EH

Endocrine System and Blood Disorders

Hormones and Glucose

  • The endocrine system uses hormones, including growth hormones.
  • Glucose is vital for brain function and cellular survival, requiring both glucose and oxygen.
  • Sources of glucose: Carbohydrates from food and drinks.
  • Insulin, produced by the pancreas, is essential for transporting glucose from the bloodstream into cells.
  • Without insulin, glucose remains in the bloodstream, causing problems.

Insulin and Pancreas

  • Pancreas contains alpha and beta cells in the Islets of Langerhans.
  • Alpha Cells: Produce glucagon which helps store excess sugar (glucose) in fat and muscle tissues as a reserve.
    • Historically important during famines.
  • Beta Cells: Produce insulin, which allows glucose to enter cells from the bloodstream.
  • Diabetes: Occurs when the body can't use glucose correctly due to insulin problems.
    • Types: Type 1, Type 2, and gestational diabetes (during pregnancy).

Diabetes and Its Complications

  • Uncontrolled diabetes leads to:
    • Blindness
    • Neuropathy (loss of sensation in hands and feet)
    • Kidney failure (potentially leading to dialysis)
    • Cardiovascular disease

Signs and Symptoms of High Blood Sugar

  • Altered mental status
  • Fruity smelling breath (ketones)
  • Excessive thirst
  • Frequent urination: Kidneys try to remove excess sugar, leading to dehydration.
  • Importance of water intake: To combat dehydration and dilute sugar concentration.

Signs and Symptoms of Low Blood Sugar

  • Altered mental status (rapid onset)
  • Cool and clammy skin
  • Shock-like symptoms

Diabetes Type 1

  • Pancreas doesn't produce enough or any effective insulin.
  • Glucose can't enter cells.
  • Treatment: Insulin injections or insulin pump.
  • Insulin Pumps:
    • Newer models: Monitor blood sugar and administer correct insulin doses.
    • Older models: Deliver set doses, which can be problematic if the person doesn't eat regularly.
  • Insulin administration: Must be injected; oral intake is ineffective.
  • Onset: Typically diagnosed before age 40.

Glucose Monitoring and Target Ranges

  • Glucometer: Used to check blood glucose levels.
  • Target Range: Generally 80-120 mg/dL, but Maryland's lower limit is around 70 mg/dL.
  • When to Check: On everyone with altered mental status, known diabetics, and ideally everyone with a pulse.

High Blood Sugar Complications

  • Insulin pump malfunction can lead to hyperglycemia.
  • Fruity breath and urine due to sugar and ketone excretion.
  • Kussmaul Respirations: Deep, fast breaths to expel excess sugar.
    • If the body can't eliminate ketones, it can lead to Diabetic Ketoacidosis (DKA).
  • DKA Symptoms:
    • Fruity breath
    • Altered mental status
    • Abdominal pain
    • Nausea and vomiting
  • Treatment: Fluid administration; transport to the hospital.
  • DKA Levels: Typically blood sugar over 400 mg/dL.
  • Glucometer Readings: May display "High" if sugar levels exceed the meter's maximum reading (e.g., 500 or 600).

Diabetes Type 2

  • Insulin resistance: Insulin is produced but doesn't effectively unlock cells to allow glucose entry.
  • Management: Healthy eating, exercise, oral medications to improve insulin function, or insulin injections.
  • Complications: Similar to type 1, including poor wound healing.

HHNS (Hyperosmolar Hyperglycemic Nonketotic Syndrome)

  • High blood sugar emergency; transport to hospital.

Hypoglycemia Treatment

  • Maryland's threshold: Treat if blood sugar is below 70 mg/dL.
  • Symptoms: Altered mental status, tiredness.
  • Treatment: Glucose administration (oral glucose).
  • Administration in Maryland: Conscious patients receive oral glucose; unconscious patients may receive glucose gel between cheek and gum with proper precautions to prevent choking.
  • Causes:
    • Too much insulin
    • Skipped meals
    • Overexertion
    • Sickness
    • Antibiotics
  • Symptoms: Shallow, rapid breathing; weakness on one side (mimicking a stroke).

Individual Variability in Blood Sugar

  • Individuals adapt to their typical blood sugar levels.
  • Example 1: A person with chronically low blood sugar may be functional at levels that would impair others.
  • Example 2: A person with chronically high blood sugar may experience symptoms of hypoglycemia at levels considered normal for others.
  • Importance of knowing the patient's normal range.
  • Long-term Consequences of Hypoglycemia: Brain damage and organ failure.

General Approach to Diabetic Emergencies

  • Check blood glucose on all patients, especially children.
  • Gestational Diabetes: Diabetes during pregnancy, usually in the first pregnancy and often resolves after.
  • Glucose Administration Precautions: Wear gloves as glucose gets everywhere.
  • Glucometer Accuracy:
    • Avoid contaminating test strips with glucose.
    • Designate one person for glucometer use or change gloves between checks.
    • Inaccurate readings can lead to misdiagnosis and improper treatment.
  • Reassessment: Check glucose levels frequently.
    • After glucose administration, check again in 5 minutes.
  • Dosage: Administer 10-15 grams of glucose initially; more can be given with consultation.
  • Trauma Considerations: Medical issues (like diabetes) can cause trauma (e.g., falls).

Assessment and Treatment

  • Airway, Breathing, Circulation (ABCs) are priority.
  • Smell for fruity breath.
  • Pay attention to skin color and temperature.
  • Prioritization: High or low priority depends on the patient's condition.
  • SAMPLE History: Gather information about insulin use, eating habits, medication changes, and activity levels.
  • Glucometer Use: Use your own glucometer to ensure accuracy.

Refusals

  • Patients may refuse transport despite low blood sugar.
  • Steps to take:
    • Ensure they understand the risks, including death.
    • Give them a sandwich to help stabilize their blood sugar.
    • Document everything, including monitoring their condition, explaining risks, and obtaining a witnessed refusal signature.
    • Educate them on what to do if their condition worsens.
  • Glucose Use: Rapidly raises blood sugar but doesn't sustain it.

Interventions and Documentation

  • Hospital Treatment: Hospitals provide longer-lasting food options to stabilize blood sugar.
  • ALS Interventions: May include Dextrose or Glucagon (not yet available in Maryland).
  • Dead Glucometer: If unsure whether sugar is too high or low, err on the side of caution and give glucose if the patient is unresponsive.
  • Document refusal of care.
  • Narratives: Paint a clear picture of what happened.

Glucose Administration and Seizures

  • Glucose Paste: Common form of glucose administration.
  • Precautions: Avoid putting fingers in the patient's mouth; wear gloves.
  • Seizures: Treat seizures related to diabetic issues the same as other seizures.

AEIOU TIPS (Causes of Altered Mental Status)

  • A: Alcohol, Allergies
  • E: Epilepsy, Electrolytes, Encephalitis
  • I: Insulin
  • O: Overdose, Oxygen
  • U: Uremia (Kidney Failure)
  • T: Trauma, Temperature
  • I: Infection
  • P: Poisoning, Psychiatric
  • S: Stroke, Shock, Space-occupying lesion, Sepsis
  • Assessment: Exclude possible causes, check blood sugar, look for medical identification.

Hematologic Emergencies

Sickle Cell Disease

  • Red blood cells are misshapen (sickle-shaped), impairing oxygen transport and causing blockages.
  • Impaired oxygen carrying capacity.
  • Clots and blockages restrict blood flow and oxygen delivery.
  • More common in African Americans.
  • Complications:
    • Anemia (low blood count)
    • Gallstones
    • Spleen problems
    • Chest pain
    • Strokes
    • Joint issues
    • Organ failure

Hemophilia

  • Bleeding disorder: Blood doesn't clot properly due to missing clotting factors.
  • Primarily affects males.
  • Minor injuries can become life-threatening.
  • Similar concerns as with blood thinners.

Thrombophilia

  • Blood clots too easily and spontaneously.
  • Can lead to:
    • Heart attack
    • Stroke
    • Deep Vein Thrombosis (DVT)
  • DVT: Clot occluding blood flow, often in the leg.
    • Symptoms: Leg pain, coldness, absent pulse.
  • Risk factors:
    • Prolonged sitting (long car/plane rides)
    • Surgery
    • Older age
  • Prevention: Compression stockings, movement.
  • Complications: Clots can travel to the lungs or heart, causing breathing difficulties.

Anemia

  • Low red blood cell count, reducing oxygen delivery to the body.
  • Pulse oximetry can be misleading; SpO2 reading might be high, but the overall number of red blood cells could be deficient.
  • Treatment: Oxygen administration.

General Management of Hematologic Issues

  • Look for signs of bleeding.
  • Prioritize patient as high priority.
  • Assessment: Ask targeted questions related to the specific condition.
  • Documentation: Thorough documentation is crucial.