Diabetes is a condition where there is a malfunction in the ability of the body to produce or utilize insulin correctly. The result is a condition where glucose remains in the bloodstream longer than it should. The 2 types of emergencies that stem from this condition are hypoglycemia and hyperglycemia.
The 2 hormones in the body responsible for glucose management are Insulin, and Glucagon. Insulin functions to mobilize glucose into the cells for use and storage as glycogen; it is released when BGL rises. Glucagon is released in response to a drop in BGL, and converts stored glycogen into glucose.
In the diabetic patient (type 1 or 2), there is a malfunction in insulin production or cellular sensitivity to insulin. The result is that glucose cannot be stored or utilized by cells for energy.
Type 1 Diabetes: Also called insulin dependent diabetes (IDDM), these patients have damaged pancreatic beta cells, which do not produce any insulin. This has an onset in childhood and is usually addressed early on with supplemental insulin therapy, through daily injections.
Type 2 Diabetes: Non insulin dependent diabetes (NIDDM), is the result of cellular desensitization to insulin, or decrease in insulin production later in life. This is usually the result of poor eating habits, obesity, and sedentary lifestyle. These patients still produce insulin, however they either don't have enough, or they cannot utilize it effectively. Oral hyperglycemic medications are taken, and lifestyle adjustments are used to correct blood sugar anomalies.
Hypoglycemia: The “normal”or medically accepted limits for fasting blood sugar are:
<2 yrs old: >3mmol/L – 6mmol/L
>2 yrs old >4mmol/L – 6mmol/L
In the hypoglycemic patient, the BGL drops below the bottom threshold. The result is insufficient circulating glucose to allow for the metabolic activities required to sustain life. We typically see this in IDDM, and the most common cause is the use of injected insulin without sufficient intake of oral glucose/carbohydrates, or an accidental overdose of insulin. Signs of hypoglycemia include:
Altered LOA
Diaphoresis
Tachycardia
Anxiety
Seizure
Treatment of these patients is actually quite simple, as we only need to correct BGL to restore homeostasis. Depending upon the degree of hypoglycemia this can mean:
Oral Glucose.
Injectable Glucagon (not helpful in emaciated patients, those with liver disease, or alcoholics).
IV Dextrose
Hyperglycemia: This is a less common problem now that medications have advanced to where they are today. Nonetheless, we do still encounter hyperglycemia in diabetic patients from time to time. There are essentially 2 critical hyperglycemic states we need to be aware of: HHNK, and DKA.
HHNK: Hyperglycemic Hyperosmolar Nonketotic Syndrome is a hyperglycemic state seen in NIDDM patients. In these patients, there is a massive spike in BGL, usually >30 mmol/L, which results in the circulating fluid becoming hyperosmolar. This change in concentration gradient results in a fluid shift out of the cells and tissues, into the circulating blood volume. As a result we see profound, systemic, dehydration and electrolyte disturbances. The resulting increase in vascular fluid, leads to glucose and fluid dumping through urination. Unlike DKA, this process is somewhat insidious because it occurs gradually over a period of several days. We don't typically see these patients until they have become so critical that they slip into a coma state.
Symptoms include:
Dehydration/hypotension
Hyperglycemia
Increased thirst
Dry skin
Tachycardia
Lethargy and altered LOA/LOC
Treatment involves airway management and fluid resuscitation via IV isotonic saline. A patch to the BHP is suggested to consider a bolus for patients who do not meet hypotensive protocol requirements.
DKA: Diabetic Ketoacidosis is a condition in IDDM where BGL spikes and there is insufficient insulin to address it. As a result, cells shift to fat metabolism to create energy. A biproduct of this process is Ketones. Ketones are acids, and they put the body into a state of metabolic acidosis. Symptoms include:
Altered LOA
Kussmauls respirations
Acetone breath
Warm dry skin
Tachycardia
Lethargy
Seizure
Treatment is essentially the same as that of HHNK
Comments