism, growth, and body temperature.

Hyperglycemia

An abnormally high blood glucose level

Hyperosmolar Hyperglycemic nonketotic Syndrome (HHNS)

A life-threatening condition resulting from high blood glucose that typically occurs in older adults in Type 2, and which causes altered mental status, dehydration, and organ damage *Leads to a much more ominous fluid imbalance, NO KETONES are produced, little fat is burned, Slower onset than DKA (no sweet breath)

Hypoglycemia

abnormally low level of sugar in the blood

Insulin

A hormone produced by the islets of Langerhans (endocrine gland located throughout the PANCREAS) that enables glucose in the blood to enter cells; used in synthetic form to treat and control diabetes mellitus, without - cells would starve

Kussmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.

Polydipsia

Excessive thirst that persists for long periods, despite reasonable fluid intake; often the result of excessive urination.

Polyphagia

Excessive eating; in diabetes, the inability to use glucose properly can cause a sense of hunger.

Polyuria

The passage of an unusually large volume of urine in a given period; in diabetes, this can result from the wasting of glucose in the urine.

Sickle cell disease

A hereditary disease that causes normal, round red blood cells to become oblong, or sickle shaped; lead to dysfunction in oxygen binding and unintentional clot formation; may result in a blockage known as vasoocclusive - must maintain hydration

Symptomatic hyperglycemia

A state of unconscious resulting from several problems, including ketoacidosis, dehydration because of excessive urination

symptomatic hypoglycemia

Severe hypoglycemia resulting in changes in mental status.

Thrombophilia

A tendency toward the development of blood clots as a result of an abnormality of the system of coagulation; inherited, medications, or cancer causing

thrombosis

A blood clot, either in the arterial or venous system.

type 1 diabetes

An autoimmune disorder in which the individual's immune system produces antibodies to the pancreatic beta cells, and therefore the pancreas cannot produce insulin; onset in early childhood is common through the 4th decade of life (missing the pancreatic hormone insulin); cannot survive without insulin

type 2 diabetes

A condition in which insulin resistance develops in response to increased blood glucose levels; can be managed by exercise and diet modification, but is often managed by medications; "the key cannot open the lock"

vasoocclusive crisis

Ischemia and pain caused by sickle-shaped red blood cells that obstruct blood flow to a portion of the body.

Allergen

a substance that causes an allergic reaction

Allergic reaction

The body's exaggerated immune response to an internal or surface agent/substance

Anaphylaxis

An extreme, life-threatening systemic allergic reaction that may include shock and respiratory failure; Can rapidly result in shock and death

Angioedema

Localized areas of swelling beneath the skin, often around the eyes and lips, but it can also involve other body areas as well.

envenomation

The act of injecting venom.

Epinephrine

A substance produced by the body (commonly called adrenaline), and a drug produced by pharmaceutical companies that increases pulse rate and blood pressure; the drug of choice for an anaphylactic reaction - Rapidly reverses the effects of anaphylaxis

Histamines

Chemical substances released by the immune system in allergic reactions that are responsible for many of the symptoms of anaphylaxis, such as vasodilation.

immune response

The body's response to a substance perceived by the body as foreign

Immunology

study of the immune system

Immune system

The body system that includes all of the structures and processes designed to mount a defense against foreign substances/organisms and disease-causing agents.

Leukotrienes

Chemical substances that contribute to anaphylaxis; released by the immune system in allergic reactions.

Stridor

A harsh, high-pitched respiratory sound, generally heard during inspiration, that is caused by partial blockage or narrowing of the upper airway; may be audible without a stethoscope - can lead to total airway obstruction

Toxin

A harmful substance produced by living cells or organisms

urticaria

Small areas of generalized itching and/or burning that appear as multiple raised areas on the skin; hives.

Wheal

A raised, swollen, well-defined area on the skin resulting from an insect bite or allergic reaction.

Wheezing

A high-pitched, whistling breath sound that is most prominent on expiration, and which suggests an obstruction or narrowing of the lower airways; occurs in asthma and bronchiolitis.

Glucose metabolism

Pancreas produces and stores two hormones that play major role (Glucagon and Insulin); in a person without diabetes, the pancreas stores and secretes insulin and glucagon in the blood.

Alpha cells

produce glucagon

Beta cells

produce insulin

When a person eats, glucose rises in blood

pancreas secretes insulin into the blood, allows extra glucose to be stored in liver and skeletal muscles for later use (called glycogen)

If a meal is skipped or delayed, a message is sent to

the pancreas to secrete glucagon; glucagon then stimulates the liver and the skeletal muscles to release glycogen (stored glucose),and converts it back to glucose for use as cellular fuel

Hyperglycemia signs and symptoms

(altered mental status, mimic alcohol intoxication) Dry, warm skin, deep and rapid, strong pulse, normal BP *wounds that do not heal, numbness in hands and feet, blindness, renal failure, and gastric motility problems

Hypoglycemia signs and symptoms

(altered mental status, mimic alcohol intoxication) Normal to shallow or rapid respirations/pulse (weak), Pale, moist skin, Diaphoresis, Dizziness, headache, Rapid pulse, Normal to LOW blood pressure, Anxious or combative behavior, Seizure, fainting, or coma, Weakness on one side of the body, Rapid changes in mental status

HHNS signs and symptoms

Hyperglycemia, Altered mental status, drowsiness, lethargy, Severe dehydration, thirst, dark urine, Visual or sensory deficits, Partial paralysis or muscle weakness, seizures

Insulin is the KEY

to the DOOR of the Cell

implanted insulin pump (type 1)

Continuously measures glucose levels and provides insulin.

Most common metabolic disease of childhood

Diabetes Mellitus Type 1

New-onset patient will have symptoms related to eating and drinking

Polyuria, Polydipsia, Polyphagia, Weight loss, and Fatigue

Normal blood glucose is

between 80 to 120 mg/dL (neonates should be above 70 mg/dL)

When glucose is unavailable to cells

the body turns to burning fat

When the body burns fat instead of glucose, this forms

acid waste, called ketones

Ketones

very difficult to eliminate and accumulate in the blood causing acidosis (Patient breathes faster and deeper - Kussmaul respirations)

In dysfunction, kidneys cannot maintain

acid–base balance

If fat metabolism and ketone production continue

Diabetic Ketoacidosis (DKA) can develop

If not recognized and treated, DKA can result in

death; generally higher than 400 mg/dL, can be up in the 1000’s

Oral medications and diet are used to treat

type 2 diabetes (injectable medications and insulin are also used)

In type 1 diabetes, Symptomatic Hyperglycemia leads to

ketoacidosis with dehydration from excessive urination

In type 2 diabetes, Symptomatic Hyperglycemia leads to

nonketotic hyperosmolar state of dehydration

Higher glucose levels in the blood cause the

excretion of glucose in the urine

Unconsciousness resulting from several problems

Hyperglycemia, DKA, HHNS (sugar >800)

Signs of Diabetic Coma

Typically occurs over hours or days; Kussmaul respirations, Cardiovascular system tries to compensate for Dehydration (Very dry warm skin, Sunken eyes, Dry mucous membranes, Skin tenting/turgor problems), Fruity breath, Varying degrees of unresponsiveness

When you suspect a diabetes-related problem, focus on

mental status, ability to swallow, and ability to protect airway

Hypoglycemic, unconscious, risk of aspiration

GET ALS ENROUTE ASAP, Patient needs intravenous (IV) glucose or intramuscular (IM or IN) glucagon, When in doubt, consult medical control

Oral glucose Works better if

let dissolved rather than swallowed

Complications of Diabetes

Heart disease (Atherosclerosis, cholesterol/triglyceride problems, silent MI), Renal failure (Damage to minute vessels in kidneys, Can lead to dialysis), Stroke (Damage to vessels, atherosclerosis), Skin Ulcers/Infections of the feet and toes (Poor circulation, amputations), Seizures/Altered mental status (Injuries, accidents, airway problems)

Children pose management problems

Will let ketones develop to lose weight

Four disorders that can create a prehospital emergency

Sickle cell disease, Hemophilia A, Thrombophilia, Anemia

Blood is made up of four components

Red blood cells (contain hemoglobin, which carries 97% of the oxygen to the tissues), White blood cells (collect dead cells and provide for their correct disposal), Plasma (essential for clot formation), Plasma (serves as the transportation medium)

Sickle cell disease Physical signs

Swelling of fingers and toes, Priapism, Jaundice

deep vein thrombosis (DVT)

Common medical problem in sedentary patients and in patients who have had recent injury or surgery

Anemia

abnormally low number of RBCs; May result from Chronic or acute bleeding, Deficiency in certain vitamins or minerals, Underlying disease process; unable to deliver adequate amounts of oxygen to the tissues

Some people do not have a reaction with their

first exposure to an allergen (They become sensitized after first exposure)

Systemic reaction

involves multiple organs, anapyhlaxis

Local reaction

involves tissues around sting site, local swelling, hives

Three common signs of anaphylaxis

Urticaria, Angioedema, Wheezing

Wasps and hornets can sting

multiple times

Insect Stings Signs and symptoms

Sudden pain, Swelling, Localized heat, Urticaria, Redness in light-skinned individuals, Itching and a wheal

In severe, anaphylactic, cases (of Insect Stings) patients may experience

Dramatic swelling, Stridor, Bronchospasm and wheezing, Chest tightness and coughing, Dyspnea, Anxiety, Gastrointestinal complaints, Hypotension

Airway and breathing, Assist the patient into

high Fowler position to maximize ventilations (If signs of shock, place the patient in supine position)

Definitive treatment for anaphylactic shock is

epinephrine

Decision to apply oxygen should be based on

Airway patency, Work of breathing, Abnormal lung sounds

Mild reactions require

supportive care and monitoring

Anaphylaxis requires

epinephrine and ventilatory support (this first)

Epinephrine concentration

1:1000 mg/ml

Side effects of epinephrine

High blood pressure, Increased pulse rate, Anxiety, Cardiac arrhythmias, Pallor, Dizziness, Chest pain, Headache, Nausea, Vomiting

Do not give epinephrine to

Patients without signs of respiratory compromise or hypotension, Those who do not meet the criteria for a diagnosis of anaphylaxis (Some patients may just be having a mild allergic reaction)

Type 1 diabetes is a condition in which

glucose utilization is impaired

A 45-year-old man with type 1 diabetes is found unresponsive. Which of the following questions is MOST important to ask his wife?

Did he take his insulin today?”

A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of

excretion of glucose and water from the kidneys

Which combination of factors would MOST likely cause a hypoglycemic crisis in a diabetic patient?

Skipping a meal and taking insulin

A 19-year-old diabetic male was found unresponsive on the couch by his roommate. After confirming that the patient is unresponsive, you should

manually open his airway

What breathing pattern would you MOST likely encounter in a patient with diabetic ketoacidosis (DKA)?

Rapid and deep

A woman called EMS because her 12-year-old son, who had been experiencing excessive urination, thirst, and hunger for the past 36 hours, has an altered mental status and is breathing fast. You should be MOST suspicious for

hyperglycemic crisis

If the cells do not receive glucose, they will begin to metabolize

fat

In contrast to a hyperglycemic crisis, a hypoglycemic crisis

usually responds immediately after treatment