hello and welcome to chapter 20 endocrine and hematologic emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the significance and characteristics of diabetes sickle cell disease clotting disorders and the complications associated with each you will be able to demonstrate knowledge of the characteristics of type 1 and type 2 diabetes you will be able to list appropriate steps for assessment and pre-hospital treatment of diabetic emergencies and you will also be able to discuss hematologic emergencies and describe sickle cell disease hemophilia thrombophilia and deep vein thrombosis okay so let's get started with one of my favorite chapters and this is because the endocrine system directly or indirectly influences nearly every cell organ and function of the body and endocrine disorders are often seen with a multiple of signs and symptoms hematologic emergencies they're difficult to assess and treat in the pre-hospital setting so let's talk about some of the anatomy and physiology the endocrine system is a communication system that controls functions inside the body so we'll talk about the endocrine glands and they secrete messenger hormones which travel through the blood to end organs tissues or cells that they affect endocrine disorders are caused by an internal communication problem if a gland is not functioning normally it may produce more hormones and this is called hyper secretion or not enough hormones and this is hypo secretion a gland may be functioning correctly but the receiving organ may not be responding so there's glucose metabolism now we know that the brain needs two things to survive and that's glucose and oxygen insulin is necessary for glucose to enter those cells we say the insulin is the key that unlocks the door right to let the sh the glucose into the cells without enough insulin the cells do not get fed the pancreas produces and stores two hormones so it produces and stores glucagon and insulin the inlets of lagrange are found in small portions of the pancreas with the within these inlets are alpha and beta cells now alpha cells produce glucagon and beta cells produce insulin the pancreas stores and secretes insulin and glucagon in response to the level of glucose in the blood so let's talk about the pathophysiology so 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 without treatment blood glucose levels become high in severe cases it may cause life-threatening illness or coma and death if not managed well it can have severe complications such as blindness cardiovascular disease and kidney failure there are three types of diabetes you have diabetes mellitus type 1 diabetes mellitus type 2 and then pregnancy induce we call that gestational diabetes treatments for diabetes include medications and injectable hormones that lower blood glucose levels if administered correctly or incorrectly it can create a medical emergency for the patients with diabetes low blood glucose levels hypoglycemia if unrecognized and untreated can be life-threatening you must also recognize the signs and symptoms of high blood glucose levels and we this is hyper glycemia and it can result in a common death and if treated treatment exceeds a patient's needs it can cause a life-threatening state of hypoglycemia meaning if the patient took too much insulin it can cause life-threatening hypoglycemia hyperglycemia and hypoglycemia can occur with both diabetes mellitus type 1 and type 2. you will encounter many patients displaying the signs and symptoms of high and low blood glucose levels hyperglycemia and hypoglycemia can be quite similar in their presentation patients present with altered mental status and can often mimic alcohol intoxication intoxicated patients often have abnormal glucose levels as well so let's talk about hypoglycemia low blood sugar it can develop if a person takes his or her medications but fails to eat enough food so if a person takes too much medication and this will result in low blood glucose levels and despite eating their normal dietary intake okay all hypoglycemic patients require prompt transport diabetes mellitus type one so let's talk about this first this is an autoimmune disorder in which the immune system produces antibodies against the patriotic beta cells so missing the pancreatic hormone insulin is what it's going to cause and the glucose cannot enter the cell without that insulin so the pancreas isn't producing any of its own insulin the onset usually happens from early childhood through the fourth decade of life the immune system destroys the ability of the pancreas to produce insulin and the patient must obtain insulin from an external source so patients with diabetic type 1 diabetes cannot survive without insulin many people with type 1 diabetes have an implanted insulin pump it continuously measures glucose levels and provides insulin and and correction doses of insulin based on the carbohydrate intake at meal times this limits the number of times the patients have to check their finger stick glucose level it can malfunction and diabetic emergencies can develop so always inquire about the presence of an insulin pump type 1 diabetes is the most common metabolic disease of childhood a patient with new onset type 1 diabetes will have the symptoms related to eating and drinking okay so they will have polyuria which means increased urination polydipsnia increased thirst polyphagia increased hunger weight loss and fatigue normal blood glucose is between 80 and 120 when a patient's blood glucose level is above normal the kidneys filtration system becomes overwhelmed and glucose spills into the urine when glucose is unavailable to the cells the body turns to burning fat when the body burns fat rather than glucose it produces acid waste which are ketones as ketone levels go up in the blood they spill into the urine kidneys will become saturated with glucose and ketones and cannot maintain acid-base balances in the body the patient breathes faster and deeper as the body attempts to produce the acid level by re reducing acid level by releasing more carbon dioxide through the lungs known as couch mall respirations if fat metabolism and ketone production continue a life-threatening illness called diabetic ketoacidosis or dka can develop dka may present as generalized illness along with abdominal pain body aches nausea vomiting alter mental status or unconsciousness is severe if not rapidly recognized and treated dka can result in death so obtain a glucose level with a finger stick using a lancet and a glucometer diabetic ketoacidosis is uh generally higher than a blood glucose level of 400 millimeters or milligrams of deciliter diabetes mellitus type 2 so this is caused by resistance to the effects of insulin at a cellular level obesity predisposes patients to type 2 diabetes the pancreas will produce insulin to make up for the increased levels of blood glucose and dysfunction of cellular insulin receptors so insulin resistance can sometimes be improved by exercise and dietary modification oral medications used to treat type 2 diabetes so some increase secretion of insulin and pose a high risk of hypoglycemic reaction and then some stimulate receptors for insulin others decrease the effects of glucagon and decrease the release of glucose stored in the liver injectable medications and insulin are also used for type 2 diabetes so type 2 diabetes is often diagnosed at a yearly medical exam from complaints related to high blood glucose levels and these complaints can include recurrent infections or change in vision or numbness in the feet symptomatic hyperglycemia occurs when blood glucose levels are very high the patient is in a state of altered mental status resulting from several combined problems so let's talk about type 1 diabetes this leads to ketoacidosis with dehydration from excessive urination in type 2 diabetes this leads to a non-chaotic hypo somalia state of dehydration due to discharge of fluids from all of the body systems and eventually out through the kidneys leading to fluid imbalance an individual has hyperglycemia for a protracted length of time consequences of diabetes may present as you could have wounds that do not heal or numbness in the hands and feet perhaps blindness renal failure or gastric motility problems when blood glucose levels are not controlled in diabetes mellitus type 2 a condition known as hyperosmalia hyper glymatic non-chaotic syndrome so its hns can develop and key signs and symptoms of hhs include hyperglycemia altered mental status drowsiness lethargy severe dehydration thirst and dark urine because remember they're urinating often visual and sensory defects partial paralysis or muscle weakness and perhaps seizures higher glucose levels in the blood causes excretion of glucose into the urine so patients respond by increasing their fluid intake which causes polyuria in hhns the patient cannot drink enough fluid to keep up with that exceedingly high glucose levels in the blood urine becomes dark and concentrated the patient may become unconscious or have a seizure activity due to that severe dehydration symptomatic hypoglycemia okay so this is the exact opposite low sugar so an acute emergency in which the patient's blood glucose level drops and must be corrected swiftly they can occur in patients who inject their insulin or use oral medications to stimulate the pancreas to produce more insulin so when insulin levels remain high glucose is rapidly taken out of the blood if glucose levels fall there may be an insufficient amount of supply to the brain the mental status of the patient declines and he or she may become aggressive or display unusual behavior unconsciousness or and or permanent brain damage can quickly follow so common reasons for low blood sugar level to develop include correct dose of insulin with change in the routine or more insulin than normal or correct dose of insulin without the patient eating or correct dose of insulin and the patient developed an acute illness okay so signs and symptoms of hypoglycemia it's normal to shallow or rapid respirations they can be pale moist skin diaphoresis dizziness a headache rapid pulse or normal to low blood sugar blood pressure altered mental status anxious or combative behavior seizures fainting or coma weakness on one side of the body it may mimic a stroke or rapid changes and they met in mental status so hypoglycemia is quickly reversed by giving the patient glucose without glucose the patient can can sustain permanent brain damage so let's start talking about the patient assessment of diabetes and of course we're going to start with that scene size up and we need to be careful of the presence of syringes used by patients with diabetes further insulin okay so be alert for clues um also of course syringes insulin bottles maybe some food or some orange juice that may help you decide what is wrong with the patient use standard precautions question bystanders on events leading to your arrival and keep open the possibility that trauma may have also occurred determine the mechanism of injury moi or nature of illness which is the noi and now let's get into a primary assessment so how does the patient look remember we're going to get our general impression that's the very first thing of our primary assessment we're going to identify those threats and provide life-saving interventions particularly when it comes to airway management determine the level of consciousness we're going to use that avpoo scale alert verbal painful or unresponsive so if unresponsive and you suspect that patient has diabetes of course you need to call for advanced life support a patient may have undiagnosed diabetes so if the patient has altered mental status assess blood glucose levels if you have proper equipment and training perform cervical spine immobilization when necessary and provide rapid transport now we're going to go to the a and the b so assess the patient's breathing patients showing signs and symptoms of inadequate breathing a pulse ox level less than that of 94 or any type of altered mental status should receive high flow oxygen at 12 to 15 liters via a non-rebreather mask hyperglycemic patients will have a rapid or deep which is koosh mall respirations and sweet fruity breath you'll also hear them say acetone type breath okay so like fingernail polish remover hypoglycemic patients will have a normal or shallow or rapid respirations if the patient is not breathing or having difficulty breathing of course we're going to open that airway insert an adjunct administer oxygen or assist ventilations and continue the monitor ventilations throughout patient care next is the c after a and the b we're going to go to the c and that's dry warm skin for hypo or hyper glycemic and then moist pale skin for hypoglycemia also a rapid weak pulse can be a symptomatic hypoglycemic and then there's the d so after abc we're going to have the d and that's the transport decision so patients with altered mental status and impaired ability to swallow should be transported properly patients capable of swallowing and conscious enough to maintain their own airway may be further evaluated unseen and interventions can be performed history taking so we want to investigate that chief complaint obtain the history of the present illness and that's that opqrst and then obtain the history of the patient and if the patient has eaten but not taken insulin hyperglycemia is more likely obtain that sample history and that's that history of the patient okay so for a known patient with diabetes ask them do you take insulin or pills to lower your blood sugar and do you wear an insulin pump is it working properly have you taken your insulin or the usual insulin dose or the pills of course or have you eaten normally today have you had an illness unusual amount of activity or stress look for an emergency medical identification tag and these can include maybe a wallet card or necklace or bracelet then we move to that secondary assessment and when we're doing with the nature of illness we're going to do that physical exam we're going to focus we're going to focus on a neurological assessment okay so we're going to assess not unresponsive patients from head to toe with the secondary assessment of the entire body to look for clues so be alert for secondary injury or illness such as trauma because they're altered mental status okay and when you suspect a diabetes related problem we want to focus on that mental status ability to swallow and the ability to protect their airway so obtain a glass calcoma score and that's a gcs score vital signs is our next thing we want to make sure we get that blood glucose level level so we're going to use a glucometer if available and protocols allow overall hypoglycemia the respirations are going to be normal to rapid pulse is going to be weak and rapid and skin is typically pale and clammy with a low blood sugar hyperglycemia however is going to have wrapper respirations may be deep and rapid pulse may be rapid weak and thready and the skin may be warm and dry with a normal blood pressure so we need a portable glucometer and so you need to study the operator's manual for proper use in the field get to know the upper and lower ranges at which the glucometer functions so normal non-fasting adult and child blood glucose levels should be like we said earlier between 80 to 120 neonate should be above 70. then we get to the reassessment so reassess the patient with diabetes frequently to assess changes has their mental status improved are their abcs still intact has or how is the patient acting to the interventions that we've performed and how must you adjust or change your interventions based on administration of glucose on serial glucometer readings or a deteriorating level of consciousness okay so provide the indicated interventions for hypoglycemic conscious conscious is the key word patients who can swallow they have to be able to swallow we need to encourage them to take some glucose tablets if available or drink some juice containing sugar you also might have a gel prepared such as the glucose tubes or sugar drink if local protocol permits provide rapid transport to the hospital for unconscious unconscious hypoglycemic patients or patients with risk of aspiration meaning they can't maintain their airway they're going to need an iv with glucose or an intramuscular shot or an intranasal gluca glucagon is what they need so which most emts are not permitted to give if in doubt whether the patient is symptomatic hyper glycemia or hypoglycemia most protocols will err on the side of giving some sugar so determining blood glucose levels in a patient with diagnosed diabetes can be difficult when signs and symptoms are confusing and you have no way to test for the blood glucose value in these situations perform a thorough assessment contact the hospital to help sort out some of the signs and symptoms coordinate communication and documentation patients who refuse transport because their symptoms improve after taking oral glucose may require even more thorough documentation okay so giving emergency care to a diabetic so this is what i was talking about the the oral glucose there are three types of oral glucose preparations available commercially there's the rapidly dissolving gel there's large chewable tablets and then there's a liquid formulation the only concentration or contraindications are the inability to swallow and of course the patient being unconscious we want to wear gloves before putting anything in a patient's mouth and follow local protocols for glucose administration reassess the patient frequently and provide transport to the next level of care so the presentation of hypoglycemia you could have seizures and hypoglycemia is uh is a possible causes of seizures so though brief seizures are not harmful they may indicate a potentially life-threatening underlying condition so management of the seizures we have to maintain that airway place the patient on his or her side if there is no possibility of cervical spine trauma do not place anything in the patient's mouth have suction equipment ready in case the patient vomits and if the patient is cyanotic or appears to be breathing inadequately provide oxygen or artificial ventilations and of course transport promptly treatment of altered mental status and this may be caused by complications of the disease so it could be hypoglycemia or ketoacidosis use the mnemonic aeiou tips okay and always suspect to check for blood glucose in a patient with altered mental status so management ensure the airway is clear be prepared to provide artificial ventilations be prepared to suction if they vomit and provide transport promptly misdiagnosis of a neurological dysfunction so occasionally patients with a diabetic emergency are thought to be intoxicated a diabetic patient confirmed by police is at risk all right so an emergency medical identification bracelet necklace or card may help to save the patient's life in such situations a blood glucose test performed on scene if the protocol allows of course or in the emergency department will identify the real problem so be alert to the potential for diabetes and alcoholism to coexist in the same patient relationship to airway management so may not have a gag reflex and vomit or tongue may obstruct that airway so carefully monitor the airway place the patient in the lateral recumbent position make sure the suction is readily available at all times all right so now let's get into the hematologic emergencies we've moved from endocrine to the hematologic and hematology is the study of blood-related diseases three disorders that can create pre-hospital emergencies are sickle cell disease hemophilia thrombophilia and anemia so let's talk about the anatomy and physiology first blood is made up of four components we know that's the erythrocytes leukocytes platelet and plasmas and each of these components of the blood serves a purpose in maintaining the body's hemostatic balance so red blood cells of course contain hemoglobin and they carry the oxygen to the tissues white blood cells respond to infection and collect dead cells and provide their provide for correct disposal then we have platelets and they are essential for clotting plasma serves as that transport medium for blood components proteins and minerals pathophysiology of sickle cell disease also called hemoglobin s disease and that's inherited blood disorder that affects red blood cells it's pre it's found predominantly in people of african caribbean or south american ancestry people with sickle cells disease have misshapen red blood cells that lead to dysfunction in oxygen binding and unintentional clot formation fickle cells have a short life span and this results in more cellular waste products in the bloodstream and contributes to sludging and that's clumping of the blood so maintaining hydration is important and insufficient hydration leads to increased clumping complications associated with sickle cell disease include anemia gallstones jaundice and spleen dysfunction vascular occlusion with ischemia and so you could have acute chest syndrome strokes joint necrosis pain crisis acute or chronic organ dysfunction or failure retinal hemorrhages or increased risk of infections and so you could see the sickled cells on this slide they're shaped like a sickle and many of these complications are very painful and potentially life-threatening the patient is also more susceptible to in functions infections all right so now after sickle cells let's talk about clotting disorders and we're going to talk about hemophilia it's very rare only about 20 000 americans have this disorder hemophilia a affects mostly males people with hemophilia a have a decreased ability to create a clot after an injury which can be life-threatening so patients with hemophilia a can be prescribed medications to replace these missing clotting factors that are released and stored clotting factors or prevent the breakdown of blood clots common complications of hemophilia a include long-term joint problems that may require joint replacements or bleeding in the brain or thrombosis due to treatment thrombophilia that's a disorder of the body's ability to maintain smooth flow of blood through the venous and arterial systems the concentration of particular elements in the blood creates clogging or blockage issues thrombophilia is a general term for many different conditions that result in the blood clotting more easily than normal so you could have an inherited or genetic disorder or medications or other factors or patients with cancer clots can spontaneously develop in the blood of a patient so that leads us right into deep vein thrombosis okay so or dvts it's a common medical problem in sedimentary patients and the patients who have had recent injury or surgery methods to prevent blood clot formation include they could take blood thinning medications or compression stockings or also mechanical devices will help risk factors what we just talked about is a recent history of some type of replacement or and or complications of leg swelling so remaining sedimentary for long periods of time can also be a risk factor treatment for dvts include anticoagulation therapy oral medications are typically administered for at least three months after diagnosis of a dvt and a clot from the dvt it may travel from the patient's lower extremity to the lung causing a pulmonary emboli next we're going to talk about is anemia so this is an abnormally low number of red blood cells they can result from chronic or acute bleeding deficiency in certain vitamins or minerals or there could be some underlying disease process happening so blood is unable to deliver adequate amounts of oxygen to the tissues and pulse ox may indicate in an adequate saturation even though the underlying tissues are hypoxic so let's talk about the assessment of these disorders so we're going to start with the zinc size up and we have to ensure scene safety and most sickle cell patients will have had a crisis before of course we're going to wear gloves and eye protection at a minimum and determine the number of patients involved we're going to be alert for possible trauma and consider advanced life support and next is our primary assessment we're going to perform that cervical immobilization if we need to and form the general impression and then into the abs and c so um for patients with inadequate breathing or altered mental status of course we're going to get that high flow oxygen at 12 to 15 liters via a non-rebreather mask patients experiencing a sickle cell crisis will have increased respirations or exhibit signs of pneumonia so for patients with difficulty breathing open that airway in certain adjuncts administer oxygen and assist ventilations if needed assess the patient's circulatory statuses next the c sickle cell crisis patients will have increased heart rate to force those sickled cells through smaller blood vessels and so for suspected hemophilia patients though be alert for signs of blood loss and no bleeding of an unknown origin and be alert for signs of hypoxia which could be due to that blood loss and then of course the d abcd and that's that decision we need to transport them to an emergency room and it's always recommended to any patient who's experiencing a sickle cell crisis or hemophilia and then the history taken so we're going to investigate that chief complaint and obtain the history of the present illness from responsive patients family or bystanders be alert for signs indicating sickle cell crisis and these are going to include swelling of the fingers and toes of prypism or jaundice and then ask some questions okay so is the pain isolated to that single location or are you feeling it throughout the body is the patient having any visual disturbances and is the patient experiencing nausea vomiting or abdominal cramping and is the patient experiencing chest pain or shortness of breath then of course we're going to obtain that sample history for uh from responsive patients or we could get it from a family member if needed and have you had a crisis before when was the last crisis and how did your crisis resolve or how or have you had any illnesses unusual amount of activity or stress lately then the secondary so systemically examine that patient focus on the joints evaluate and document the mental status and obtain a complete set of vital signs and including oxygen saturation levels normal sickle cell crisis vital signs will be normal to rapid weak rapid pulse pale clammy skin or low blood pressure use pulse ox if available to monitor that oxygen set readings may be inaccurate due to patients who are in an anemic state and it's our reassessment so we're going to reassess vital signs frequently to determine changes in the patient's condition we're going to evaluate those interventions and then we're going to communicate with the hospital staff for continuity of care and document clearly now we're going to talk about the emergency medical care we can provide for these emergencies okay or disorders emergency care is mainly supportive and symptomatic okay so for patients with inadequate breathing or altered mental status we could give them high flow oxygen at 12 to 15 liters we could place them in the position of comfort and transport rapidly to the hospital okay so this concludes the chapter 20 endocrine in hematologic emergencies of the emergency care and transportation of the sick and injured 12th edition so now we're going to see how much we've learned through the review questions type 1 diabetes is a condition in which let's see glucose utilization is impaired and that's a fancy way of just saying that the cells cannot get the glucose because of course it does not have the insulin so type 1 diabetes is the disease in which the pancreas fails to produce that insulin a 45 year old man with type 1 diabetes is found unresponsive which of the following questions is most approp important to ask his wife so the insulin did he take it today how long has he been a diabetic has he seen the physician recently or what kind of insulin does he take i would think it would be did he take his insulin today yeah all of those are pretty important but you want to see if he took the insulin today okay all right a diabetic patient presents with blood glucose level of 310 and severe dehydration so the patient's dehydration is a result of well i think it's the excretion of glucose and water from the kidneys remember the kidneys are trying to maintain that balance and so you're going to get polyuria okay so it is a excretion of glucose and water from the kidneys which of the following combination of factors would most likely cause hypoglycemic crisis in a diaper diabetic patients hypo so low sugar i think it's skipping a meal but still taking their insulin right yeah because you're going to take the insulin combination of yep that's right so skipping that meal but still taking their insulin they're not going to have any sugar okay a 19 year old diabetic male is found unresponsive on the couch by his roommate after confirming that the patient is unresponsive you should well the first thing we need to do is i'm pretty sure is open that airway if he's unresponsive right immediately determine and the first action should be to open the airway yeah we need to open that airway to see if he's breathing what breathing pattern would most likely encounter during a patient with diabetic ketoacidosis so dka we know that these are going to be usually rapid and deep they're trying to blow off any of that sugar they can right that's right koosh malls that's the rapid and deep breathing pattern okay so a woman called ems because her 12 year old son who has been experiencing excessive urination thirst and hunger for about 36 hours and now has altered mental status he's breathing fast so this sounds like deep diabetic ketoacidosis you should of most be suspicious for and we're right away hyper glycemic crisis he has not been diagnosed yet and so he's going to have high blood sugar yes polyuria plot ledepsnia polyphasia hyperglycemic crisis okay if the cells do not receive glucose they will begin to metabolize we know this we know this right they're going to begin to metabolize fat okay so fat metabolism results in that keto acids right so ketoacidosis is going to result in contrast to a hyperglycemic crisis hypoglycemic crisis let's see i'm going to say immediately response to treatment because we're going to give them sugar yep immediately usually responds immediately after treatment all right patients with diabetic ketoacidosis experiencing polydipsnia because all right they're thirsty so let's see they're usually dehydrated secondary to that excessive urination right yeah because their kidneys are trying to excrete okay this concludes chapter 20 endocrine and hematologic emergencies and thank you for joining us today