Understanding Endocrine and Hematologic Emergencies

Chapter 20. Endocrine and Hematologic Emergencies. Introduction. The endocrine system directly or indirectly influences almost every cell, organ, and function of the body. Consequently, patients with an endocrine disorder often are seen with a multitude of signs and symptoms that require a thorough assessment, and immediate treatment. This chapter discusses diabetes mellitus types 1 and 2. you will gain an understanding of the role of the pancreas in hormone production and release. The determination of hyperglycemia versus hypoglycemia is explained in detail, because their presentations can be similar with only subtle differences. Further discussion focuses on the signs and symptoms of low and high blood glucose levels as well as the adverse effects of chronically high blood glucose levels. This chapter also discusses common hematologic emergencies that are often missed in patients. Although hematologic disorders can be difficult to assess and treat in a pre-hospital setting, your actions may save a patient's life. Endocrine Emergencies Anatomy and Physiology The endocrine system is a communication system that controls functions inside the body. This system, along with the other systems, maintains the body's homeostasis. Endocrine glands secrete messenger hormones, which are chemical substances produced by a gland. Hormones travel through the blood to the end organs, tissues, or cells that they're intended to affect. When the hormone arrives, the cell, tissue, or organ receives the message, and an action or cellular process takes place. Endocrine disorders are caused by an internal communication problem. If a gland is not functioning normally, It may produce more hormone than is needed or it may not produce enough hormone . A gland may be functioning correctly, but the receiving organ may not be responding. In these cases, the receiving organ is less responsive to the amount of hormone that it would take to initiate an action or cellular response under normal circumstances. The brain needs two things to survive, glucose and oxygen. Insulin is necessary for glucose to enter the cells for metabolism. Without the proper balance of hormones, that is, without enough insulin, the cells do not get fed. The pancreas produces and stores two hormones that play a major role in glucose metabolism, glucagon and insulin. A small portion of the pancreas is filled with the islets of longarhots. Within these islets are alpha and beta cells. the alpha cells produce glucagon and the beta cells produce insulin in a person without diabetes the pancreas stores and secretes insulin and glucagon in response to the level of glucose in the blood when a person eats the level of glucose in his or her blood rises in response the pancreas secretes insulin into the blood this allows the glucose to enter the body cells and be used for energy it also allows glucose to be stored in the form of glycogen in the liver and skeletal muscles for use at a later time as blood glucose levels return to normal insulin stops being secreted and the body is said to be in a state of being fed as time passes the body will become hungry again if the hungry individual skips or delays a meal a message is sent to the pancreas to secrete glucagon glucagon then stimulates the liver and the skeletal muscles to release glycogen and converts it back to glucose for use as cellular fuel. Pathophysiology According to the American Diabetes Association, in 2015 diabetes mellitus affected approximately 9.4% of the population. Each year, diabetes is diagnosed in 1.5 million Americans. Diabetes mellitus is a disorder of glucose metabolism. such that the body has an impaired ability to get glucose into the cells to be used for energy. The patient with diabetes has either impaired insulin production or not enough functional receptors on the surface of the cells for the insulin to bind to. Glucose cannot get into the cell, the cell goes unfed, and the level of glucose in the blood remains high and continues to rise. Without treatment, blood glucose levels become too high. which in severe cases may cause life-threatening illness or coma and death. When diabetes mellitus is properly and effectively managed, a process that involves both the patient and physician, the patient can live a relatively normal life. However, people with diabetes who are unable to achieve good control of their blood glucose levels often experience severe complications, including blindness, cardiovascular disease, and kidney failure. which dramatically affect the length and quality of life. There are three types of diabetes, diabetes mellitus type 1, diabetes mellitus type 2, and pregnancy-induced gestational diabetes. A more detailed discussion of gestational diabetes can be found in Chapter 34, Obstetrics and Neonatal Care. Treatments for diabetes include medications, and injectable hormones that lower the patient's blood glucose level. These hormones and medications, whether administered correctly or incorrectly, can create a medical emergency for the patient with diabetes if left unrecognized and untreated a low blood glucose level hypoglycemia can be life-threatening you must also recognize the signs and symptoms of a high blood glucose level hyperglycemia so you can provide the appropriate treatment and deliver the patient to the next level of care hyperglycemia is a state in which the blood glucose level is above normal hypoglycemia is a state in which the blood glucose level is below normal hyperglycemia and hypoglycemia can occur with both diabetes mellitus types 1 & 2 in the field you will encounter many patients displaying the signs and symptoms of both high and low blood glucose levels hyperglycemia and hypoglycemia have some similarities in their presentation as an emergency medical technician you must look for the differences that define one disorder from the other patients at both extremes with extremely low and extremely high blood glucose levels can present with altered mental status patients with severe hypoglycemia are more likely to have a depressed level of consciousness than patients with hyperglycemia be careful not to incorrectly label patients as being intoxicated Altered mental status related to diabetic emergencies can often mimic alcohol intoxication, and intoxicated patients often have abnormal glucose levels. Be thorough and check a finger stick glucose level for all patients with altered mental status. Hypoglycemia can develop if a person with diabetes takes his or her medications, pills or insulin, as prescribed but fails to eat enough food. Alternatively, A person with diabetes may intentionally or accidentally take too much medication, resulting in low blood glucose levels despite normal dietary intake. All hypoglycemic patients require prompt treatment with oral glucose paste, if alert and able to protect their airway, or injection of glucose, dextrose, or glucagon by an advanced life support provider. Diabetes mellitus type 1 Type 1 diabetes is an autoimmune disorder in which the individual's immune system produces antibodies against the pancreatic beta cells. Essentially, this disease is about the missing pancreatic hormone insulin. Insulin is the key to the door of the cell. Without insulin, glucose cannot enter the cell, and the cell cannot produce energy. The onset of this disorder usually happens from early childhood through the fourth decade of life. The patient's immune system progressively destroys the ability of the pancreas to produce insulin. Without the insulin from the pancreatic beta cells, the patient must obtain insulin from an external source. Patients with type 1 diabetes cannot survive without insulin. Patients who inject insulin often need to check their blood glucose levels up to 6 times per day or more using a lancet and a small capillary blood sample read by using a glucometer. many people with type 1 diabetes have an implanted insulin pump some of these devices continuously measure the body's glucose levels and provide an adjustable infusion of insulin and correction doses of insulin based on carbohydrate intake at mealtimes the presence of an insulin pump that automatically measures blood glucose limits the number of times patients have to check their finger stick glucose level some insulin pumps do not measure blood glucose automatically but rather deliver a continuous baseline dose of insulin that may be supplemented by an additional bolus dose depending on the blood glucose measurement the patient takes at mealtimes. Unfortunately, insulin pumps can malfunction, and hyperglycemic or hypoglycemic diabetic emergencies can develop. Always inquire about the presence of an insulin pump, particularly in patients with type 1 diabetes, and ask the patient if it is working properly. Type 1 diabetes is the most common metabolic disease of childhood. A patient with new-onset type 1 diabetes will have symptoms related to eating and drinking, polyuria, polydipsia, polyphagia, weight loss, fatigue. Normal blood glucose level is between 80 and 120 milligrams per deciliter. The body's metabolism is sensitive to the levels of particular substances, such as glucose, in the blood. The kidneys filter the blood, and thus manage all substances present in the blood. At normal levels, glucose remains in the blood as it is filtered. When a patient's blood glucose level is above normal, the kidney's filtration system becomes overwhelmed. glucose spills into the urine the increased amount of glucose in the urine causes more water to be pulled out of the bloodstream into the urine this results in more frequent urination or polyuria increased urine production and urination also caused dehydration and increased thirst which can lead to severe electrolyte abnormalities an increase in fluid consumption called polydipsia occurs in an attempt to quench this thirst In the early phase of diabetes, patients may report severe hunger, and increased food intake, a condition known as polyphagia. Over time, particularly if diabetes remains undiagnosed or untreated, appetite will decrease, and patients often lose weight. The autoimmune destruction of the pancreatic beta cell takes time to progress. For this reason, initial symptoms are typically subtle and not readily apparent to the patient. As the lack of insulin becomes more profound, the patient will notice increasing fatigue and malaise along with vague symptoms of generalized illness. When the body's cells do not receive the glucose they require for energy, the body resorts to burning fat for energy. When the body burns fat rather than glucose, acid waste is produced. These acids are called ketones. As ketone levels increase in the blood, the ketones also begin to spill into the urine. as does the excess glucose when the kidneys become saturated with glucose and ketones they do not work properly to maintain acid-base balance in the body the body responds with a backup system and the patient begins to breathe faster and deeper this respiratory pattern is the body's attempt to reduce the acid level by releasing more carbon dioxide through the lungs this breathing pattern is known as cuss mal respirations If fat metabolism and ketone production continue, a life-threatening illness called diabetic ketoacidosis can develop in patients with diabetes. Diabetic ketoacidosis may present as generalized illness, accompanied by abdominal pain, body aches, nausea, vomiting, altered mental status or unconsciousness, if severe. If diabetic ketoacidosis is not rapidly recognized and treated it can result in death when a patient with diabetic ketoacidosis has an altered mental status ask the patient's family and friends about the patient's history and presentation obtain a glucose level with a finger stick using a lens and a glucometer this procedure is covered in chapter 10 patient assessment The patient with diabetic ketoacidosis will generally have a finger stick glucose level higher than 400 mg per deciliter. This presentation of the patient with type 1 diabetes and diabetic ketoacidosis does not only occur when there is an absolute lack of insulin. Diabetic ketoacidosis may also present in cases of a relative lack of insulin, which may occur when there is an acute illness. or an untreated infection or other stressor on the body that leaves the patient with type 1 diabetes in a weakened condition diabetes mellitus type 2 type 2 diabetes is caused by resistance to the effects of insulin at the cellular level recall that we described insulin as the key to the door of the cell insulin resistance means the lock is unable to accept the key as a review in type 1 diabetes no insulin is produced so there are no keys in type 2 diabetes there are typically fewer insulin receptors obesity predisposes patients to type 2 diabetes there is an association between obesity and increased resistance to the effects of insulin as the number of obese people continues to rise so does the number of patients with type 2 diabetes when diabetes begins the individuals panc pancreas produces more insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors. Over time this response becomes inefficient. The blood glucose levels continue to rise, and do not respond when the pancreas secretes insulin, a process called insulin resistance. In some cases, insulin resistance can be improved by exercise, and dietary modification. In many instances diet and exercise alone cannot control insulin resistance, and oral medications must be started to better control blood glucose levels. Oral medications used to treat type 2 diabetes vary widely. Some of them increase the secretion of insulin, and create a high risk of hypoglycemic reaction, whereas others do not. Injectable medications and various insulin preparations are also used for type 2 diabetes when oral medications alone will not regulate blood glucose. Insulin is a hormone that is destroyed when taken by mouth, so it must be injected. Many of the oral medications listed in Table 20-2 either encourage the pancreas to produce more insulin or the cells to stimulate receptors for insulin. Other medications decrease the effects of glucagon. decrease the release of glucose stored in the liver glycogen and prevent increased blood glucose levels during sleep or sedentary periods none of the available medications is the perfect solution for every patient however diabetes mellitus type 2 is often diagnosed at a yearly medical examination in some cases the patient's physician discovers diabetes mellitus type 2 when treating the patient for a complaint related to high blood glucose levels Examples of such complaints include recurrent infection, change in vision, or numbness in the feet. Symptomatic hyperglycemia. Symptomatic hyperglycemia occurs when blood glucose levels are very high. Early signs and symptoms include frequent urination, increased thirst, blurred vision, and fatigue. If the high blood glucose levels go untreated, the patient may present with a fruity odor on his or her breath, nausea and vomiting, shortness of breath, and a high blood pressure. breath dry mouth weakness or altered mental status the patient is in a state of altered mental status resulting from several combined problems in type 1 diabetes hyperglycemia leads to ketoacidosis and dehydration from excessive urination in type 2 diabetes hyperglycemia leads to a state of dehydration due to the discharge of fluids from all body systems and and eventually out through the kidneys. leading to a much more ominous situation of fluid imbalance known as hyperosmolar hyperglycemic non-catotic syndrome. Hyperglycemia does not always result in a crisis event. If an individual has hyperglycemia for a prolonged time, it is not uncommon for the secondary consequences of diabetes to present. These are wounds that do not heal, numbness in the hands and feet, blindness, renal failure, and gastric motility problems. to name a few when blood glucose levels are not controlled in diabetes mellitus type 2 hyperosmolar hyperglycemic non-catotic syndrome can develop hyperosmolar hyperglycemic non-catotic syndrome can present similarly to the diabetic ketoacidosis seen in patients with type 1 diabetes the onset of this disorder is commonly associated with a profound infection or illness Key signs and symptoms of hyperosmolar hyperglycemic non-catotic syndrome include the following. Hyperglycemia. Altered mental status. Drowsiness. Lethargy. Severe dehydration. Thirst. Dark urine. Visual or sensory deficits. Partial paralysis or muscle weakness. Seizures. Higher glucose levels in the blood cause the excretion of glucose in the urine. Patients respond by increasing their fluid intake precipitously, polydipsia, causing an equally precipitous excretion of fluid, polyuria. In hyperosmolar hyperglycemic non-catotic syndrome, however, the patient cannot drink enough fluid to keep up with the exceedingly high glucose levels in the blood. The kidneys become overwhelmed, and the patient's blood becomes much more concentrated than normal. As hyperosmolar hyperglycemic non-catotic syndrome progresses, the urine becomes rather dark and concentrated. The term hyperosmolarity describes very concentrated blood as a result of relative dehydration. As hyperosmolar hyperglycemic non-catotic syndrome progresses, the patient may become unconscious or have seizure activity due in part to the severe dehydration that results. Symptomatic hypoglycemia Symptomatic hypoglycemia is an acute emergency in which a patient's blood glucose level drops, and must be corrected swiftly. A low blood glucose level can occur in patients who inject insulin or use oral medications that stimulate the pancreas to produce more insulin. When insulin levels remain high, glucose is rapidly taken out of the blood to fuel the cells. If glucose levels fall too low, there may be an insufficient amount to supply the brain. The mental status of the patient declines precipitously and he or she may become aggressive or display unusual behavior. If blood glucose remains low, unconsciousness and permanent brain damage can quickly follow. symptomatic hypoglycemia can occur for many different reasons some of the more common reasons for a low blood glucose level to develop there because the patient or caregiver administered one of the following a correct dose of insulin with a change in routine the patient exercised more consumed a meal later than usual or skip the meal more insulin than necessary a correct dose of insulin without the patient eating a sufficient amount correct dose of insulin and an acute illness developed in the patient hypoglycemia develops much more quickly than hyperglycemia in some instances it can occur in a matter of minutes hypoglycemia can be associated with the following signs and symptoms normal to shallow or rapid respirations pale moist clammy skin in dark skin people paleness is more apparent by examining the mucus membranes inside the lower eyelid Diaphoresis, sweating, dizziness, headache, rapid pulse, normal to low blood pressure, altered mental status, aggressive, confused, lethargic, or unusual behavior, anxious or combative behavior, seizure, fainting, or coma. Weakness on one side of the body may mimic stroke. Rapid changes in mental status. hyperglycemia is a complex metabolic condition that usually develops over time and involves all the tissues of the body correcting this condition may take many hours in a well-controlled hospital setting hypoglycemia however is an acute condition that can develop rapidly a patient with diabetes who has taken his or her standard insulin dose and missed lunch may have symptomatic hypoglycemia before dinner the condition is just as quickly reversed by giving the patient glucose without the glucose however the patient can sustain permanent brain damage minutes count patient assessment of diabetes scene size up evaluate scene safety as you arrive on scene and as you approach the patient make sure that all hazards are addressed remember that patients with diabetes often use syringes to administer insulin it is possible you may be stuck by a used needle that was not disposed of properly insulin syringes on the nightstand insulin bottles in the refrigerator a plate of food or a glass of orange juice are important clues that may help you decide what is possibly wrong with your patient evaluate each situation quickly and make sure necessary personal protective equipment is readily available use standard precautions as you approach Question bystanders on events leading to your arrival. Although your report from dispatch may be for a patient with an altered mental status, keep open the possibility that trauma may have occurred because of a medical incident. Determine the mechanism of injury and or nature of illness. Do not let your guard down, even on what appears to be a routine call. Primary assessment. Perform a primary assessment to form a general impression of the patient. How does the patient look? Does the patient appear anxious, restless, or listless? Is the patient apathetic or irritable? Is the patient interacting appropriately with his or her environment? These initial observations may lead you to suspect high or low blood glucose values, identify life threats, and provide life-saving interventions, particularly airway management. Determine the patient's level of consciousness using the awake and alert verbal stimuli pain unresponsive scale. If a patient whom you suspect has diabetes is unresponsive, call for advanced life support immediately. An unconscious patient may have undiagnosed diabetes. In patients with altered mental status, you may be able to determine whether a diabetic emergency exists by assessing the patient's blood glucose level. At the emergency department, diabetes and its complications can be quickly diagnosed. Remember that even though a person has diabetes, the diabetes may not be causing the current problem, heart attack, stroke, or another medical emergency may be the cause. For this reason, you must always carry out a thorough, careful primary assessment, paying attention to the airway, breathing, and circulations. While you are forming your general impression, assess the patient's 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 at 12 to 15 liters per minute via non-rebreathing mask. A patient who is hyperglycemic may have rapid, deep respirations, cosmolyl respirations, and sweet, fruity breath. A patient who is hypoglycemic will have normal or shallow to rapid respirations. If the patient is not breathing or is having difficulty breathing, open the airway and insert an airway adjunct, administer oxygen, and assist ventilations. Continue to monitor the airway while you provide care. Once you have assessed the airway and breathing and have performed the necessary life-saving interventions, check the patient's circulatory status. Dry and warm skin indicates hyperglycemia, whereas moist and pale skin indicates hypoglycemia. Because skin paleness can be difficult to detect in patients with dark skin, instead check for pale mucous membranes inside the inner lower eyelid or slow capillary refill. The patient with symptomatic hypoglycemia will have a rapid Weak pulse. Whether you decide to transport at this stage of the assessment will depend on the patient's level of consciousness, and the ability to swallow. Patients with an altered mental status, and impaired ability to swallow should be transported promptly. Patients who have the ability to swallow and are conscious enough to maintain their own airway may be further evaluated on scene and interventions performed if appropriate. History taking. Investigate the chief. complaint or the history of the present illness. Responsive patients usually are able to provide their own medical history. If the patient has eaten but has not taken insulin, it is more likely that hyperglycemia is developing. If the patient has taken insulin but has not eaten, the problem is more likely to be hypoglycemia. A patient with diabetes will often know, or strongly suspect, what is wrong. If the patient is not thinking or speaking clearly, or is unconscious ask a family member or bystander the same questions physical signs such as tremors abdominal cramps vomiting a fruity breath odor or a dry mouth may guide you in determining whether the patient is hypoglycemic or hyperglycemic you will need to obtain a signs and symptoms allergies medications pertinent past medical history last oral intake Events leading up to the illness or injury history from your patient or the family or bystanders if the patient is unable to speak. In addition, be sure to ask the following questions of a patient known to have diabetes. Do you take insulin or any pills that lower your blood sugar? Do you wear an insulin pump? Is it working properly? Have you taken your usual dose of insulin, or pills, today? Have you eaten normally today? Have you had any illness, unusual amount of activity, or stress? When you are assessing a patient who might have diabetes, check to see whether the patient has an emergency medical identification device, a wallet card, necklace, or bracelet, or ask the patient or a family member. Remember that the environment, bystanders, and medical identification devices may provide important clues about your patient's condition. Secondary Assessment In some instances where the patient is critically ill or injured or the transport time is short, you may not have time to conduct a secondary assessment. In other instances, the secondary assessment may occur on scene or en route to the emergency department. First, assess unresponsive patients from head to toe with a secondary assessment of the entire body, looking for clues to their condition. The patient may have experienced trauma resulting from dizziness or from changes in level of consciousness. As with every call, you should perform a secondary assessment when time permits. With unconscious patients or patients with an altered mental status, you must assume the role of detective and look for problems or injuries that are not obvious because the patient is unable to communicate these to you. Although an altered mental status may be caused by a blood glucose level that is too high or too low, the patient may have sustained trauma or have another metabolic problem. An altered mental status may also be caused by something else, such as intoxication, poisoning, or a head injury. A systematic examination of the patient may provide you with information essential to proper patient care. When you suspect a diabetes-related problem, a secondary assessment should focus on the patient's mental status and ability to swallow and protect the airway. Obtain a Glasgow Coma Scale score to track the patient's neurologic status. Obtain a complete set of vital signs, including a measurement of the patient's blood glucose level using a glucometer. The portable blood glucose monitor measures the glucose level in whole blood using either capillary or venous samples. Advances in technology now allow patients to track their blood glucose in real time using wearable sensors such as Dexcom and Freestyle that send information via Bluetooth to the patient's phone. In hypoglycemia, respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure. Although paleness, or a decrease in blood flow, can be difficult to detect in dark-skinned people, it may be observed. by examining mucous membranes inside the inner lower eyelid, and capillary refill. On general observation, the patient may appear ashen or gray. In 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. At times the blood pressure may be low. It should be easier for you to identify abnormal vital signs when you know the blood glucose level is too high or too low. Remember, the patient may have abnormal vital signs, and a normal blood glucose value. When this is the case, something else may be causing the patient's altered mental status, vomiting, or other complaints. It is important to read and understand the operator's manual before using a portable glucometer because the specifications of the device may vary depending on the manufacturer. Some glucometers indicate low when they detect a glucose reading less than 20 mg per deciliter, whereas others display low when they detect a reading less than 30 mg per deciliter. The same is true with a high reading, some glucometers read high at 550 mg per deciliter. and some at 600 milligrams per deciliter. Therefore, it is important to know both the upper and lower ranges at which your glucometer functions. The normal range for glucose levels in blood in non-fasting adults and children is 80 to 120 milligrams per deciliter. The blood glucose level in neonates should be above 70 milligrams per deciliter. Reassessment. It is important to reassess the patient with diabetes frequently to assess changes. Is there an improvement in the patient's mental status? Are the airway, breathing, and circulation still intact? How is the patient responding to the interventions performed? How must you adjust or change the interventions? In many patients with diabetes, you will note marked improvement with appropriate treatment. Document each assessment, your findings, the time of the interventions, and any changes in the patient's condition. Base your administration of glucose on serial glucometer readings. If a glucometer is not available, a deteriorating level of consciousness indicates that you need to provide more glucose. If your patient is hypoglycemic, conscious, and able to swallow without the risk of aspiration, encourage him or her to take glucose tablets. If those are not available, household sources of glucose may be used, such as juice or other drinks that contain sugar. do not be afraid to give too much sugar do not give sugar-free drinks that are sweetened with saccharin or other synthetic sweetening compounds because they will have little or no effect if you are permitted by local protocol you may also assist a patient in administering a gel preparation or sugar drink if your patient with hypoglycemia is unconscious or if there is any risk of aspiration the patient will need intravenous glucose or intramuscular or intranasal glucagon, which most emergency medical technicians are not authorized to give. Your responsibility is to provide prompt transport to the hospital, where the proper care can be given. If you are working in a tiered system, advanced emergency medical technicians and paramedics are able to start an intravenous line, and administer intravenous glucose. A patient with symptomatic hypoglycemia, rapid onset of altered mental status. hypoglycemia needs glucose immediately a patient with symptomatic hyperglycemia acidosis dehydration hyperglycemia needs insulin and intravenous fluid therapy these patients need prompt transport to the hospital for appropriate medical care When there is any doubt about whether a conscious patient with diabetes is going into symptomatic hypoglycemia or symptomatic hyperglycemia, most protocols will err on the side of giving glucose, even though the patient may have hyperglycemia or diabetic ketoacidosis. Untreated hypoglycemia will result in loss of consciousness, and can quickly cause significant brain damage or death. The condition of a patient with symptomatic hypoglycemia is far more critical and far more likely to cause permanent problems than the condition of a patient with hyperglycemia or diabetic ketoacidosis. Furthermore, the amount of sugar that is typically given to a patient with symptomatic hypoglycemia is unlikely to make a patient with diabetic ketoacidosis significantly worse. When in doubt, consult medical control. determining whether the blood glucose level is too high or too low in a patient in whom diabetes is diagnosed can be difficult when signs and symptoms are confusing and you have no way to test for a blood glucose value in these situations perform a thorough assessment and contact the hospital to help sort out the signs and symptoms the hospital should be a resource for you to help problem-solve situations and provide guidance on how to manage your patient Communication with hospital staff is important for continuity of care. Hospital personnel need to be informed about the patient's history, the present situation, your assessment findings, and your interventions, and their results. Document your assessment findings clearly, because they represent the basis for your treatment. Patients who refuse transport because their symptoms improve after taking oral glucose may require even more thorough documentation. Patients who receive treatment in the field for hypoglycemia are at great risk for development of symptomatic hypoglycemia in the near future, and should be strongly discouraged from refusing further treatment or transportation to the hospital. Many long-acting forms of insulin, and most oral diabetic medications remain in the bloodstream far longer than the glucose used to treat these patients. Follow your local protocols for patients who refuse treatment or transport. emergency medical care for diabetic emergencies giving oral glucose there are three types of oral glucose preparations available commercially the most common for emergency medical service providers is a rapidly dissolving gel the second preparation comes in a large chewable tablet the third preparation is a liquid formulation glucose gel acts to increase a patient's blood glucose levels if authorized by your system you should administer glucose gel to any patient with a decreased level of consciousness who has a history of diabetes the only contraindications to oral glucose are an inability to swallow and unconsciousness because aspiration inhalation of the substance can occur oral glucose itself has no side effects if it is administered properly however the risk of aspiration in a patient who does not have a gag reflex is substantial a conscious patient even if confused who does not really need glucose will not be harmed by it therefore do not hesitate to give glucose under these circumstances be sure to wear gloves before placing anything into a patient's mouth after you have confirmed that the patient is conscious and able to swallow and have obtained an online or offline order open the glucose pouch and either the emergency medical technician or the patient can squeeze the glucose into the mouth either under the tongue or into the buccal space and then swallow as an emergency medical technician you know the importance of reassessment the patient with diabetes experiencing an altered mental status event that you treat with a glucose product is one of the most important patients to reassess frequently as rapidly as you may see a response to your treatment you can see a deterioration Be mindful of the airway when giving an oral medication such as a glucose product, not only from the standpoint of placing something into the mouth but for resultant regurgitation of that product, which can be aspirated. Anytime you change a patient's mental status with a drug, follow-up must be provided. Therefore, it is always best to provide transport to the next level of care. The presentation of hypoglycemia. Recognition of the patient with hypoglycemia requires an intuitive approach. There are many classic, by-the-book presentations of hypoglycemia. However, each of the altered mental status presentations is identified in much the same way. The discovery comes from a rapid examination utilizing a list of possible conditions to rule out, leading to the ultimate identification of hypoglycemia. Seizures. Although seizures are rarely life-threatening, you should consider them to be very serious, even in patients with a history of chronic seizures. Seizures, which may be brief or prolonged, are often caused by infections, poisoning, hypoglycemia, trauma, or decreased levels of oxygen, or they may be idiopathic, of unknown cause. In children, they may be caused by fever or epilepsy. Although brief seizures are not harmful, they may indicate a more dangerous and potentially life-threatening underlying condition because seizures can be the result of a head injury consider trauma as a cause in the patient with diabetes you should also consider hypoglycemia emergency medical care of seizures includes ensuring that the airway is clear and placing the patient on his or her side do not attempt to place anything in the patient's mouth For example, a bite stick or an oral airway. be sure to have suctioning equipment ready in case the patient vomits provide oxygen or artificial ventilation if the patient is cyanotic or appears to be breathing inadequately and provide prompt transport altered mental status although altered mental status is often caused by complications of diabetes it may also be caused by a variety of other conditions including poisoning infection head injury Part of the Postictal State following a seizure and decreased perfusion to the brain in diabetes altered mental status can be caused by hypoglycemia and by ketoacidosis the mnemonic a eio u tips is easily remembered and covers a multitude of conditions that can lead to altered mental status as such many of the conditions covered by the mnemonic can be confused resulting in a misdiagnosis when the patient's blood glucose level is not assessed. AEIOU Tips stands for the following conditions. Alcohol, epilepsy, endocrine, electrolytes, insulin, opiates and other drugs, uremia, kidney failure, trauma, temperature, infection, poisoning, psychogenic causes, shock, stroke, seizure, space-occupying lesion, subarachnoid hemorrhage. Most of the items on the preceding list. can be associated with or can cause hypoglycemia. A patient might have a seizure due to hypoglycemia. A patient with an altered mental status after a heroin overdose might also be hypoglycemic. Remember to consider diabetic emergencies in patients who present with any of these emergencies, which can alter or depress mental status. Also remember that patients who present with trauma and are unconscious may have become unconscious as a result of a low blood glucose level and secondarily became injured always suspect and check for low blood glucose in a patient with altered mental status begin emergency medical care of altered mental status by ensuring that the airway is clear be prepared to provide artificial ventilation and suctioning in case the patient vomits and provide prompt transport misdiagnosis of neurologic dysfunction Occasionally, patients with hypoglycemia or hyperglycemia are thought to be intoxicated, especially if their condition has caused a motor vehicle crash or other incident. Confined by police at a police station, a patient with diabetes is at risk. In such situations, an emergency medical identification bracelet, necklace, or card may help to save the patient's life. often Only a blood glucose test performed at the scene or in the emergency department will identify the real problem. In many emergency medical service systems, you will be trained and allowed to perform blood glucose testing at the scene. Regardless, until proven otherwise, you must always suspect hypoglycemia in any patient with an altered mental status. Certainly, diabetes and alcoholism can coexist in a patient. you must be alert to the similarity in symptoms of acute alcohol intoxication and diabetic emergencies likewise hypoglycemia and a head injury can coexist and you must appreciate the potential for hypoglycemia even when the head injury is obvious relationship to airway management patients with an altered mental status particularly those who are difficult to awaken may not have a gag reflex When the gag reflex is not working, Patients cannot expel foreign materials in their mouths, including vomit, and their tongues will often relax and obstruct the airway. Therefore, you must carefully monitor the airway in patients with hyperglycemia, hypoglycemia, or a complication related to diabetes such as stroke or seizure. place the patient in a lateral recumbent position and make sure suction is readily available hematologic emergencies hematology is the study of blood-related diseases this section begins by explaining the composition of blood it then focuses on four disorders that may be seen in a pre-hospital emergency sickle cell disease also called hemoglobin s disease hemophilia also called classic hemophilia or factor VE deficiency thrombophilia anemia anatomy and physiology blood and its parts blood is made up of four components erythrocytes red blood cells leukocytes white blood cells platelets plasma each of the components of the blood serves a purpose in maintaining a person's homeostatic balance Each of the body's other systems provides for and utilizes the blood in a specific way. In turn, the blood transports oxygen and carbon dioxide into and out of tissues to sustain the function of the organ system and tissues. Red blood cells make up 42% to 47% of a person's total blood volume. Red blood cells contain an important protein, hemoglobin, which carries 97% of the oxygen in the blood, and some of the carbon dioxide. White blood cells make up 0.1% to 0.2% of a person's blood cell volume. In a healthy person, white blood cells collect dead cells, and provide for their correct disposal. In times of health, white blood cells levels are low. When an infection develops, white blood cells, and all of their complementary defense systems are activated, and their numbers grow. platelets make up 4% to 7% of a person's blood cell volume, and are essential for clot formation. When damage occurs to your skin or to a blood vessel, platelets are sent to the site of injury to assist in forming a blood clot to stop the bleeding. Without this protective response, bleeding from a simple cut could be uncontrollable. Plasma serves as the transportation medium for all blood components as well as proteins and minerals. Pathophysiology Sickle cell disease. Sickle cell disease, also called hemoglobin S disease, is an inherited blood disorder that affects the red blood cells. The name sickle cell comes from the first case report of the disease in 1910, when Dr. James Herrick wrote that the red blood cells looked like a sickle. The odd-shaped cells protect the individual from contracting malaria. This protection is useful to people who live in sub-Saharan Africa where malaria is common. but it is not useful to people who do not live in regions endemic for malaria. There are several variants that make up this genetic disease. It is sufficient to simply understand that the issues of sickle cell can happen with any of the variants. This disease is common among people of African, Caribbean, and South American ancestry. It is present but less common in Mediterranean and Middle Eastern people. All newborns in the United States are tested for sickle cell disease shortly after birth, regardless of their race or ethnic background. The sharp and misshapen cells lead to dysfunction in oxygen binding and unintentional clot formation. These unintentional clots may result in a blockage known as vaso-occlusive crisis. People with sickle cell disease can experience hypoxia, or a lack of oxygen in the body's cells and tissues. The blockages that result from sickle cell crises or vaso-occlusive crises can result in substantial pain and organ damage, which can trigger calls to emergency medical service for help. The lifespan of normal red blood cells is approximately 110 to 120 days. Sickled cells have a much shorter lifespan. This results in more cellular waste products in the bloodstream, which can contribute to sludging, clumping, of the blood. Maintaining hydration status is important to these patients, as is maintaining their general health, because insufficient hydration leads to increased clumping of cells. Complications associated with sickle cell disease include the following. Anemia, gallstones, jaundice, splenic dysfunction, vascular occlusion with ischemia, acute chest syndrome, hypoxia, dyspnea, chest discomfort, and fever. stroke bone necrosis a vascular necrosis specifically the head of the femur and the humerus pain crises acute and chronic organ dysfunction or failure retinal hemorrhages increased risk of infection many of these complications are very painful and potentially life-threatening in the face of these complications the patient with sickle cell anemia is also more susceptible to infections hemophilia hemophilia is rare according to the hemophilia Federation of America there are only approximately 20,000 Americans who have the disorder hemophilia a mostly affects males Males inherit the condition from a mother who is a carrier but does not have the disease. Females only inherit the condition if their mother is a carrier, and their father has the disease. People with hemophilia A have a decreased ability to create a clot after an injury. The blood of a healthy individual will clot in as little as 13 seconds after a paper cut, and not longer than approximately 7 minutes following a more serious injury that requires direct pressure. Having an extended bleeding time from the inability to clot can be life-threatening. A patient who is otherwise healthy but has hemophilia A can have a serious reaction to a minor trauma, such as a simple ankle sprain while playing soccer. Most people would ignore the sprain, and simply continue to play the game. The patient with hemophilia A would begin to experience swelling from uncontrolled bleeding in the region of the injury, and continue to do so. making the seemingly minor injury a significant problem. Acute bleeding from any source may be life-threatening, depending on where the bleeding occurs. Patients with hemophilia A can be prescribed medications to replace the missing clotting factors, release the clotting factors that are stored in the patient's body, or prevent the breakdown of blood clots. Common complications of hemophilia A include the following. Long-term joint problems. which may require a joint replacement bleeding in the brain intracerebral hemorrhage thrombosis due to treatment thrombophilia from the philia is a disorder in the body's ability to maintain the viscosity and smooth flow of blood through the venous and arterial systems in thrombophilia the concentration of particular elements in the blood creates what amounts to clogging or blockage issues Thrombophilia is a general term for many different conditions that result in the blood clotting more easily than normal. This results from either inherited, genetic, disorders, medications, or other factors. Patients with cancer are at increased risk of forming life-threatening blood clots. Whatever the risk factors, the common theme is that clots can spontaneously develop in the blood of the patient. Deep vein thrombosis Deep Deep vein thrombosis is a common medical problem in sedentary patients, and in patients who have had recent injury or surgery. Although several risk factors increase the chance that a deep vein thrombosis will develop, there are several methods to prevent blood clot formation, including blood thinning medications, compression stockings, and mechanical devices, all of which you may encounter in the field. Vein thrombosis is a particularly worrisome risk for patients who have had joint replacement surgery. Be suspicious of this in a patient with a recent history of joint replacement who complains of leg swelling. Travelers, truck and long-distance bus drivers, and bedridden nursing home patients all are at higher risk for deep vein thrombosis because they are sedentary for long periods of time. If deep vein thrombosis develops in an individual, Anticoagulation therapy may be administered. A patient with deep vein thrombosis may be treated in the hospital with intravenous medications, and then transition to oral medications or self-administered subcutaneous injectable medications to treat or prevent deep vein thrombosis. Patients who have been prescribed medications such as heparin, warfarin, coumadin, dabigatran, pradaxa, or rivaroxaban, xarelto. to treat deep vein thrombosis are at increased risk of bleeding complications that is gastrointestinal bleeding or stroke and minor trauma is more likely to produce severe internal or external hemorrhage a life threat can develop if the clot from the deep vein thrombosis travels from the patient's lower extremity to the lung causing a pulmonary embolus pulmonary emboli can cause chest pain difficulty breathing or if the clots are large Sudden cardiac arrest. Pulmonary embolism is discussed in Chapter 16, Respiratory Emergencies. Anemia. Anemia is an abnormally low number of red blood cells. Red blood cells contain hemoglobin, an iron-containing pigment that is responsible for 97% of the transport of oxygen from the lungs to the cells of the body Each hemoglobin molecule is able to bind two and carry four molecules of oxygen. Anemia may be the result of either chronic or acute bleeding, a deficiency in certain vitamins or minerals, or an underlying disease process. If anemia is present, tissues may become hypoxic because the blood is unable to deliver adequate amounts of oxygen to the tissues, even though the available hemoglobin is fully saturated with oxygen, and the lungs are delivering enough oxygen to the blood. In this situation, a pulse oximeter may indicate that there is adequate saturation, even though the tissues are hypoxic. This type of hypoxia is known as hypoxemic hypoxia. Patient Assessment of Hematologic Disorders Scene Size Up Although your report from dispatch may be for a patient with an unknown medical problem, most patients presenting with a sickle cell crisis have had a crisis before and will relay that information to the dispatcher. As you approach the scene, ensure your safety by assessing for hazards. Standard precautions should consist of gloves, mask, and eye protection at a minimum. Determine whether this is your only patient, and whether trauma was involved. Decide whether you will need any additional resources. Patients experiencing a vaso-occlusive crisis are often in extreme pain, and would benefit from advanced life support providers being able to administer analgesics. Remember that trauma may have occurred because of a medical incident. Determine the mechanism of injury and or nature of illness. Primary assessment. An African-American patient or any patient of Mediterranean descent who reports severe pain may have undiagnosed sickle cell disease. Perform a primary assessment to form an initial general impression of the patient. How does the patient look? Does the patient appear anxious, restless, or listless? Is the patient apathetic or irritable? Determine the patient's level of consciousness. While you are forming your general impression, assess the patient's airway and breathing. Patients showing signs of inadequate breathing or altered mental status should receive high-flow oxygen at 12 to 15 liters per minute via non-rebreathing mask. A patient who is experiencing a sickle cell crisis may have increased respirations as a result of severe pain or exhibit signs of pneumonia. If the patient is having difficulty breathing, open the airway and insert an airway adjunct, administer oxygen, and assist ventilations. Continue to monitor the airway as you provide care. Once you have assessed the airway and breathing and have performed the necessary interventions, check the patient's circulatory status. An increased heart rate represents a compensatory mechanism to force the sickled cells through smaller blood vessels. In patients with suspected hemophilia. Be alert for signs of acute blood loss such as pallor, weak pulse, and hypotension. Note any bleeding, such as nosebleeds, bloody sputum, swollen joints, and blood in the urine or stool. Because of blood loss, patients with hemophilia may exhibit signs of hypoxia. Whether you decide to rapidly transport the patient will depend on the severity of the patient's pain, and the patient's wishes. Patients with a history of sickle cell disease. but those who have not had a crisis in some time may require emotional support and refuse transport however transport to an emergency department should always be recommended to any patient who is experiencing a sickle cell crisis or hemophilia history taking if the patient is conscious what is the chief complaint or history of present illness Responsive medical patients are able to provide their own medical history to help you identify a cause for their severe pain. Physical signs, such as swelling of the fingers and toes, priapism, and jaundice, may guide you in determining whether the patient is experiencing a sickle cell crisis. It is also important to ascertain whether the pain is isolated to a single location or if pain is felt throughout the entire body. Is the patient having any visual disturbances? Is the patient experiencing any gastrointestinal problems, such as nausea, vomiting, or abdominal cramping? Is the patient reporting any chest pain or shortness of breath? In a patient with known sickle cell disease, ask the following questions in addition to obtaining a signs and symptoms. Allergies, medications, pertinent past medical history, less oral intake, events leading up to the illness or injury history. Have you had a crisis before? When was the last time you had a crisis? How did your last crisis resolve? Have you had any illness, unusual amount of activity, or stress lately? Secondary assessment. Next, systematically examine the patient, focusing on major joints at which cells congregate. Evaluate and document mental status using the awake and alert verbal stimuli pain unresponsive scale. Obtain a complete set of vital signs, including a measurement of the patient's oxygen saturation level. In patients experiencing a sickle cell crisis, respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure. Use pulse oximetry, if available. However, keep in mind that the oxygen saturation reading you obtain may be inaccurate as a result of the patient's anemic state. Reassessment. Reassess the patient frequently to determine if there have been changes in the patient's condition. For example, are there changes in the patient's mental status? Are the airway, breathing, and circulation still intact? How is the patient responding to the interventions performed? Should you adjust or change the interventions? Document each assessment, your findings, the time of the interventions, and any changes in the patient's condition. Administer supplemental oxygen via non-rebreathing mask at 12 to 15 minutes. 15 liters per minute to attempt to compensate for decreased cellular oxygenation related to the sickled cells or hemophilia. At the hospital, care for patients with sickle cell disease can include analgesics for pain, penicillin to treat infection, intravenous fluid for hydration, and, depending on the severity of the crisis, a blood transfusion. Distinguishing a true sickle cell crisis from other non-specific causes of pain can be difficult. Remember to perform a thorough assessment and consult with medical control as soon as feasible. Hospital care for a patient with hemophilia may include intravenous therapy to treat hypotension and a transfusion of plasma. Analgesics may also be appropriate. Communication with hospital staff is important for continuity of care. Inform hospital personnel about the patient's history, the current situation, your assessment findings, and your interventions. and their results. Document your assessment findings clearly, as they represent the basis for your treatment. Follow your local protocols for patients who refuse treatment or transport. Emergency medical care for hematologic disorders. Emergency care for patients with hematologic disorders is mainly supportive and symptomatic. Patients showing signs of inadequate breathing, decreased oxygen saturation. or altered mental status should receive high flow oxygen at 12 to 15 liters per minute via non-rebreathing mask and should be placed in a position of comfort and transported rapidly to the hospital

Chapter 20. Endocrine and Hematologic Emergencies. Introduction. The endocrine system directly or indirectly influences almost every cell, organ, and function of the body.

Consequently, patients with an endocrine disorder often are seen with a multitude of signs and symptoms that require a thorough assessment, and immediate treatment. This chapter discusses diabetes mellitus types 1 and 2. you will gain an understanding of the role of the pancreas in hormone production and release. The determination of hyperglycemia versus hypoglycemia is explained in detail, because their presentations can be similar with only subtle differences.

Further discussion focuses on the signs and symptoms of low and high blood glucose levels as well as the adverse effects of chronically high blood glucose levels. This chapter also discusses common hematologic emergencies that are often missed in patients. Although hematologic disorders can be difficult to assess and treat in a pre-hospital setting, your actions may save a patient's life.

Endocrine Emergencies Anatomy and Physiology The endocrine system is a communication system that controls functions inside the body. This system, along with the other systems, maintains the body's homeostasis. Endocrine glands secrete messenger hormones, which are chemical substances produced by a gland.

Hormones travel through the blood to the end organs, tissues, or cells that they're intended to affect. When the hormone arrives, the cell, tissue, or organ receives the message, and an action or cellular process takes place. Endocrine disorders are caused by an internal communication problem. If a gland is not functioning normally, It may produce more hormone than is needed or it may not produce enough hormone .

A gland may be functioning correctly, but the receiving organ may not be responding. In these cases, the receiving organ is less responsive to the amount of hormone that it would take to initiate an action or cellular response under normal circumstances. The brain needs two things to survive, glucose and oxygen.

Insulin is necessary for glucose to enter the cells for metabolism. Without the proper balance of hormones, that is, without enough insulin, the cells do not get fed. The pancreas produces and stores two hormones that play a major role in glucose metabolism, glucagon and insulin.

A small portion of the pancreas is filled with the islets of longarhots. Within these islets are alpha and beta cells. the alpha cells produce glucagon and the beta cells produce insulin in a person without diabetes the pancreas stores and secretes insulin and glucagon in response to the level of glucose in the blood when a person eats the level of glucose in his or her blood rises in response the pancreas secretes insulin into the blood this allows the glucose to enter the body cells and be used for energy it also allows glucose to be stored in the form of glycogen in the liver and skeletal muscles for use at a later time as blood glucose levels return to normal insulin stops being secreted and the body is said to be in a state of being fed as time passes the body will become hungry again if the hungry individual skips or delays a meal a message is sent to the pancreas to secrete glucagon glucagon then stimulates the liver and the skeletal muscles to release glycogen and converts it back to glucose for use as cellular fuel. Pathophysiology According to the American Diabetes Association, in 2015 diabetes mellitus affected approximately 9.4% of the population. Each year, diabetes is diagnosed in 1.5 million Americans.

Diabetes mellitus is a disorder of glucose metabolism. such that the body has an impaired ability to get glucose into the cells to be used for energy. The patient with diabetes has either impaired insulin production or not enough functional receptors on the surface of the cells for the insulin to bind to.

Glucose cannot get into the cell, the cell goes unfed, and the level of glucose in the blood remains high and continues to rise. Without treatment, blood glucose levels become too high. which in severe cases may cause life-threatening illness or coma and death. When diabetes mellitus is properly and effectively managed, a process that involves both the patient and physician, the patient can live a relatively normal life. However, people with diabetes who are unable to achieve good control of their blood glucose levels often experience severe complications, including blindness, cardiovascular disease, and kidney failure.

which dramatically affect the length and quality of life. There are three types of diabetes, diabetes mellitus type 1, diabetes mellitus type 2, and pregnancy-induced gestational diabetes. A more detailed discussion of gestational diabetes can be found in Chapter 34, Obstetrics and Neonatal Care. Treatments for diabetes include medications, and injectable hormones that lower the patient's blood glucose level. These hormones and medications, whether administered correctly or incorrectly, can create a medical emergency for the patient with diabetes if left unrecognized and untreated a low blood glucose level hypoglycemia can be life-threatening you must also recognize the signs and symptoms of a high blood glucose level hyperglycemia so you can provide the appropriate treatment and deliver the patient to the next level of care hyperglycemia is a state in which the blood glucose level is above normal hypoglycemia is a state in which the blood glucose level is below normal hyperglycemia and hypoglycemia can occur with both diabetes mellitus types 1 & 2 in the field you will encounter many patients displaying the signs and symptoms of both high and low blood glucose levels hyperglycemia and hypoglycemia have some similarities in their presentation as an emergency medical technician you must look for the differences that define one disorder from the other patients at both extremes with extremely low and extremely high blood glucose levels can present with altered mental status patients with severe hypoglycemia are more likely to have a depressed level of consciousness than patients with hyperglycemia be careful not to incorrectly label patients as being intoxicated Altered mental status related to diabetic emergencies can often mimic alcohol intoxication, and intoxicated patients often have abnormal glucose levels.

Be thorough and check a finger stick glucose level for all patients with altered mental status. Hypoglycemia can develop if a person with diabetes takes his or her medications, pills or insulin, as prescribed but fails to eat enough food. Alternatively, A person with diabetes may intentionally or accidentally take too much medication, resulting in low blood glucose levels despite normal dietary intake.

All hypoglycemic patients require prompt treatment with oral glucose paste, if alert and able to protect their airway, or injection of glucose, dextrose, or glucagon by an advanced life support provider. Diabetes mellitus type 1 Type 1 diabetes is an autoimmune disorder in which the individual's immune system produces antibodies against the pancreatic beta cells. Essentially, this disease is about the missing pancreatic hormone insulin.

Insulin is the key to the door of the cell. Without insulin, glucose cannot enter the cell, and the cell cannot produce energy. The onset of this disorder usually happens from early childhood through the fourth decade of life. The patient's immune system progressively destroys the ability of the pancreas to produce insulin. Without the insulin from the pancreatic beta cells, the patient must obtain insulin from an external source.

Patients with type 1 diabetes cannot survive without insulin. Patients who inject insulin often need to check their blood glucose levels up to 6 times per day or more using a lancet and a small capillary blood sample read by using a glucometer. many people with type 1 diabetes have an implanted insulin pump some of these devices continuously measure the body's glucose levels and provide an adjustable infusion of insulin and correction doses of insulin based on carbohydrate intake at mealtimes the presence of an insulin pump that automatically measures blood glucose limits the number of times patients have to check their finger stick glucose level some insulin pumps do not measure blood glucose automatically but rather deliver a continuous baseline dose of insulin that may be supplemented by an additional bolus dose depending on the blood glucose measurement the patient takes at mealtimes.

Unfortunately, insulin pumps can malfunction, and hyperglycemic or hypoglycemic diabetic emergencies can develop. Always inquire about the presence of an insulin pump, particularly in patients with type 1 diabetes, and ask the patient if it is working properly. Type 1 diabetes is the most common metabolic disease of childhood.

A patient with new-onset type 1 diabetes will have symptoms related to eating and drinking, polyuria, polydipsia, polyphagia, weight loss, fatigue. Normal blood glucose level is between 80 and 120 milligrams per deciliter. The body's metabolism is sensitive to the levels of particular substances, such as glucose, in the blood. The kidneys filter the blood, and thus manage all substances present in the blood. At normal levels, glucose remains in the blood as it is filtered.

When a patient's blood glucose level is above normal, the kidney's filtration system becomes overwhelmed. glucose spills into the urine the increased amount of glucose in the urine causes more water to be pulled out of the bloodstream into the urine this results in more frequent urination or polyuria increased urine production and urination also caused dehydration and increased thirst which can lead to severe electrolyte abnormalities an increase in fluid consumption called polydipsia occurs in an attempt to quench this thirst In the early phase of diabetes, patients may report severe hunger, and increased food intake, a condition known as polyphagia. Over time, particularly if diabetes remains undiagnosed or untreated, appetite will decrease, and patients often lose weight.

The autoimmune destruction of the pancreatic beta cell takes time to progress. For this reason, initial symptoms are typically subtle and not readily apparent to the patient. As the lack of insulin becomes more profound, the patient will notice increasing fatigue and malaise along with vague symptoms of generalized illness. When the body's cells do not receive the glucose they require for energy, the body resorts to burning fat for energy. When the body burns fat rather than glucose, acid waste is produced.

These acids are called ketones. As ketone levels increase in the blood, the ketones also begin to spill into the urine. as does the excess glucose when the kidneys become saturated with glucose and ketones they do not work properly to maintain acid-base balance in the body the body responds with a backup system and the patient begins to breathe faster and deeper this respiratory pattern is the body's attempt to reduce the acid level by releasing more carbon dioxide through the lungs this breathing pattern is known as cuss mal respirations If fat metabolism and ketone production continue, a life-threatening illness called diabetic ketoacidosis can develop in patients with diabetes.

Diabetic ketoacidosis may present as generalized illness, accompanied by abdominal pain, body aches, nausea, vomiting, altered mental status or unconsciousness, if severe. If diabetic ketoacidosis is not rapidly recognized and treated it can result in death when a patient with diabetic ketoacidosis has an altered mental status ask the patient's family and friends about the patient's history and presentation obtain a glucose level with a finger stick using a lens and a glucometer this procedure is covered in chapter 10 patient assessment The patient with diabetic ketoacidosis will generally have a finger stick glucose level higher than 400 mg per deciliter. This presentation of the patient with type 1 diabetes and diabetic ketoacidosis does not only occur when there is an absolute lack of insulin. Diabetic ketoacidosis may also present in cases of a relative lack of insulin, which may occur when there is an acute illness.

or an untreated infection or other stressor on the body that leaves the patient with type 1 diabetes in a weakened condition diabetes mellitus type 2 type 2 diabetes is caused by resistance to the effects of insulin at the cellular level recall that we described insulin as the key to the door of the cell insulin resistance means the lock is unable to accept the key as a review in type 1 diabetes no insulin is produced so there are no keys in type 2 diabetes there are typically fewer insulin receptors obesity predisposes patients to type 2 diabetes there is an association between obesity and increased resistance to the effects of insulin as the number of obese people continues to rise so does the number of patients with type 2 diabetes when diabetes begins the individuals panc pancreas produces more insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors. Over time this response becomes inefficient. The blood glucose levels continue to rise, and do not respond when the pancreas secretes insulin, a process called insulin resistance. In some cases, insulin resistance can be improved by exercise, and dietary modification. In many instances diet and exercise alone cannot control insulin resistance, and oral medications must be started to better control blood glucose levels.

Oral medications used to treat type 2 diabetes vary widely. Some of them increase the secretion of insulin, and create a high risk of hypoglycemic reaction, whereas others do not. Injectable medications and various insulin preparations are also used for type 2 diabetes when oral medications alone will not regulate blood glucose. Insulin is a hormone that is destroyed when taken by mouth, so it must be injected. Many of the oral medications listed in Table 20-2 either encourage the pancreas to produce more insulin or the cells to stimulate receptors for insulin.

Other medications decrease the effects of glucagon. decrease the release of glucose stored in the liver glycogen and prevent increased blood glucose levels during sleep or sedentary periods none of the available medications is the perfect solution for every patient however diabetes mellitus type 2 is often diagnosed at a yearly medical examination in some cases the patient's physician discovers diabetes mellitus type 2 when treating the patient for a complaint related to high blood glucose levels Examples of such complaints include recurrent infection, change in vision, or numbness in the feet. Symptomatic hyperglycemia. Symptomatic hyperglycemia occurs when blood glucose levels are very high. Early signs and symptoms include frequent urination, increased thirst, blurred vision, and fatigue.

If the high blood glucose levels go untreated, the patient may present with a fruity odor on his or her breath, nausea and vomiting, shortness of breath, and a high blood pressure. breath dry mouth weakness or altered mental status the patient is in a state of altered mental status resulting from several combined problems in type 1 diabetes hyperglycemia leads to ketoacidosis and dehydration from excessive urination in type 2 diabetes hyperglycemia leads to a state of dehydration due to the discharge of fluids from all body systems and and eventually out through the kidneys. leading to a much more ominous situation of fluid imbalance known as hyperosmolar hyperglycemic non-catotic syndrome.

Hyperglycemia does not always result in a crisis event. If an individual has hyperglycemia for a prolonged time, it is not uncommon for the secondary consequences of diabetes to present. These are wounds that do not heal, numbness in the hands and feet, blindness, renal failure, and gastric motility problems.

to name a few when blood glucose levels are not controlled in diabetes mellitus type 2 hyperosmolar hyperglycemic non-catotic syndrome can develop hyperosmolar hyperglycemic non-catotic syndrome can present similarly to the diabetic ketoacidosis seen in patients with type 1 diabetes the onset of this disorder is commonly associated with a profound infection or illness Key signs and symptoms of hyperosmolar hyperglycemic non-catotic syndrome include the following. Hyperglycemia. Altered mental status.

Drowsiness. Lethargy. Severe dehydration. Thirst.

Dark urine. Visual or sensory deficits. Partial paralysis or muscle weakness.

Seizures. Higher glucose levels in the blood cause the excretion of glucose in the urine. Patients respond by increasing their fluid intake precipitously, polydipsia, causing an equally precipitous excretion of fluid, polyuria. In hyperosmolar hyperglycemic non-catotic syndrome, however, the patient cannot drink enough fluid to keep up with the exceedingly high glucose levels in the blood.

The kidneys become overwhelmed, and the patient's blood becomes much more concentrated than normal. As hyperosmolar hyperglycemic non-catotic syndrome progresses, the urine becomes rather dark and concentrated. The term hyperosmolarity describes very concentrated blood as a result of relative dehydration.

As hyperosmolar hyperglycemic non-catotic syndrome progresses, the patient may become unconscious or have seizure activity due in part to the severe dehydration that results. Symptomatic hypoglycemia Symptomatic hypoglycemia is an acute emergency in which a patient's blood glucose level drops, and must be corrected swiftly. A low blood glucose level can occur in patients who inject insulin or use oral medications that stimulate the pancreas to produce more insulin.

When insulin levels remain high, glucose is rapidly taken out of the blood to fuel the cells. If glucose levels fall too low, there may be an insufficient amount to supply the brain. The mental status of the patient declines precipitously and he or she may become aggressive or display unusual behavior.

If blood glucose remains low, unconsciousness and permanent brain damage can quickly follow. symptomatic hypoglycemia can occur for many different reasons some of the more common reasons for a low blood glucose level to develop there because the patient or caregiver administered one of the following a correct dose of insulin with a change in routine the patient exercised more consumed a meal later than usual or skip the meal more insulin than necessary a correct dose of insulin without the patient eating a sufficient amount correct dose of insulin and an acute illness developed in the patient hypoglycemia develops much more quickly than hyperglycemia in some instances it can occur in a matter of minutes hypoglycemia can be associated with the following signs and symptoms normal to shallow or rapid respirations pale moist clammy skin in dark skin people paleness is more apparent by examining the mucus membranes inside the lower eyelid Diaphoresis, sweating, dizziness, headache, rapid pulse, normal to low blood pressure, altered mental status, aggressive, confused, lethargic, or unusual behavior, anxious or combative behavior, seizure, fainting, or coma. Weakness on one side of the body may mimic stroke. Rapid changes in mental status. hyperglycemia is a complex metabolic condition that usually develops over time and involves all the tissues of the body correcting this condition may take many hours in a well-controlled hospital setting hypoglycemia however is an acute condition that can develop rapidly a patient with diabetes who has taken his or her standard insulin dose and missed lunch may have symptomatic hypoglycemia before dinner the condition is just as quickly reversed by giving the patient glucose without the glucose however the patient can sustain permanent brain damage minutes count patient assessment of diabetes scene size up evaluate scene safety as you arrive on scene and as you approach the patient make sure that all hazards are addressed remember that patients with diabetes often use syringes to administer insulin it is possible you may be stuck by a used needle that was not disposed of properly insulin syringes on the nightstand insulin bottles in the refrigerator a plate of food or a glass of orange juice are important clues that may help you decide what is possibly wrong with your patient evaluate each situation quickly and make sure necessary personal protective equipment is readily available use standard precautions as you approach Question bystanders on events leading to your arrival.

Although your report from dispatch may be for a patient with an altered mental status, keep open the possibility that trauma may have occurred because of a medical incident. Determine the mechanism of injury and or nature of illness. Do not let your guard down, even on what appears to be a routine call.

Primary assessment. Perform a primary assessment to form a general impression of the patient. How does the patient look? Does the patient appear anxious, restless, or listless?

Is the patient apathetic or irritable? Is the patient interacting appropriately with his or her environment? These initial observations may lead you to suspect high or low blood glucose values, identify life threats, and provide life-saving interventions, particularly airway management.

Determine the patient's level of consciousness using the awake and alert verbal stimuli pain unresponsive scale. If a patient whom you suspect has diabetes is unresponsive, call for advanced life support immediately. An unconscious patient may have undiagnosed diabetes. In patients with altered mental status, you may be able to determine whether a diabetic emergency exists by assessing the patient's blood glucose level.

At the emergency department, diabetes and its complications can be quickly diagnosed. Remember that even though a person has diabetes, the diabetes may not be causing the current problem, heart attack, stroke, or another medical emergency may be the cause. For this reason, you must always carry out a thorough, careful primary assessment, paying attention to the airway, breathing, and circulations. While you are forming your general impression, assess the patient's 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 at 12 to 15 liters per minute via non-rebreathing mask. A patient who is hyperglycemic may have rapid, deep respirations, cosmolyl respirations, and sweet, fruity breath. A patient who is hypoglycemic will have normal or shallow to rapid respirations.

If the patient is not breathing or is having difficulty breathing, open the airway and insert an airway adjunct, administer oxygen, and assist ventilations. Continue to monitor the airway while you provide care. Once you have assessed the airway and breathing and have performed the necessary life-saving interventions, check the patient's circulatory status. Dry and warm skin indicates hyperglycemia, whereas moist and pale skin indicates hypoglycemia.

Because skin paleness can be difficult to detect in patients with dark skin, instead check for pale mucous membranes inside the inner lower eyelid or slow capillary refill. The patient with symptomatic hypoglycemia will have a rapid Weak pulse. Whether you decide to transport at this stage of the assessment will depend on the patient's level of consciousness, and the ability to swallow.

Patients with an altered mental status, and impaired ability to swallow should be transported promptly. Patients who have the ability to swallow and are conscious enough to maintain their own airway may be further evaluated on scene and interventions performed if appropriate. History taking. Investigate the chief. complaint or the history of the present illness.

Responsive patients usually are able to provide their own medical history. If the patient has eaten but has not taken insulin, it is more likely that hyperglycemia is developing. If the patient has taken insulin but has not eaten, the problem is more likely to be hypoglycemia.

A patient with diabetes will often know, or strongly suspect, what is wrong. If the patient is not thinking or speaking clearly, or is unconscious ask a family member or bystander the same questions physical signs such as tremors abdominal cramps vomiting a fruity breath odor or a dry mouth may guide you in determining whether the patient is hypoglycemic or hyperglycemic you will need to obtain a signs and symptoms allergies medications pertinent past medical history last oral intake Events leading up to the illness or injury history from your patient or the family or bystanders if the patient is unable to speak. In addition, be sure to ask the following questions of a patient known to have diabetes. Do you take insulin or any pills that lower your blood sugar?

Do you wear an insulin pump? Is it working properly? Have you taken your usual dose of insulin, or pills, today?

Have you eaten normally today? Have you had any illness, unusual amount of activity, or stress? When you are assessing a patient who might have diabetes, check to see whether the patient has an emergency medical identification device, a wallet card, necklace, or bracelet, or ask the patient or a family member.

Remember that the environment, bystanders, and medical identification devices may provide important clues about your patient's condition. Secondary Assessment In some instances where the patient is critically ill or injured or the transport time is short, you may not have time to conduct a secondary assessment. In other instances, the secondary assessment may occur on scene or en route to the emergency department.

First, assess unresponsive patients from head to toe with a secondary assessment of the entire body, looking for clues to their condition. The patient may have experienced trauma resulting from dizziness or from changes in level of consciousness. As with every call, you should perform a secondary assessment when time permits.

With unconscious patients or patients with an altered mental status, you must assume the role of detective and look for problems or injuries that are not obvious because the patient is unable to communicate these to you. Although an altered mental status may be caused by a blood glucose level that is too high or too low, the patient may have sustained trauma or have another metabolic problem. An altered mental status may also be caused by something else, such as intoxication, poisoning, or a head injury. A systematic examination of the patient may provide you with information essential to proper patient care.

When you suspect a diabetes-related problem, a secondary assessment should focus on the patient's mental status and ability to swallow and protect the airway. Obtain a Glasgow Coma Scale score to track the patient's neurologic status. Obtain a complete set of vital signs, including a measurement of the patient's blood glucose level using a glucometer.

The portable blood glucose monitor measures the glucose level in whole blood using either capillary or venous samples. Advances in technology now allow patients to track their blood glucose in real time using wearable sensors such as Dexcom and Freestyle that send information via Bluetooth to the patient's phone. In hypoglycemia, respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure. Although paleness, or a decrease in blood flow, can be difficult to detect in dark-skinned people, it may be observed.

by examining mucous membranes inside the inner lower eyelid, and capillary refill. On general observation, the patient may appear ashen or gray. In 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. At times the blood pressure may be low.

It should be easier for you to identify abnormal vital signs when you know the blood glucose level is too high or too low. Remember, the patient may have abnormal vital signs, and a normal blood glucose value. When this is the case, something else may be causing the patient's altered mental status, vomiting, or other complaints.

It is important to read and understand the operator's manual before using a portable glucometer because the specifications of the device may vary depending on the manufacturer. Some glucometers indicate low when they detect a glucose reading less than 20 mg per deciliter, whereas others display low when they detect a reading less than 30 mg per deciliter. The same is true with a high reading, some glucometers read high at 550 mg per deciliter.

and some at 600 milligrams per deciliter. Therefore, it is important to know both the upper and lower ranges at which your glucometer functions. The normal range for glucose levels in blood in non-fasting adults and children is 80 to 120 milligrams per deciliter.

The blood glucose level in neonates should be above 70 milligrams per deciliter. Reassessment. It is important to reassess the patient with diabetes frequently to assess changes.

Is there an improvement in the patient's mental status? Are the airway, breathing, and circulation still intact? How is the patient responding to the interventions performed? How must you adjust or change the interventions?

In many patients with diabetes, you will note marked improvement with appropriate treatment. Document each assessment, your findings, the time of the interventions, and any changes in the patient's condition. Base your administration of glucose on serial glucometer readings. If a glucometer is not available, a deteriorating level of consciousness indicates that you need to provide more glucose.

If your patient is hypoglycemic, conscious, and able to swallow without the risk of aspiration, encourage him or her to take glucose tablets. If those are not available, household sources of glucose may be used, such as juice or other drinks that contain sugar. do not be afraid to give too much sugar do not give sugar-free drinks that are sweetened with saccharin or other synthetic sweetening compounds because they will have little or no effect if you are permitted by local protocol you may also assist a patient in administering a gel preparation or sugar drink if your patient with hypoglycemia is unconscious or if there is any risk of aspiration the patient will need intravenous glucose or intramuscular or intranasal glucagon, which most emergency medical technicians are not authorized to give.

Your responsibility is to provide prompt transport to the hospital, where the proper care can be given. If you are working in a tiered system, advanced emergency medical technicians and paramedics are able to start an intravenous line, and administer intravenous glucose. A patient with symptomatic hypoglycemia, rapid onset of altered mental status. hypoglycemia needs glucose immediately a patient with symptomatic hyperglycemia acidosis dehydration hyperglycemia needs insulin and intravenous fluid therapy these patients need prompt transport to the hospital for appropriate medical care When there is any doubt about whether a conscious patient with diabetes is going into symptomatic hypoglycemia or symptomatic hyperglycemia, most protocols will err on the side of giving glucose, even though the patient may have hyperglycemia or diabetic ketoacidosis.

Untreated hypoglycemia will result in loss of consciousness, and can quickly cause significant brain damage or death. The condition of a patient with symptomatic hypoglycemia is far more critical and far more likely to cause permanent problems than the condition of a patient with hyperglycemia or diabetic ketoacidosis. Furthermore, the amount of sugar that is typically given to a patient with symptomatic hypoglycemia is unlikely to make a patient with diabetic ketoacidosis significantly worse.

When in doubt, consult medical control. determining whether the blood glucose level is too high or too low in a patient in whom diabetes is diagnosed can be difficult when signs and symptoms are confusing and you have no way to test for a blood glucose value in these situations perform a thorough assessment and contact the hospital to help sort out the signs and symptoms the hospital should be a resource for you to help problem-solve situations and provide guidance on how to manage your patient Communication with hospital staff is important for continuity of care. Hospital personnel need to be informed about the patient's history, the present situation, your assessment findings, and your interventions, and their results.

Document your assessment findings clearly, because they represent the basis for your treatment. Patients who refuse transport because their symptoms improve after taking oral glucose may require even more thorough documentation. Patients who receive treatment in the field for hypoglycemia are at great risk for development of symptomatic hypoglycemia in the near future, and should be strongly discouraged from refusing further treatment or transportation to the hospital.

Many long-acting forms of insulin, and most oral diabetic medications remain in the bloodstream far longer than the glucose used to treat these patients. Follow your local protocols for patients who refuse treatment or transport. emergency medical care for diabetic emergencies giving oral glucose there are three types of oral glucose preparations available commercially the most common for emergency medical service providers is a rapidly dissolving gel the second preparation comes in a large chewable tablet the third preparation is a liquid formulation glucose gel acts to increase a patient's blood glucose levels if authorized by your system you should administer glucose gel to any patient with a decreased level of consciousness who has a history of diabetes the only contraindications to oral glucose are an inability to swallow and unconsciousness because aspiration inhalation of the substance can occur oral glucose itself has no side effects if it is administered properly however the risk of aspiration in a patient who does not have a gag reflex is substantial a conscious patient even if confused who does not really need glucose will not be harmed by it therefore do not hesitate to give glucose under these circumstances be sure to wear gloves before placing anything into a patient's mouth after you have confirmed that the patient is conscious and able to swallow and have obtained an online or offline order open the glucose pouch and either the emergency medical technician or the patient can squeeze the glucose into the mouth either under the tongue or into the buccal space and then swallow as an emergency medical technician you know the importance of reassessment the patient with diabetes experiencing an altered mental status event that you treat with a glucose product is one of the most important patients to reassess frequently as rapidly as you may see a response to your treatment you can see a deterioration Be mindful of the airway when giving an oral medication such as a glucose product, not only from the standpoint of placing something into the mouth but for resultant regurgitation of that product, which can be aspirated.

Anytime you change a patient's mental status with a drug, follow-up must be provided. Therefore, it is always best to provide transport to the next level of care. The presentation of hypoglycemia. Recognition of the patient with hypoglycemia requires an intuitive approach.

There are many classic, by-the-book presentations of hypoglycemia. However, each of the altered mental status presentations is identified in much the same way. The discovery comes from a rapid examination utilizing a list of possible conditions to rule out, leading to the ultimate identification of hypoglycemia.

Seizures. Although seizures are rarely life-threatening, you should consider them to be very serious, even in patients with a history of chronic seizures. Seizures, which may be brief or prolonged, are often caused by infections, poisoning, hypoglycemia, trauma, or decreased levels of oxygen, or they may be idiopathic, of unknown cause. In children, they may be caused by fever or epilepsy.

Although brief seizures are not harmful, they may indicate a more dangerous and potentially life-threatening underlying condition because seizures can be the result of a head injury consider trauma as a cause in the patient with diabetes you should also consider hypoglycemia emergency medical care of seizures includes ensuring that the airway is clear and placing the patient on his or her side do not attempt to place anything in the patient's mouth For example, a bite stick or an oral airway. be sure to have suctioning equipment ready in case the patient vomits provide oxygen or artificial ventilation if the patient is cyanotic or appears to be breathing inadequately and provide prompt transport altered mental status although altered mental status is often caused by complications of diabetes it may also be caused by a variety of other conditions including poisoning infection head injury Part of the Postictal State following a seizure and decreased perfusion to the brain in diabetes altered mental status can be caused by hypoglycemia and by ketoacidosis the mnemonic a eio u tips is easily remembered and covers a multitude of conditions that can lead to altered mental status as such many of the conditions covered by the mnemonic can be confused resulting in a misdiagnosis when the patient's blood glucose level is not assessed. AEIOU Tips stands for the following conditions.

Alcohol, epilepsy, endocrine, electrolytes, insulin, opiates and other drugs, uremia, kidney failure, trauma, temperature, infection, poisoning, psychogenic causes, shock, stroke, seizure, space-occupying lesion, subarachnoid hemorrhage. Most of the items on the preceding list. can be associated with or can cause hypoglycemia.

A patient might have a seizure due to hypoglycemia. A patient with an altered mental status after a heroin overdose might also be hypoglycemic. Remember to consider diabetic emergencies in patients who present with any of these emergencies, which can alter or depress mental status. Also remember that patients who present with trauma and are unconscious may have become unconscious as a result of a low blood glucose level and secondarily became injured always suspect and check for low blood glucose in a patient with altered mental status begin emergency medical care of altered mental status by ensuring that the airway is clear be prepared to provide artificial ventilation and suctioning in case the patient vomits and provide prompt transport misdiagnosis of neurologic dysfunction Occasionally, patients with hypoglycemia or hyperglycemia are thought to be intoxicated, especially if their condition has caused a motor vehicle crash or other incident. Confined by police at a police station, a patient with diabetes is at risk.

In such situations, an emergency medical identification bracelet, necklace, or card may help to save the patient's life. often Only a blood glucose test performed at the scene or in the emergency department will identify the real problem. In many emergency medical service systems, you will be trained and allowed to perform blood glucose testing at the scene. Regardless, until proven otherwise, you must always suspect hypoglycemia in any patient with an altered mental status.

Certainly, diabetes and alcoholism can coexist in a patient. you must be alert to the similarity in symptoms of acute alcohol intoxication and diabetic emergencies likewise hypoglycemia and a head injury can coexist and you must appreciate the potential for hypoglycemia even when the head injury is obvious relationship to airway management patients with an altered mental status particularly those who are difficult to awaken may not have a gag reflex When the gag reflex is not working, Patients cannot expel foreign materials in their mouths, including vomit, and their tongues will often relax and obstruct the airway. Therefore, you must carefully monitor the airway in patients with hyperglycemia, hypoglycemia, or a complication related to diabetes such as stroke or seizure.

place the patient in a lateral recumbent position and make sure suction is readily available hematologic emergencies hematology is the study of blood-related diseases this section begins by explaining the composition of blood it then focuses on four disorders that may be seen in a pre-hospital emergency sickle cell disease also called hemoglobin s disease hemophilia also called classic hemophilia or factor VE deficiency thrombophilia anemia anatomy and physiology blood and its parts blood is made up of four components erythrocytes red blood cells leukocytes white blood cells platelets plasma each of the components of the blood serves a purpose in maintaining a person's homeostatic balance Each of the body's other systems provides for and utilizes the blood in a specific way. In turn, the blood transports oxygen and carbon dioxide into and out of tissues to sustain the function of the organ system and tissues. Red blood cells make up 42% to 47% of a person's total blood volume. Red blood cells contain an important protein, hemoglobin, which carries 97% of the oxygen in the blood, and some of the carbon dioxide. White blood cells make up 0.1% to 0.2% of a person's blood cell volume.

In a healthy person, white blood cells collect dead cells, and provide for their correct disposal. In times of health, white blood cells levels are low. When an infection develops, white blood cells, and all of their complementary defense systems are activated, and their numbers grow. platelets make up 4% to 7% of a person's blood cell volume, and are essential for clot formation. When damage occurs to your skin or to a blood vessel, platelets are sent to the site of injury to assist in forming a blood clot to stop the bleeding.

Without this protective response, bleeding from a simple cut could be uncontrollable. Plasma serves as the transportation medium for all blood components as well as proteins and minerals. Pathophysiology Sickle cell disease. Sickle cell disease, also called hemoglobin S disease, is an inherited blood disorder that affects the red blood cells.

The name sickle cell comes from the first case report of the disease in 1910, when Dr. James Herrick wrote that the red blood cells looked like a sickle. The odd-shaped cells protect the individual from contracting malaria. This protection is useful to people who live in sub-Saharan Africa where malaria is common. but it is not useful to people who do not live in regions endemic for malaria.

There are several variants that make up this genetic disease. It is sufficient to simply understand that the issues of sickle cell can happen with any of the variants. This disease is common among people of African, Caribbean, and South American ancestry. It is present but less common in Mediterranean and Middle Eastern people. All newborns in the United States are tested for sickle cell disease shortly after birth, regardless of their race or ethnic background.

The sharp and misshapen cells lead to dysfunction in oxygen binding and unintentional clot formation. These unintentional clots may result in a blockage known as vaso-occlusive crisis. People with sickle cell disease can experience hypoxia, or a lack of oxygen in the body's cells and tissues. The blockages that result from sickle cell crises or vaso-occlusive crises can result in substantial pain and organ damage, which can trigger calls to emergency medical service for help.

The lifespan of normal red blood cells is approximately 110 to 120 days. Sickled cells have a much shorter lifespan. This results in more cellular waste products in the bloodstream, which can contribute to sludging, clumping, of the blood. Maintaining hydration status is important to these patients, as is maintaining their general health, because insufficient hydration leads to increased clumping of cells.

Complications associated with sickle cell disease include the following. Anemia, gallstones, jaundice, splenic dysfunction, vascular occlusion with ischemia, acute chest syndrome, hypoxia, dyspnea, chest discomfort, and fever. stroke bone necrosis a vascular necrosis specifically the head of the femur and the humerus pain crises acute and chronic organ dysfunction or failure retinal hemorrhages increased risk of infection many of these complications are very painful and potentially life-threatening in the face of these complications the patient with sickle cell anemia is also more susceptible to infections hemophilia hemophilia is rare according to the hemophilia Federation of America there are only approximately 20,000 Americans who have the disorder hemophilia a mostly affects males Males inherit the condition from a mother who is a carrier but does not have the disease.

Females only inherit the condition if their mother is a carrier, and their father has the disease. People with hemophilia A have a decreased ability to create a clot after an injury. The blood of a healthy individual will clot in as little as 13 seconds after a paper cut, and not longer than approximately 7 minutes following a more serious injury that requires direct pressure.

Having an extended bleeding time from the inability to clot can be life-threatening. A patient who is otherwise healthy but has hemophilia A can have a serious reaction to a minor trauma, such as a simple ankle sprain while playing soccer. Most people would ignore the sprain, and simply continue to play the game.

The patient with hemophilia A would begin to experience swelling from uncontrolled bleeding in the region of the injury, and continue to do so. making the seemingly minor injury a significant problem. Acute bleeding from any source may be life-threatening, depending on where the bleeding occurs.

Patients with hemophilia A can be prescribed medications to replace the missing clotting factors, release the clotting factors that are stored in the patient's body, or prevent the breakdown of blood clots. Common complications of hemophilia A include the following. Long-term joint problems.

which may require a joint replacement bleeding in the brain intracerebral hemorrhage thrombosis due to treatment thrombophilia from the philia is a disorder in the body's ability to maintain the viscosity and smooth flow of blood through the venous and arterial systems in thrombophilia the concentration of particular elements in the blood creates what amounts to clogging or blockage issues Thrombophilia is a general term for many different conditions that result in the blood clotting more easily than normal. This results from either inherited, genetic, disorders, medications, or other factors. Patients with cancer are at increased risk of forming life-threatening blood clots. Whatever the risk factors, the common theme is that clots can spontaneously develop in the blood of the patient. Deep vein thrombosis Deep Deep vein thrombosis is a common medical problem in sedentary patients, and in patients who have had recent injury or surgery.

Although several risk factors increase the chance that a deep vein thrombosis will develop, there are several methods to prevent blood clot formation, including blood thinning medications, compression stockings, and mechanical devices, all of which you may encounter in the field. Vein thrombosis is a particularly worrisome risk for patients who have had joint replacement surgery. Be suspicious of this in a patient with a recent history of joint replacement who complains of leg swelling. Travelers, truck and long-distance bus drivers, and bedridden nursing home patients all are at higher risk for deep vein thrombosis because they are sedentary for long periods of time. If deep vein thrombosis develops in an individual, Anticoagulation therapy may be administered.

A patient with deep vein thrombosis may be treated in the hospital with intravenous medications, and then transition to oral medications or self-administered subcutaneous injectable medications to treat or prevent deep vein thrombosis. Patients who have been prescribed medications such as heparin, warfarin, coumadin, dabigatran, pradaxa, or rivaroxaban, xarelto. to treat deep vein thrombosis are at increased risk of bleeding complications that is gastrointestinal bleeding or stroke and minor trauma is more likely to produce severe internal or external hemorrhage a life threat can develop if the clot from the deep vein thrombosis travels from the patient's lower extremity to the lung causing a pulmonary embolus pulmonary emboli can cause chest pain difficulty breathing or if the clots are large Sudden cardiac arrest. Pulmonary embolism is discussed in Chapter 16, Respiratory Emergencies. Anemia.

Anemia is an abnormally low number of red blood cells. Red blood cells contain hemoglobin, an iron-containing pigment that is responsible for 97% of the transport of oxygen from the lungs to the cells of the body Each hemoglobin molecule is able to bind two and carry four molecules of oxygen. Anemia may be the result of either chronic or acute bleeding, a deficiency in certain vitamins or minerals, or an underlying disease process.

If anemia is present, tissues may become hypoxic because the blood is unable to deliver adequate amounts of oxygen to the tissues, even though the available hemoglobin is fully saturated with oxygen, and the lungs are delivering enough oxygen to the blood. In this situation, a pulse oximeter may indicate that there is adequate saturation, even though the tissues are hypoxic. This type of hypoxia is known as hypoxemic hypoxia.

Patient Assessment of Hematologic Disorders Scene Size Up Although your report from dispatch may be for a patient with an unknown medical problem, most patients presenting with a sickle cell crisis have had a crisis before and will relay that information to the dispatcher. As you approach the scene, ensure your safety by assessing for hazards. Standard precautions should consist of gloves, mask, and eye protection at a minimum.

Determine whether this is your only patient, and whether trauma was involved. Decide whether you will need any additional resources. Patients experiencing a vaso-occlusive crisis are often in extreme pain, and would benefit from advanced life support providers being able to administer analgesics. Remember that trauma may have occurred because of a medical incident. Determine the mechanism of injury and or nature of illness.

Primary assessment. An African-American patient or any patient of Mediterranean descent who reports severe pain may have undiagnosed sickle cell disease. Perform a primary assessment to form an initial general impression of the patient.

How does the patient look? Does the patient appear anxious, restless, or listless? Is the patient apathetic or irritable?

Determine the patient's level of consciousness. While you are forming your general impression, assess the patient's airway and breathing. Patients showing signs of inadequate breathing or altered mental status should receive high-flow oxygen at 12 to 15 liters per minute via non-rebreathing mask. A patient who is experiencing a sickle cell crisis may have increased respirations as a result of severe pain or exhibit signs of pneumonia. If the patient is having difficulty breathing, open the airway and insert an airway adjunct, administer oxygen, and assist ventilations.

Continue to monitor the airway as you provide care. Once you have assessed the airway and breathing and have performed the necessary interventions, check the patient's circulatory status. An increased heart rate represents a compensatory mechanism to force the sickled cells through smaller blood vessels. In patients with suspected hemophilia.

Be alert for signs of acute blood loss such as pallor, weak pulse, and hypotension. Note any bleeding, such as nosebleeds, bloody sputum, swollen joints, and blood in the urine or stool. Because of blood loss, patients with hemophilia may exhibit signs of hypoxia. Whether you decide to rapidly transport the patient will depend on the severity of the patient's pain, and the patient's wishes.

Patients with a history of sickle cell disease. but those who have not had a crisis in some time may require emotional support and refuse transport however transport to an emergency department should always be recommended to any patient who is experiencing a sickle cell crisis or hemophilia history taking if the patient is conscious what is the chief complaint or history of present illness Responsive medical patients are able to provide their own medical history to help you identify a cause for their severe pain. Physical signs, such as swelling of the fingers and toes, priapism, and jaundice, may guide you in determining whether the patient is experiencing a sickle cell crisis. It is also important to ascertain whether the pain is isolated to a single location or if pain is felt throughout the entire body.

Is the patient having any visual disturbances? Is the patient experiencing any gastrointestinal problems, such as nausea, vomiting, or abdominal cramping? Is the patient reporting any chest pain or shortness of breath?

In a patient with known sickle cell disease, ask the following questions in addition to obtaining a signs and symptoms. Allergies, medications, pertinent past medical history, less oral intake, events leading up to the illness or injury history. Have you had a crisis before?

When was the last time you had a crisis? How did your last crisis resolve? Have you had any illness, unusual amount of activity, or stress lately? Secondary assessment.

Next, systematically examine the patient, focusing on major joints at which cells congregate. Evaluate and document mental status using the awake and alert verbal stimuli pain unresponsive scale. Obtain a complete set of vital signs, including a measurement of the patient's oxygen saturation level. In patients experiencing a sickle cell crisis, respirations are normal to rapid, pulse is weak and rapid, and skin is typically pale and clammy with a low blood pressure.

Use pulse oximetry, if available. However, keep in mind that the oxygen saturation reading you obtain may be inaccurate as a result of the patient's anemic state. Reassessment. Reassess the patient frequently to determine if there have been changes in the patient's condition. For example, are there changes in the patient's mental status?

Are the airway, breathing, and circulation still intact? How is the patient responding to the interventions performed? Should you adjust or change the interventions? Document each assessment, your findings, the time of the interventions, and any changes in the patient's condition. Administer supplemental oxygen via non-rebreathing mask at 12 to 15 minutes.

15 liters per minute to attempt to compensate for decreased cellular oxygenation related to the sickled cells or hemophilia. At the hospital, care for patients with sickle cell disease can include analgesics for pain, penicillin to treat infection, intravenous fluid for hydration, and, depending on the severity of the crisis, a blood transfusion. Distinguishing a true sickle cell crisis from other non-specific causes of pain can be difficult.

Remember to perform a thorough assessment and consult with medical control as soon as feasible. Hospital care for a patient with hemophilia may include intravenous therapy to treat hypotension and a transfusion of plasma. Analgesics may also be appropriate.

Communication with hospital staff is important for continuity of care. Inform hospital personnel about the patient's history, the current situation, your assessment findings, and your interventions. and their results.

Document your assessment findings clearly, as they represent the basis for your treatment. Follow your local protocols for patients who refuse treatment or transport. Emergency medical care for hematologic disorders. Emergency care for patients with hematologic disorders is mainly supportive and symptomatic.

Patients showing signs of inadequate breathing, decreased oxygen saturation. or altered mental status should receive high flow oxygen at 12 to 15 liters per minute via non-rebreathing mask and should be placed in a position of comfort and transported rapidly to the hospital

Transcript for:Understanding Endocrine and Hematologic Emergencies

Transcript for:
Understanding Endocrine and Hematologic Emergencies