Ch. 20 Endocrine and Hematologic Emergencies

hypersecretion

more hormones are produced

hyposecretion

not enough hormones are produced

what 2 things does the brain need to survive?

glucose and oxygen

what 2 hormones does the pancreas produce and store?

• glucagon and insulin

  • the pancreas stores and secretes these in response to the level of glucose in the blood

____ is necessary for glucose to enter cells

insulin

diabetes mellitus

• a disorder of glucose metabolism, such that the body has an impaired ability to get glucose into cells to be used for energy

• without treatment, blood glucose levels become too high

  • severe complications: blindness, cardiovascular disease, kidney failure

3 types of diabetes

• diabetes mellitus type 1

• diabetes mellitus type 2

• pregnancy-induced, gestational diabetes

hyperglycemia

s state in which the blood glucose level is above normal

hypoglycemia

a state in which the blood glucose level is below normal

hypoglycemia can develop:

• if a person takes their medications but fails to eat enough food

• if a person takes too much medications, resulting in low blood glucose levels despite normal dietary intake

signs/symptoms of hyperglycemia

• onset is gradual

• skin is warm and dry

• infection is common

• intense thirst

• increasing hunger

• vomiting and abdominal pain is common

• kussmaul respirations with

• sweet, fruity breath odor

• BP is normal to low

• rapid, weak, and thready pulse

• restless, abnormal or slurred speech, unsteady gait

signs/symptoms of hypoglycemia

• rapid onset

• skin is pale, cool, and moist

• thirst and hunger are absent

• normal breathing - may become shallow or ineffective

• BP is normal to low

• pulse is rapid and weak

• irritability, confusion, seizure, coma; unsteady gait

diabetes mellitus type 1

• definition: an autoimmune disorder in which the immune system produces antibodies against the pancreatic beta cells

  • missing insulin

• onset: usually occurs from early childhood through the 4th decade of life

• a pt with new-onset type 1 diabetes will have symptoms related to eating and drinking

implanted insulin pump

• common in pts with type 1 diabetes

• what it does: continuously measures glucose levels and provides insulin and correction doses of insulin based on carbohydrate intake at mealtimes

normal blood glucose level

80-120 mg/dL

polyuria

frequent urination

polydipsia

increase in fluid consumption

polyphagia

severe hunger and increased food intake

what happens when a pt’s blood glucose level is above normal?

• the kidney’s filtration system becomes overwhelmed and glucose spills into the urine

  • causes more water to be pulled out of the bloodstream

• increased urine production and urination cause dehydration and increased thirst

when glucose is unavailable to cells, what does the body do?

• the body turns to burning fat - it produces acid waste (ketones)

  • as ketone levels go increase in the blood, they spill into the urine

  • kidneys become saturated with glucose and ketones cannot maintain acid-base balance in the body

  • pt breathes faster + deeper (Kussmaul respirations) as the body atttempts to reduce the acid level by releasing more carbon dioxide through the lungs

• if metabolism and ketone production continue, diabetic ketoacidosis (DKA) can develop

diabetic ketoacidosis (DKA)

• may present as: generalized illness and:

  • abdominal pain, body aches, nausea, vomiting, altered mental status or unconsciousness

• if not rapidly recognized and treated is can result in death

• obtain a glucose level

Kussmaul respirations

• do NOT attempt to have the pt slow their breathing because the rapid, deep breathing is helping to get rid of the acids

diabetes mellitus type 2

• cause: resistance to the effects of insulin at the cellular level

  • fewer insulin receptors

• obesity predisposes pts to type 2 diabetes

• the body’s response: the pancreas produces more insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors

• diagnosed: usually from complaints related to high blood glucose levels: recurrent infection, change in vision, numbness in the feet

insulin resistance

• definition: blood glucose levels continue to rise and do not respond when the pancreas secretes insulin

• can sometimes be improved by exercise and dietary modification

oral medications used to treat type 2 diabetes

• types:

  • some increase the secretion of insulin - pose a high risk of hypoglycemic reaction

  • some stimulate receptors for insulin

  • others decrease the effects of glucagon and decrease the release of glucose stored in the liver

• names:

  • Glipizide (Glucotrol); Glyburide (DiaBeta, Glynase, Micronase); Metformin (Glumetza, Glucophage); Pioglitazone (Actos); rosiglitazone (Avandia); Exenatide (Byetta, Bydureon); liraglutide (Victoza); Sitagliptan (januvia)

symptomatic hyperglycemia

• occurs when blood glucose levels are very high

• type 1 diabetes: leads to ketoacidosis with dehydration from excessive urination

• type 2 diabetes: leads to nonketotic hyperosmolar state of dehydration due to the discharge of fluids from all of the body systems and eventually out through the kidneys, leading to fluid imbalance

• if a pt has hyperglycemia for a prolonged time, secondary consequences of diabetes can occur

  • wounds that do not heal, numbness in the hands and feet, blindness, renal failure, gastric motility problems

hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

• definition: life-threatening condition resulting from high blood glucose that typically occurs in older adults; causing altered mental status, dehydration, organ damage

• signs/symptoms: hyperglycemia, altered mental status, drowsiness, lethargy, severe dehydration, thirst, dark urine, visual or sensory deficits, partial paralysis or muscle weakness, seizures

• pts struggle to drink enough fluid to keep up with the high glucose levels in the blood

symptomatic hypoglycemia

• definition: an acute emergency in which a pt’s blood glucose level drops and must be corrected swiftly

• mental status declines and pt may become aggressive or display unusual behavior

• common causes: a correct dose of insulin with a change in routine, more insulin that necessary, a correct does of insulin without the pt eating enough, a correct dose of insulin and the pt developed an acute illness

• signs/symptoms: normal to shallow respirations, pale and moist skin, diaphoresis, dizziness, headache, rapid pulse, normal to low BP, altered mental status, anxious or combative behavior, seizure, fainting, coma, weakness on one side of the body, rapid changes in mental status

hyperosmolarity

describes very concentrated blood as a result of relative dehydration

if pt has eaten but not taken insulin, ____ is more likely

hyperglycemia

if pt has taken insulin but not eaten, _____ is more likely

hypoglycemia

for a known pt with diabetes, ask:

• do you take insulin or pills that lower your blood sugar?

• do you wear an insulin pump?

• have you taken your usual insulin dose (or pills) today?

• have you eaten normally today?

• have you had any illness, unusual amount of activity, or stress?

neonates should be above ___ mg/dL

70

giving oral glucose

• 3 types

  • rapidly dissolving gel, large chewable tablets, liquid

• contraindications: the inability to swallow; unconsciousness

• wear ppe and follow local protocols for administration

• reassess the pt frequently

• squeeze the glucose under the tongue or into the buccal space and then swallow

seizures

• hypoglycemia can cause seizures

• management:

  • ensure airway is clear

  • place pt on side if no cervical trauma

  • do not place anything is pt’s mouth

  • have suctioning ready

  • administer oxygen if necessary

  • transport promptly

acidosis

the buildup of excess acid in the blood or body tissues that can result from primary illness

altered mental status

• may be caused by complication of diabetes

  • hypoglycemia; ketoacidosis

• use AEIOU-TIPS

• always check blood glucose in these pts

• management:

  • ensure the airway is clear

  • be prepared to provide ventilations

  • be prepared to suction

  • provide prompt transport

AEIOU-TIPS

• A = Alcohol

• E = epilepsy, endocrine, electrolytes

• I = Insulin

• O = Opiates and other drugs

• U = Uremia

• T = Trauma

• I = Infection

• P = Poisoning, psychogenic causes

• S = Shock, stroke, seizure, space-occupying lesion, subarachnoid hemorrhage

blood is made up of 4 components:

• erythrocytes (red blood cells)

• leukocytes (white blood cells)

• platelets

• plasma

red blood cells

• contain hemoglobin

• make up 42% - 47% of a person’s total blood volume

white blood cells

• make up 0.1% - 0.2% of a person’s blood cell volume

• respond to infection and collect dead cells for their correct disposal

platelets

• help form clots to stop bleeding

• make up 4% - 7% of a person’s blood cell volume

plasma

• serves as the transportation medium for all blood components, proteins, and minerals

sickle cell disease (Hemoglobin S disease)

• description: an inherited blood disorder that affects RBCs - leads to dysfunction in oxygen binding and unintentional clot formation

  • clots may result in a blockage known as vasooclusive crisis

  • can result in hypoxia, substantial pain, and organ damage

• found predominantly in people of African, Caribbean, and South American ancestry

• complications: anemia, gallstones, jaundice, splenic dysfunction, vascular occlusion with ischemia

• sickled cells have a short life span - contribute to sludging (clumping) of the blood

hemophilia

• rare

• affects mostly males

• pts with hemophilia A have a decreased ability to create a clot after an injury

• pts can be prescribed medications

• complications: long-term joint problems, bleeding in the brain, thrombosis due to treatment

thrombophilia

• description: a disorder in the body’s ability to maintain the smooth flow of blood through the venous and arterial systems