Endocrine, Hypoglycemia, Hyperglycemia, DKA/HHNK & Adrenal Crisis. AEMCA prep

Endocrine organs

Pineal gland, pituitary gland, thyroid gland, parathyroid gland, pancreas, adrenal glands, ovaries, and testes.

Major pancreatic hormones

Insulin and glucagon.

Role of insulin

Involved in regulation of blood glucose and cellular metabolism.

Role of glucagon

Involved in releasing stored glucose and maintaining blood glucose.

Organ maintaining blood glucose levels

The liver.

Glucose-related processes

Glycolysis, glycogenolysis, and gluconeogenesis.

Glycolysis

The process involving breakdown of glucose for energy.

Glycogenolysis

The breakdown of stored glycogen to release glucose.

Gluconeogenesis

The formation of glucose from non-carbohydrate sources.

Types of diabetes

Juvenile diabetes, gestational diabetes, late-onset diabetes, type 1 diabetes, and type 2 diabetes.

Diabetic emergencies

Hypoglycemia, hyperglycemia including diabetic coma and diabetic ketoacidosis, and hyperosmolar hyperglycemic non-ketotic acidosis or HHNK.

DKA

Diabetic ketoacidosis.

HHNK

Hyperosmolar hyperglycemic non-ketotic acidosis.

Endocrine emergencies besides diabetes

Addison’s disease, Cushing’s disease, pheochromocytoma, adrenal crisis, diabetes insipidus, hyperthyroidism including thyroid storm, hypothyroidism, and hyperaldosteronism.

Equipment for measuring blood glucose

A glucometer.

Glucometry expectations

How to perform glucometry and interpret blood glucose findings in patient assessment.

Capillary blood sample sites

The fingertip or, in pediatric patients who have not begun walking, the heel.

Blood sample from IV catheter

No.

Indication for the PCP Hypoglycemia Medical Directive

Suspected hypoglycemia.

Early treatment in suspected hypoglycemia

Glucometry.

Level of awareness for dextrose under the PCP Hypoglycemia Medical Directive

Altered level of awareness.

Minimum age for dextrose under the PCP Hypoglycemia Medical Directive

2 years or older.

Condition required before giving dextrose

The patient must be hypoglycemic.

Contraindication to dextrose

Allergy or sensitivity to dextrose.

Dextrose concentrations for hypoglycemia

10% dextrose and 50% dextrose.

PCP D10W dose for hypoglycemia

0.2 g/kg, which equals 2 mL/kg IV.

Maximum single dose of D10W

25 g, which equals 250 mL.

D10W dosing interval

10 minutes.

Maximum number of D10W doses

2.

PCP D50W dose for hypoglycemia

0.5 g/kg, which equals 1 mL/kg IV.

Maximum single dose of D50W

25 g, which equals 50 mL.

D50W dosing interval

10 minutes.

Maximum number of D50W doses

2.

Treatment goal for IV dextrose

Titrate to a level of awareness where the patient can safely consume complex carbohydrate.

Administration method for maximum single dose of D10W or D50W

Gradually over about 3 minutes.

Reason against over-administering dextrose

Overtreatment can cause rebound hyperglycemia.

Criteria for stopping IV dextrose before full dose

If the patient reaches a level of consciousness where they can safely consume carbohydrates.

PCPs authorized for administering IV dextrose

PCPs authorized for PCP Autonomous IV.

When to consider glucagon under the Hypoglycemia Medical Directive

When treating hypoglycemia and dextrose is not being used.

Level of awareness for glucagon

Altered level of awareness.

Contraindications to glucagon

Allergy or sensitivity to glucagon and pheochromocytoma.

IM glucagon dose for <25 kg

0.5 mg IM.

IM glucagon dose for ≥25 kg

1 mg IM.

Dosing interval for IM glucagon

20 minutes.

Maximum number of IM glucagon doses

2.

Intranasal glucagon option

Intranasal glucagon powder.

Minimum age for intranasal glucagon powder

4 years.

Intranasal glucagon powder dose

3 mg IN.

Dosing interval for intranasal glucagon

20 minutes.

Maximum number of intranasal glucagon doses

2.

What to do if glucagon is given with no improvement

Repeat glucometry and if the patient remains hypoglycemic, administer dextrose.

When to give oral glucose after dextrose or glucagon

When the patient responds and can safely ingest carbohydrates.

When to use oral glucose instead of dextrose or glucagon

When the patient has only mild signs or symptoms and can safely ingest carbohydrates.

Carbohydrate rule for mild hypoglycemia

The 15-15 rule may be used in patients who can safely ingest carbohydrates.

Safety requirement before giving oral carbohydrate

The patient must be able to safely ingest and swallow it.

Difference between hypoglycemia and hyperglycemia

Hypoglycemia means low blood glucose, while hyperglycemia means elevated blood glucose.

Danger of hypoglycemia

It can rapidly affect neurological function and level of consciousness.

Hypoglycemia in altered LOC

It is a potentially reversible cause of altered neurological status.

Conditions from severe hypoglycemia

Altered LOC, seizure, and other neurological impairment.

DKA in AEMCA syllabus

A form of acute hyperglycemia.

HHNK in AEMCA syllabus

A hyperosmolar hyperglycemic emergency.

Expectations for hypoglycemia, DKA, and HHNK

Know common causes, pathophysiology, possible consequences, and differences in clinical manifestations.

Diabetic control methods

Diet and exercise, oral antidiabetic agents, continuous subcutaneous insulin infusion pumps, insulin injections, and self-glucose monitoring.

Oral antidiabetic medication classes

Biguanides and sulfonylureas.

Insulin information expectations

Peak time and duration time for different insulin types.

First major assessment priority in endocrine emergency

Identify immediate ABC problems and assess the patient's neurological and circulatory status.

Medication history importance in diabetic patient

Assessment of diabetic control methods including insulin, oral medications, and insulin pumps.

Insulin pump definition

A continuous subcutaneous insulin infusion device used for diabetic control.

Endocrine condition with primary adrenal failure

Addison’s disease.

Adrenal crisis definition

An acute emergency occurring in a patient with adrenal failure and clinical signs of adrenal crisis.

Indication for PCP Suspected Adrenal Crisis Medical Directive

A patient with primary adrenal failure who is experiencing clinical signs of an adrenal crisis.

Medication for suspected adrenal crisis

Hydrocortisone, when the patient meets the directive and their hydrocortisone is available.

Paramedics carrying hydrocortisone for adrenal crisis

The directive requires paramedics to be presented with a vial of hydrocortisone for the identified patient.

Findings qualifying patient for Suspected Adrenal Crisis Medical Directive

Age-related hypoglycemia, GI symptoms, syncope, fever or suspected fever, altered level of awareness, age-related tachycardia, or age-related hypotension.

GI symptoms supporting suspected adrenal crisis

Vomiting, diarrhea, or abdominal pain.

Temperature finding supporting suspected adrenal crisis

Temperature of 38°C or higher or suspected or reported fever.

Altered level of awareness sign for adrenal crisis

Yes.

Hypotension sign for adrenal crisis

Yes, age-related hypotension is listed.

Tachycardia sign for adrenal crisis

Yes, age-related tachycardia is listed.

Hypoglycemia sign for adrenal crisis

Yes, age-related hypoglycemia is listed.

Contraindication to hydrocortisone

Allergy or sensitivity to hydrocortisone.

PCP hydrocortisone dose for suspected adrenal crisis

2 mg/kg.

Maximum single dose of hydrocortisone

100 mg.

Hydrocortisone dose rounding

To the nearest 10 mg.

Routes for hydrocortisone administration

IM or IV.

Hydrocortisone doses under the directive

One dose.

PCPs authorized for hydrocortisone IV

PCPs authorized for PCP Autonomous IV.

Examples of stress making a patient critically ill

Hypoglycemia, hypotension, gastrointestinal issues, and fractures.

Transport requirement after adrenal crisis treatment

Yes, these patients should be transported for additional care and follow-up.

Treat-and-discharge age criteria for hypoglycemia

Patient must be 18 years old and younger than 65 years old.

Required diagnosis for hypoglycemia treat and discharge

A diagnosis of diabetes.

Cause explaining hypoglycemic episode for treat and discharge

Insulin administration with inadequate oral intake.

Patient response to treatment for hypoglycemia treat and discharge

The hypoglycemia must promptly respond to treatment.

Number of symptomatic hypoglycemic episodes for treat and discharge

One isolated episode.

Minimum blood glucose after treatment for hypoglycemia treat and discharge

4.0 mmol/L or greater.

Neurological condition after treatment for hypoglycemia

Return to the patient's normal level of consciousness.

Vital signs requirement for hypoglycemia treat and discharge

A complete set of vital signs must be within expected normal ranges.

Intentional overdose qualification for hypoglycemia treat and discharge

No.

Hypoglycemia related to substance use for treat and discharge

No.

Seizure before paramedic treatment qualification

No.