Endocrine and Hematologic Emergencies Study Guide

Endocrine and Hematologic Emergencies

National EMS Education Standard Competencies

• Medicine: Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient.
• Awareness that diabetic emergencies can cause altered mental status.
• Anatomy, physiology, pathophysiology, assessment, and management of acute diabetic emergencies, sickle cell crisis, and clotting disorders.

Introduction

• The endocrine system influences nearly every cell, organ, and function of the body.
• Endocrine disorders can manifest with various signs and symptoms.
• Hematologic emergencies can be difficult to assess and treat.

Anatomy and Physiology: Endocrine System

• The endocrine system is a communication system that controls functions inside the body.
• Glands secrete messenger hormones that affect target organs, tissues, or cells.
• Endocrine disorders arise from internal communication problems.

Anatomy and Physiology: Glucose Metabolism

• The brain requires glucose and oxygen for proper function.
• Insulin is essential for glucose to enter cells.
• Without sufficient insulin, cells are not adequately nourished.

Pancreas and Glucose Regulation

• The pancreas produces and stores glucagon and insulin.
• Islets of Langerhans within the pancreas contain alpha and beta cells.
• Alpha cells produce glucagon, which increases blood glucose levels.
• Beta cells produce insulin, which facilitates glucose uptake by cells.

Pathophysiology: Diabetes Mellitus

• Diabetes mellitus impairs the body's ability to utilize glucose for fuel.
• Untreated diabetes leads to elevated blood glucose levels.
• Complications of diabetes include blindness, cardiovascular disease, and kidney failure.
• It is crucial to recognize the signs and symptoms of both hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose).
• Both hyperglycemia and hypoglycemia can occur in type 1 and type 2 diabetes mellitus.
• Hypoglycemia necessitates prompt treatment.

Diabetes Mellitus Type 1

• Type 1 diabetes is an autoimmune disorder where the immune system attacks pancreatic beta cells.
• This results in a deficiency of the pancreatic hormone insulin.
• Without insulin, glucose cannot enter cells, impairing energy production.
• Onset typically occurs from early childhood through the fourth decade of life.
• The immune system destroys the pancreas's ability to produce insulin.
• Patients with type 1 diabetes require an external source of insulin to survive.

Insulin Pumps

• Many individuals with type 1 diabetes use implanted insulin pumps.
• These pumps continuously measure glucose levels and administer insulin.
• Insulin pumps reduce the frequency of fingerstick glucose checks.
• Malfunctions can occur, leading to diabetic emergencies, so it's crucial to inquire about insulin pump usage.

Symptoms of New-Onset Type 1 Diabetes

• Type 1 diabetes is the most common metabolic disease of childhood.
• New-onset patients often exhibit symptoms related to eating and drinking, including:
  • Polyuria (frequent urination)
  • Polydipsia (excessive thirst)
  • Polyphagia (excessive hunger)
  • Weight loss
  • Fatigue

Normal Blood Glucose and Renal Threshold

• Normal blood glucose levels range from 80 to 120 mg/dL.
• When blood glucose levels exceed this range, the kidneys' filtration system is overwhelmed, resulting in glucose spillage into the urine.

Ketone Production in Type 1 Diabetes

• When glucose is unavailable for cells:
  • The body resorts to burning fat for energy.
  • This process generates acid waste products called ketones.
  • Elevated ketone levels in the blood lead to their excretion in the urine.
  • The kidneys struggle to maintain acid-base balance.
  • The patient may exhibit Kussmaul respirations (rapid, deep breathing).

Diabetic Ketoacidosis (DKA)

• If fat metabolism and ketone production persist, diabetic ketoacidosis (DKA) can develop.
• DKA may manifest with:
  • Generalized illness
  • Abdominal pain
  • Body aches
  • Nausea
  • Vomiting
  • Altered mental status or unconsciousness

DKA Treatment and Glucose Levels

• Untreated DKA can be fatal.
• Assess glucose levels using a fingerstick with a lancet and glucometer.
• Generally, glucose levels in DKA are higher than 400 mg/dL.

Diabetes Mellitus Type 2

• Type 2 diabetes results from resistance to the effects of insulin at the cellular level.
• Obesity increases the risk of developing type 2 diabetes.
• The pancreas compensates by producing more insulin.
• Insulin resistance can sometimes be improved through exercise and dietary modifications.

Medications for Type 2 Diabetes

• Oral medications are commonly used to manage type 2 diabetes.
• Injectable medications and insulin may also be used.

Diagnosis of Type 2 Diabetes

• Type 2 diabetes is often diagnosed during routine medical exams.
• Diagnosis may stem from complaints related to elevated blood glucose levels, such as:
  • Recurrent infections
  • Changes in vision
  • Numbness in the feet

Symptomatic Hyperglycemia

• Symptomatic hyperglycemia occurs when blood glucose levels are elevated.
• Patients may experience altered mental status due to a combination of problems.
• In type 1 diabetes, hyperglycemia can lead to ketoacidosis and dehydration from frequent urination.
• In type 2 diabetes, it can lead to a nonketotic hyperosmolar state of dehydration.

Long-Term Consequences of Hyperglycemia

• Protracted hyperglycemia can result in:
  • Wounds that do not heal
  • Numbness in the hands and feet
  • Blindness
  • Renal failure
  • Gastric motility problems

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

• When blood glucose levels are poorly controlled in type 2 diabetes, HHNS can develop.
• Key signs and symptoms of HHNS include:
  • Hyperglycemia
  • Altered mental status, drowsiness, lethargy
  • Severe dehydration, thirst, dark urine
  • Visual or sensory deficits
  • Partial paralysis or muscle weakness
  • Seizures

Hyperglycemia and Dehydration

• Elevated glucose levels in the blood cause glucose excretion in the urine.
• Increased fluid intake leads to polyuria.
• Urine becomes dark and concentrated.
• Severe dehydration can lead to unconsciousness or seizure activity.

Symptomatic Hypoglycemia

• Symptomatic hypoglycemia occurs when a patient's blood glucose level drops too low.
• This condition requires prompt correction.
• It can occur in patients who inject insulin or take oral medications that stimulate insulin production.
• High insulin levels cause rapid glucose removal from the blood.
• If glucose levels fall too low, the brain may not receive an adequate supply.

Effects of Hypoglycemia on Mental Status

• Hypoglycemia can cause a decline in mental status.
• Patients may become aggressive or exhibit unusual behavior.
• Unconsciousness and permanent brain damage can rapidly ensue.

Causes of Hypoglycemia

• Common reasons for low blood glucose include:
  • Correct insulin dose with a change in routine.
  • More insulin than necessary.
  • Correct insulin dose without sufficient food intake.
  • Correct insulin dose with an acute illness.

Signs and Symptoms of Hypoglycemia

• Signs and symptoms of hypoglycemia include:
  • Normal to shallow or rapid respirations
  • Pale, moist skin
  • Diaphoresis (excessive sweating)
  • Dizziness, headache
  • Rapid pulse
  • Normal to low blood pressure
  • Altered mental status
  • Anxious or combative behavior
  • Seizure, fainting, or coma
  • Weakness on one side of the body
  • Rapid changes in mental status

Treatment of Hypoglycemia

• Hypoglycemia is quickly reversed by administering glucose.
• Without glucose, permanent brain damage can occur.

Scene Size-Up

• Assess scene safety, noting that patients with diabetes may use syringes.
• Be alert for clues and use standard precautions.
• Question bystanders about events leading to your arrival.
• Consider the possibility of trauma.
• Determine the mechanism of injury (MOI) or nature of illness (NOI).

Primary Assessment

• Form a general impression.
• Airway and breathing:
  • Patients with inadequate breathing, pulse oximetry ≤ 94%, or altered mental status should receive high-flow oxygen (12 to 15 L/min via nonrebreathing mask).
  • Hyperglycemic patients may have Kussmaul respirations and sweet, fruity breath.
  • Hypoglycemic patients will have normal or shallow to rapid respirations.
• Circulation:
  • Dry, warm skin suggests hyperglycemia.
  • Moist, pale skin suggests hypoglycemia.
  • A rapid, weak pulse indicates symptomatic hypoglycemia.
• Transport decisions:
  • Provide prompt transport for patients with altered mental status and inability to swallow.
  • Further evaluate conscious patients who can swallow and maintain their airway.

History Taking

• Investigate the chief complaint.
• Obtain a history of the present illness from responsive patients, family, or bystanders.
• If the patient has eaten but not taken insulin, hyperglycemia is more likely.
• If the patient has taken insulin but not eaten, hypoglycemia is more likely.
• Use the SAMPLE history mnemonic:
  • Do you take insulin or pills to lower blood sugar?
  • Do you wear an insulin pump? Is it working properly?
  • Have you taken your usual insulin dose (or pills) today?
  • Have you eaten normally today?
  • Have you had any illnesses, unusual activity, or stress?

Secondary Assessment

• Physical examination:
  • Assess unresponsive patients from head to toe.
  • In suspected diabetes-related problems, focus on mental status, ability to swallow, and ability to protect the airway.
• Vital signs:
  • Use a glucometer if available and protocols allow.
  • Hypoglycemia: respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure.
  • Hyperglycemia: respirations may be deep and rapid; pulse may be rapid, weak, and thready; and skin may be warm and dry with a normal blood pressure.

Portable Glucometer

• Study the operator's manual for proper use in the field.
• Know the upper and lower ranges at which your glucometer functions.
• Normal nonfasting adult and child blood glucose level range: 80 to 120 mg/dL; neonates should be above 70 mg/dL.

Reassessment

• Reassess frequently.
• Provide indicated interventions.
  • Hypoglycemic, conscious, and able to swallow:
    • Encourage patient to take glucose tablets or drink juice containing sugar.
    • Administer highly concentrated sugar gel.
    • Provide rapid transport.
    • Hypoglycemic, unconscious, or at risk for aspiration:
      • Patient needs intravenous (IV) glucose or intramuscular (IM or IN) glucagon.
      • When in doubt, consult medical control.
• If unable to test for blood glucose:
  • Perform a thorough assessment.
  • Contact the hospital for assistance.
• Communication and documentation:
  • Patients who refuse transport after symptom improvement require thorough documentation.

Emergency Medical Care for Diabetic Emergencies

• Giving oral glucose:
  • Three types: rapidly dissolving gel, large chewable tablets, liquid formulation.
  • Contraindications: inability to swallow and unconsciousness.
  • Wear gloves before putting anything in patient’s mouth.
  • Follow local protocols for glucose administration.
  • Reassess frequently and provide transport.

Presentation of Hypoglycemia

• Seizures:
  • Consider hypoglycemia or an underlying condition.
  • Ensure airway is clear.
  • Place patient on their side, and put nothing in their mouth.
  • Have suctioning equipment ready.
  • Provide oxygen or artificial ventilations for inadequate breathing or cyanosis.
  • Transport promptly.
• Altered mental status:
  • May be caused by diabetes complications.
  • Use the mnemonic AEIOU-TIPS.
  • Always suspect and check for hypoglycemia.
  • Ensure airway is clear and be prepared to provide artificial ventilations and suctioning if patient vomits.
  • Provide prompt transport.
• Misdiagnosis of neurologic dysfunction:
  * Symptoms mistaken for intoxication
  * Look for emergency medical identification bracelet, necklace, or card.
  * Perform blood glucose test at the scene (if protocols allow) or ED.
  * Diabetes and alcoholism can coexist in a patient.
• Relationship to airway management:
  * Patients with altered mental status can lose gag reflex.
  * Vomit or tongue may obstruct airway.
  * Carefully monitor airway, place patient in lateral recumbent position, and ensure suction is available.

Hematologic Emergencies

• Hematology is the study of blood-related diseases.
• Four disorders that can create a prehospital emergency:
  • Sickle cell disease
  • Hemophilia A
  • Thrombophilia
  • Anemia

Anatomy and Physiology of Blood

• Blood is made up of four components:
  • Red blood cells: Contain hemoglobin, which carries oxygen to the tissues.
  • White blood cells: Collect dead cells and provide for their correct disposal.
  • Platelets: Essential for clot formation.
  • Plasma: Serves as the transportation medium.

Pathophysiology: Sickle Cell Disease

• Inherited disorder affecting red blood cells.
• Predominantly affects people of African, Caribbean, and South American ancestry.
• Misshapen RBCs lead to dysfunction in oxygen binding and unintentional clot formation.
• Sickled cells have a short life span, resulting in more cellular waste products and contributing to sludging of the blood.
• Complications include:
  • Anemia
  • Gallstones
  • Jaundice
  • Splenic dysfunction
  • Vascular occlusion with ischemia leads to acute chest syndrome, stroke, joint necrosis, pain crises, acute and chronic organ dysfunction/failure, retinal hemorrhages, and increased risk of infection.

Pathophysiology: Hemophilia

• Clotting disorders—hemophilia is a rare disorder where only about 20,000 Americans have the disorder, and Hemophilia A affects mostly males.
  • Decreased ability to create a clot after an injury, which can be life threatening
  • Patients can be prescribed medications to replace missing clotting factors, release stored clotting factors, or prevent the breakdown of blood clots.
• Common complications of hemophilia A include:
  • Long-term joint problems that may require a joint replacement
  • Bleeding in the brain and thrombosis due to treatment

Pathophysiology: Thrombophilia & DVT

• Thrombophilia: A disorder in the body’s ability to maintain the smooth flow of blood through the venous and arterial systems, where the concentration of particular elements in the blood creates clogging or blockage issues.
  • General term for conditions that result in blood clotting more easily than normal, where clots can spontaneously develop in the blood of the patient.
• Deep Vein Thrombosis (DVT): A common medical problem in sedentary patients and in patients who have had recent injury or surgery.
  • Methods to prevent blood clot formation include blood-thinning medications, compression stockings, and mechanical devices.
  • Risk factors include joint replacement surgery and remaining sedentary for long periods.
• Treatment includes anticoagulation therapy, where medications are typically administered for at least 3 months after diagnosis of a DVT.
  • A clot from the DVT can travel from the patient’s lower extremity to the lung, causing a pulmonary embolus.

Pathophysiology: Anemia

• An abnormally low number of RBCs where blood is unable to deliver adequate amounts of oxygen to the tissues.
• Pulse oximetry may indicate an adequate saturation, even though the tissues are hypoxic.

Scene Size-Up for Hematologic Disorders

• Most sickle cell patients will have had a crisis before.
• Wear gloves and eye protection at a minimum and consider ALS support.

Primary Assessment for Hematologic Disorders

• Perform cervical spine immobilization, if necessary.
• In inadequate breathing or altered mental status, administer high-flow oxygen at 12 to 15 L/min via nonrebreathing mask.
• Sickle cell crisis patients may have increased respirations or signs of pneumonia; therefore, manage respiratory distress.
• Sickle cell patients will have increased heart rates.
  • Suspected hemophilia patients: Be alert for signs of acute blood loss and bleeding of unknown origin. Also, be alert for signs of hypoxia and make a transport decision.

History Taking for Hematologic Disorders

• Physical signs indicating sickle cell crisis:
  • Swelling of fingers and toes
  • Priapism
  • Jaundice
• Ask about:
  • Single location or felt throughout the body?
  • Visual disturbances?
  • Nausea, vomiting, or abdominal cramping?
  • Chest pain or shortness of breath?
• Obtain SAMPLE history from responsive patient or family member:
  • Have you had a crisis before?
  • When was the last time you had a crisis?
  • How did your last crisis resolve?
  • Recent illness, unusual amount of activity, or stress?

Secondary Assessment for Hematologic Disorders

• Focus physical examination on major joints.
• Evaluate and document mental status using (AVPU).
• Obtain complete set of vital signs, look for signs of sickle cell crisis, and use pulse oximeter, if available.

Reassessment for Hematologic Disorders

• Reassess vital signs frequently and evaluate interventions.
• Adjust or change the interventions as needed.
• Document each assessment and communicate with hospital staff for continuity of care.

Emergency Medical Care for Hematologic Disorders

• Mainly supportive and symptomatic.
• Patients with inadequate breathing or altered mental status:
  • Administer high-flow oxygen at 12 to 15 L/min via nonrebreathing mask.
  • Place in a position of comfort and transport rapidly to hospital.

Review Questions Explanation

• Type 1 diabetes is a disease in which the pancreas fails to produce enough insulin (or produces none at all). Insulin is a hormone that promotes the uptake of sugar from the bloodstream and into the cells. Without insulin, glucose utilization is impaired because it cannot enter the cell.
• All of these questions are important to ask the spouse of an unconscious diabetic. However, it is critical to ask if the patient took his insulin. This will help you differentiate hypoglycemic crisis from hyperglycemic crisis. For example, if the patient took his insulin and did not eat, or accidentally took too much insulin, you should suspect hypoglycemic crisis. If the patient did not take his insulin, you should suspect hyperglycemic crisis.
• In severe hyperglycemia, the kidneys excrete excess glucose from the body. This process requires a large amount of water to accomplish; therefore, water is excreted with the glucose, resulting in dehydration.
• The combination that would most likely cause a hypoglycemic crisis is skipping a meal and taking insulin. The patient will use up all available glucose in the bloodstream and become hypoglycemic. Left untreated, hypoglycemic crisis may cause permanent brain damage or even death.
• Immediately after determining that a patient is unresponsive, your first action should be to manually open his or her airway (eg, head tilt–chin lift, jaw-thrust). Use suction as needed to clear secretions from the patient’s mouth. After manually opening the airway and ensuring it is clear of obstructions, insert a nasal airway adjunct and then assess the patient’s breathing.
• Kussmaul respirations—a rapid and deep breathing pattern seen in patients with DKA—indicates that the body is attempting to eliminate ketones via the respiratory system. A fruity or acetone breath odor is usually present in patients with Kussmaul respirations.
• The child is experiencing a hyperglycemic crisis secondary to severe hyperglycemia. Hyperglycemic crisis is characterized by a slow onset and excessive urination (polyuria), thirst (polydipsia), and hunger (polyphagia). Other signs include rapid, deep breathing with a fruity or acetone breath odor (Kussmaul respirations); a rapid, thready pulse; and an altered mental status.
• If the body’s cells do not receive glucose, they will begin to metabolize the next most readily available substance—fat. Fat metabolism results in the production of ketoacids, which are released into the bloodstream (hence the term “ketoacidosis”).
• Hypoglycemic crisis usually responds immediately following treatment with glucose. Patients with hyperglycemic crisis generally respond to treatment gradually, within 6–12 hours following the appropriate treatment. Seizures can occur with both hyperglycemic crisis and hypoglycemic crisis, but are more common in patients with hypoglycemic crisis.
• Severe hyperglycemia—which leads to diabetic ketoacidosis—causes the body to excrete large amounts of glucose and water. As a result, the patient becomes severely dehydrated, which leads to excessive thirst (polydipsia).
• Hematology is the study and prevention of blood-related diseases, such as sickle cell disease and hemophilia.
• The blood is made up of two main components: cells and plasma. The cells in the blood include red blood cells (erythrocytes), white blood cells (leukocytes), and platelets. These cells are suspended in a straw-colored fluid called plasma.
• SAMPLE is the mnemonic used in taking the history of all patients. In addition to asking the SAMPLE, EMTs should also ask about past crises.
• Although analgesics would benefit a patient suffering from a hematologic disorder, the administration of such medications is not in the scope of practice for the EMT. ALS providers would have to be present to provide this emergency care.