Chapter 20

Endocrine and Hematologic Emergencies

  • Endocrine system influences nearly every: 

    • Cell

    • Organ

    • Function of the body

  • Patients with endocrine disorders have a multitude of signs and symptoms.

  • Hematologic emergencies

    • Difficult to assess and treat


Endocrine Emergencies: Anatomy and
Physiology

  • The endocrine system is a regulatory system that works with other systems to maintain homeostasis.

    • Endocrine glands secrete messenger chemicals called hormones.

    • Hormones travel through blood to organs, tissues, or cells they affect.

    • When they arrive, an action or cellular process takes place.

  • Endocrine disorders are caused by problems regulating the production, secretion, or reception of hormones.

  • Glucose is important to all cells in the body.

  • Cells metabolize glucose with oxygen to make ATP, a cell's energy source.

  • Insulin is necessary for glucose to enter cells.

  • The pancreas produces and stores two hormones that play a major role in glucose metabolism:

    • Glucagon

    • Insulin

  • In a person without diabetes, the pancreas stores and secretes insulin and glucagon in response to the level of glucose in the blood.


Pathophysiology

  • Diabetes includes disorders of insulin production and insulin sensitivity.

  • Impaired insulin production or insulin resistance by cells can prevent glucose from moving into cells and tissues.

  • The glucose level in blood remains high and continues to rise while cells are left without adequate glucose for ATP production.

  • Medications and injectable hormones that lower blood glucose levels help maintain consistent levels, and/or help cells become more sensitive to insulin.

  • If administered correctly or incorrectly, can create a medical emergency.

  • Low blood glucose level (hypoglycemia) can be life threatening.

  • Hyperglycemia: blood glucose level above normal 

  • Hypoglycemia: blood glucose level below normal

  • Hyperglycemia and hypoglycemia can occur with all diabetes types.

  • Patients at both extremes can present with altered mental status. 

  • Altered mental status related to diabetic emergencies can mimic alcohol intoxication, and intoxicated patients often have abnormal glucose levels.

    • Check glucose levels for all patients with altered mental status or diabetes.


Diabetes Mellitus Type 1

  • Autoimmune disorder in which immune system produces antibodies against pancreatic beta cells

  • Missing the pancreatic hormone insulin

  • Onset usually early childhood through fourth decade.

  • Patient must obtain insulin from an external source.

  • Patients who inject insulin often check blood glucose levels up to six times or more a day.

  • Some patients track their blood glucose in real time using wearable sensors that provide continuous glucose monitoring.

  • Sensor wirelessly transmits information to receiver, usually a smartphone or insulin pump. 

  • Continuous glucose monitoring can help patients make more accurate decisions about glucose requirements and need to adjust medications.

  • Insulin pump: continuously measures glucose levels and provides insulin and correction doses of insulin based on carbohydrate intake at mealtimes

  • Pumps can malfunction and diabetic emergencies can develop.

    • Always inquire about presence of an insulin pump.

    • If you suspect hypoglycemia in an unconscious patient with an insulin pump, you should disconnect it if possible.

  • Normal blood glucose level is between 80 and 120 mg/dL.

  • Most common metabolic disease of childhood

  • New-onset type 1 diabetes symptoms:

    • Polyuria

      • Increased urination due to high glucose levels in the blood leading to increased glucose in the urine.

    • Polydipsia

      • Increased thirst resulting from dehydration caused by excessive urination.

    • Polyphagia

      • Increased hunger stemming from the body's inability to properly utilize glucose for energy, leading to a heightened appetite.

    • Weight loss

    • Fatigue

  • When blood glucose level is above normal, kidney's filtration system becomes overwhelmed and tries to offload glucose into urine.

    • This causes more water to be pulled into the urine (polyuria).

    • Increased urine production causes dehydration and thirst (polydipsia).

    • Patients may report severe hunger and increased food intake (polyphagia).


Diabetes Mellitus Type 2

  • Caused by resistance to the effects of insulin at cellular level

    • Obesity predisposes patients to type 2 diabetes.

    • Pancreas produces more insulin.

    • Insulin resistance can sometimes be improved by exercise and dietary modification. 

  • normally the bigger people

  • Medications used to treat type 2 diabetes include oral medications, injectable medications, and various insulin preparations.

    • Some increase secretion of insulin and pose a high risk of hypoglycemic reaction.

    • Some stimulate receptors for insulin.

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

  • Often diagnosed at yearly medical examination from complaints related to high blood glucose levels:

    • Wounds that do not heal

    • Numbness in hands and feet (could lose a limb)

    • Blindness

    • Kidney failure

    • Gastric motility problems


Symptomatic Hyperglycemia

  • Occurs when blood glucose levels are very high

  • Early signs and symptoms include frequent urination, increased thirst, blurred vision, and fatigue.

  • If untreated, the patient may present with abdominal pain, nausea and vomiting, shortness of breath, dry mouth, weakness, or altered mental status.

  • Two types of hyperglycemic emergencies

    • Diabetic ketoacidosis

    • Hyperosmolar hyperglycemic


Diabetic Ketoacidosis

  • When glucose is unavailable to cells, the body burns fat.

    • When the body burns fat, it produces acid waste (ketones).

  • Diabetic ketoacidosis (DKA) is metabolic acidosis caused by insufficient insulin.

    • In response to metabolic acidosis, body begins to breathe faster and deeper.

    • Kussmaul respirations

  • DKA may present as generalized illness plus:

    • Abdominal pain

    • Body aches

    • Nausea

    • Vomiting

    • Altered mental status or unconsciousness (if severe)

    • Blood glucose levels over 350 mg/dL

    • Kussmaul respirations

    • Fruity odor on the breath (related to ketones)

  • If not rapidly recognized and treated, DKA can result in death.

  • Obtain a glucose level with a fingerstick using a lancet and a glucometer.

  • Generally higher than 350 mg/dL

  • DKA may also present in a patient with type 1 diabetes with an acute illness, an untreated infection, or other stressor.


Hyperosmolar Hyperglycemic State (HHS)

  • Diabetic complication that occurs more often in people with type 2 diabetes

  • High blood glucose levels lead to increased urination that results in dehydration.

  • Excess glucose in the blood pulls fluids from tissues into blood vessels, and subsequently, into urine.

  • Signs and symptoms of HHS 

    • Hyperglycemia

    • Altered mental status, drowsiness, lethargy

    • Severe dehydration, thirst, dark urine

    • Visual or sensory deficits

    • Partial paralysis or muscle weakness

    • Seizures

    • Very high glucose levels, above 600 mg/dL

  • Patients respond by increasing fluid intake, which causes polyuria.

  • Patient cannot drink enough fluid to keep up with high glucose levels in blood.

  • Urine becomes dark and concentrated.

  • Patient may become unconscious or have seizure due to severe dehydration.


Symptomatic Hypoglycemia

  • An acute emergency in which a patient's blood glucose level drops and must be corrected swiftly.

    • Can occur in patients who inject insulin or use oral medications that stimulate pancreas to produce more insulin

    • When insulin levels remain high, glucose is rapidly taken out of the blood. 

    • If glucose levels fall, there may be an insufficient amount to supply the brain.

  • Mental status of the patient declines.

  • Patient may become aggressive or display unusual behavior. 

  • Unconsciousness and permanent brain damage can quickly follow.

  • Factors that can contribute to hypoglycemia

    • Change in routine (eg, exercised more, skipped meal)

    • Patient did not eat enough food.

    • Patient is experiencing an acute illness.

  • All hypoglycemic patients require prompt treatment.

    • EMTs can administer oral glucose if patient is able to protect their airway.

    • ALS clinicians can administer glucose or glucagon by injection.

    • Glucagon is also prescribed to patients as an emergency kit for self-administration.

  • Hypoglycemia develops much more quickly than hyperglycemia.

  • Signs and symptoms of hypoglycemia

    • Normal to shallow or rapid respirations

    • Pale, moist skin

    • Diaphoresis 

    • 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


Scene Size-up

  • Scene safety

    • Patients with diabetes may use syringes.

    • Be alert for clues.

    • Take standard precautions.

    • Question bystanders on events leading to your arrival.

    • Keep open the possibility that trauma may have occurred.

  • Determine MOI/NOI.


Primary Assessment

  • Form a general impression.

  • Airway and breathing

    • Patients showing signs of inadequate breathing, a pulse oximetry level less than or equal to 94% on room air, or altered mental status should receive high-flow oxygen (12 to 15 L/min via nonrebreathing mask) to achieve an oxygen saturation of 94% to 98%. 

    • Hyperglycemic patients may have Kussmaul respirations and sweet, fruity breath.

    • Hypoglycemic patients will have normal or shallow to rapid respirations. 

  • Circulation

    • Dry, warm skin: hyperglycemia

    • Moist, pale skin: hypoglycemia

    • Rapid, weak pulse: symptomatic hypoglycemia

  • Make transport decision.

  • Patients with altered mental status and impaired ability to swallow should be transported promptly


History Taking

  • Investigate chief complaint

    • Obtain history of present illness from responsive patient, family, or bystanders.

    • If patient has eaten but not taken insulin, hyperglycemia is more likely.

    • If patient has taken insulin but not eaten, hypoglycemia is more likely.

    • SAMPLE history—ask the patient:

      • 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 amount of activity, or stress?

    • Look for an emergency medical identification device


Secondary Assessment

  • Physical examination

    • Assess unresponsive patients from head to toe. 

    • When you suspect a diabetes-related problem, focus on mental status, ability to swallow, and ability to protect airway.

  • Vital signs

    • Include blood glucose level using a glucometer.

    • Normal nonfasting adult and child blood glucose level range: 80 to 120 mg/dL; neonates should be above 70 mg/dL


Reassessment

  • Reassess patient with diabetes frequently to assess changes.

    • Improved mental status?

    • ABCs intact?

    • How is patient reacting to interventions performed?

    • Base administration of glucose on serial glucometer readings or a deteriorating level of consciousness.

  • Determining blood glucose level in a patient with diagnosed diabetes can be difficult when signs and symptoms are confusing and you have no way to determine blood glucose value. In these situations:

    • Perform a thorough assessment.

    • Contact the hospital to help sort out signs and symptoms.

  • Coordinate communication and documentation.

    • Patients who refuse transport because their symptoms improve after taking oral glucose may require even more thorough documentation.


Emergency Medical Care for Diabetic
Emergencies

  • If in doubt whether that patient has symptomatic hyperglycemia or hypoglycemia, most protocols will err on the side of giving glucose.

  • Three types of oral glucose

    • Rapidly dissolving gel

    • Large chewable tablets

    • Liquid formulation

  • Only contraindications are inability to swallow and unconsciousness.

  • After you have confirmed that patient is conscious and able to swallow and have obtained an online or off-line order, administer it: 

    • Open glucose pouch.

    • Squeeze glucose into patient's mouth, either under tongue or into buccal space. 

    • Patient should then swallow.

  • Some patients may have prescribed glucagon emergency kits.

    • Local protocols may allow you to assist with administration.

  • Use household sources of glucose, such as juice or drinks that contain sugar.

  • For unconscious, hypoglycemic patients, or patients with risk of aspiration, intravenous (IV) glucose or intramuscular or intranasal glucagon is needed.

  • Provide transport to the next level of care.

  • Request an ALS intercept to start an IV line and administer IV glucose.

  • Reassess patient after administering glucose.

  • Monitor airway, remaining mindful of potential for vomiting and aspiration.

  • Provide a thorough reassessment to ensure that patient returns to normal mental status.


The Presentation of Hypoglycemia

  • Seizures

    • Consider hypoglycemia or an underlying condition.

    • Ensure airway is clear.

    • Place patient on side.

    • Put nothing in patient's 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 low blood glucose in a patient with altered mental status.

    • Ensure airway is clear.

    • Be prepared to provide artificial ventilations and suctioning if patient vomits.

    • Provide prompt transport.

  • Misdiagnosis of neurologic dysfunction

    • Occasionally, patients with diabetic emergencies are thought to be intoxicated.

    • A diabetic patient confined by police is at risk.

    • An emergency medical ID may help to save the patient's life in such situations.

    • Blood glucose test performed at the scene will identify real problem.

    • Be alert to potential for diabetes and alcoholism to 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.

    • Make sure suction is available.


Hematologic Emergencies

  • Hematology is the study of blood-related diseases.

  • Five disorders that can create a prehospital emergency

    • Sickle cell disease

    • Hemophilia

    • Thrombophilia 

    • Deep vein thrombosis

    • Anemia


Anatomy and Physiology

  • 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 are essential for clot formation.

    • Plasma serves as the transportation medium.


Sickle Cell Disease

  • Inherited disorder, affects red blood cells

  • More common among people of African; Central or South American; and Middle Eastern, Asian, Indian, or Mediterranean ancestry.

  • Sharp and misshapen sickled cells lead to dysfunction in oxygen binding and unintentional clot formation.

  • Sickled cells have a short life span, resulting in more cellular waste products in the bloodstream and contributing to sludging (clumping) of the blood.

  • Maintaining hydration is important, as insufficient hydration leads to increased clumping.

  • Complications associated with sickle cell disease

    • Anemia

    • Gallstones

    • Jaundice

    • Splenic dysfunction

    • Vascular occlusion with ischemia

  • Many of these complications are very painful and potentially life threatening. 


Hemophilia

  • Hereditary condition in which patient lacks one or more of blood's normal clotting factors.

    • Rare: only about 33,000 people in the US have the disorder.

    • Hemophilia A affects mostly males.