The Endocrine System EMS Professions Temple College
Endocrine Glands <ul><li>Controls many body functions </li></ul><ul><ul><li>exerts control by releasing special chemical s...
Hormones <ul><li>Chemicals produced by endocrine glands </li></ul><ul><li>Act on target organs elsewhere in body </li></ul...
Hormones <ul><li>Hormones are classified as: </li></ul><ul><ul><li>Proteins </li></ul></ul><ul><ul><li>Polypeptides (amino...
Hormones <ul><li>Amount of hormone reaching target tissue directly correlates with concentration of hormone in blood. </li...
The Endocrine System <ul><li>Consists of several glands located in various parts of the body </li></ul><ul><li>Specific Gl...
Pituitary Gland <ul><li>Small gland located on stalk hanging from base of brain -  AKA </li></ul><ul><li>“ The Master Glan...
Pituitary Gland <ul><li>Two areas </li></ul><ul><ul><li>Anterior Pituitary </li></ul></ul><ul><ul><li>Posterior Pituitary ...
Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Thyroid-Stimulating Hormone (TSH) </li></ul></ul><ul><ul>...
Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Growth Hormone (GH) </li></ul></ul><ul><ul><ul><li>stimul...
Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Follicle Stimulating Hormone (FSH) </li></ul></ul><ul><ul...
Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Prolactin </li></ul></ul><ul><ul><ul><li>stimulates breas...
Pituitary Gland <ul><li>Posterior Pituitary </li></ul><ul><ul><li>Stores, releases two hormones produced in hypothalamus <...
Pituitary Gland <ul><li>Posterior Pituitary </li></ul><ul><ul><li>Antidiuretic hormone (ADH) </li></ul></ul><ul><ul><ul><l...
Hypothalamus <ul><li>Produces several releasing and inhibiting factors that stimulate or inhibit anterior pituitary’s secr...
Hypothalamus <ul><li>Also responsible for: </li></ul><ul><ul><li>Regulation of water balance </li></ul></ul><ul><ul><li>Es...
Pineal Gland <ul><li>Located within the Diencephalon </li></ul><ul><li>Melatonin </li></ul><ul><ul><li>Inhibits ovarian ho...
Thyroid <ul><li>Located below larynx and low in neck </li></ul><ul><ul><li>Not over the thyroid cartilage </li></ul></ul><...
Parathyroids <ul><li>Located on posterior surface of thyroid </li></ul><ul><li>Frequently damaged during thyroid surgery <...
Parathyroids <ul><li>Underactivity </li></ul><ul><ul><li>Decrease serum Ca 2+ </li></ul></ul><ul><ul><ul><li>Hypocalcemic ...
Parathyroids <ul><li>Overactivity </li></ul><ul><ul><li>Increased serum Ca 2+ </li></ul></ul><ul><ul><ul><li>Pathological ...
Thymus Gland <ul><li>Located in anterior chest  </li></ul><ul><li>Normally absent by ~ age 4 </li></ul><ul><li>Promotes de...
Adrenal Glands <ul><li>Small glands located near (ad) the kidneys (renals)  </li></ul><ul><li>Consists of: </li></ul><ul><...
Adrenal Glands <ul><li>Adrenal Medulla </li></ul><ul><ul><li>the Adrenal Medulla secretes the  catecholamine hormones  nor...
Adrenal Glands <ul><li>Adrenal Cortex </li></ul><ul><ul><li>Aldosterone (Mineralocorticoid) </li></ul></ul><ul><ul><ul><li...
Adrenal Glands <ul><li>Adrenal Cortex </li></ul><ul><ul><li>Glucocorticoids </li></ul></ul><ul><ul><ul><li>accounts for 95...
Adrenal Glands <ul><li>Adrenal Cortex </li></ul><ul><ul><li>Mineralcorticoids </li></ul></ul><ul><ul><ul><li>work to regul...
Ovaries <ul><li>Located in the abdominal cavity adjacent to the uterus </li></ul><ul><li>Under the control of LH and FSH f...
Ovaries <ul><li>Estrogen </li></ul><ul><ul><li>Development of female secondary sexual characteristics </li></ul></ul><ul><...
Testes <ul><li>Located in the scrotum </li></ul><ul><li>Controlled by anterior pituitary hormones FSH and LH </li></ul><ul...
Pancreas <ul><li>Located in retroperitoneal space between duodenum and spleen </li></ul><ul><li>Has both endocrine and exo...
Pancreas <ul><li>Exocrine function </li></ul><ul><ul><li>Secretes </li></ul></ul><ul><ul><ul><li>amylase </li></ul></ul></...
Pancreas <ul><li>Alpha  Cells </li></ul><ul><ul><li>Glucagon </li></ul></ul><ul><ul><ul><li>Raises blood glucose levels </...
Disorders of the Endocrine System
Abnormal Thyroid Function <ul><li>Hypothyroidism </li></ul><ul><ul><li>Too little thyroid hormone </li></ul></ul><ul><li>H...
Hypothyroidism <ul><li>Thyroid hormone deficiency causing a decrease in the basal metabolic rate </li></ul><ul><ul><li>Per...
Hypothyroidism <ul><li>Confusion, drowsiness, coma </li></ul><ul><li>Cold intolerant </li></ul><ul><li>Hypotension, Bradyc...
Hypothyroidism <ul><li>Myxedema Coma </li></ul><ul><ul><li>Severe hypothyroidism that can be fatal   </li></ul></ul><ul><l...
Hyperthyroidism <ul><li>Excessive levels of thyroid levels cause hypermetabolic state </li></ul><ul><ul><li>Person is “spe...
Hyperthyroidism <ul><li>Nervousness, irritable, tremors, paranoid </li></ul><ul><li>Warm, flushed skin </li></ul><ul><li>H...
Hyperthyroidism <ul><li>Treatment </li></ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul><ul><ul><li>ECG monitor <...
Thyroid Storm/Thyrotoxicosis <ul><li>Severe form of hyperthyroidism that can be fatal </li></ul><ul><ul><li>Acute life-thr...
Thyroid Storm/Thyrotoxicosis <ul><li>Severe tachycardia </li></ul><ul><li>Heart Failure </li></ul><ul><li>Dysrhythmias </l...
Thyroid Storm/Thyrotoxicosis <ul><li>Management </li></ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul><ul><ul><li...
Abnormal Adrenal Function  <ul><li>Hyperadrenalism </li></ul><ul><ul><li>Excess activity of the adrenal gland </li></ul></...
Hyperadrenalism <ul><li>Primary Aldosteronism  </li></ul><ul><ul><li>Excessive secretion of aldosterone by adrenal cortex ...
Hyperadrenalism <ul><li>Adrenogenital syndrome </li></ul><ul><ul><li>“ Bearded Lady” </li></ul></ul><ul><ul><li>Group of d...
Hyperadrenalism <ul><li>Cushing’s Syndrome </li></ul><ul><ul><li>Results from increased adrenocortical secretion of cortis...
Hyperadrenalism <ul><li>Cushing’s Syndrome </li></ul><ul><ul><li>Characterized by: </li></ul></ul><ul><ul><ul><li>truncal ...
Hyperadrenalism <ul><li>Cushing’s Disease </li></ul><ul><ul><li>Too much adrenal hormone production </li></ul></ul><ul><ul...
Hyperadrenalism <ul><li>Cushing’s Syndrome </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Airway/Ventilat...
Hyperadrenalism <ul><li>Pheochromocytoma </li></ul><ul><ul><li>Catecholamine secreting tumor of adrenal medulla </li></ul>...
Hyperadrenalism <ul><li>Pheochromocytoma </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Supportive care b...
Hypoadrenalism <ul><li>Adrenal Insufficiency </li></ul><ul><ul><li>decrease production of glucocorticoids, mineralcorticoi...
Hypoadrenalism <ul><li>Presentation </li></ul><ul><ul><li>Hypotension, Shock </li></ul></ul><ul><ul><li>Hyponatremia, Hype...
Hypoadrenalism <ul><li>Management </li></ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul><ul><ul><li>ECG monitor <...
Diabetes Mellitus
Diabetes Mellitus <ul><li>Chronic metabolic disease </li></ul><ul><li>One of the most common diseases in North America </l...
Regulation of Glucose <ul><li>Dietary Intake </li></ul><ul><ul><li>Components of food : </li></ul></ul><ul><ul><ul><li>Car...
Regulation of Glucose <ul><li>The other 3 major food sources for glucose are </li></ul><ul><ul><li>carbohydrates </li></ul...
Regulation of Glucose  <ul><li>Carbohydrates </li></ul><ul><ul><li>Found in sugary, starchy foods </li></ul></ul><ul><ul><...
Regulation of Glucose <ul><li>Fats </li></ul><ul><ul><li>Broken down into fatty acids and glycerol by enzymes </li></ul></...
Regulation of Glucose <ul><li>Pancreatic hormones are required to regulate blood glucose level </li></ul><ul><ul><li>gluca...
Regulation of Glucose <ul><li>Alpha (  ) cells release  glucagon  to control blood glucose level </li></ul><ul><ul><li>Wh...
Regulation of Glucose <ul><li>Beta Cells  (  )  release  insulin  (antagonistic to glucagon) to control blood glucose lev...
Regulation of Glucose <ul><li>Delta Cells (  ) produce  somatostatin,  which inhibits both glucagon and insulin </li></ul...
Regulation of Glucose <ul><li>Breakdown of sugars carried out by enzymes in the GI system </li></ul><ul><ul><li>As  simple...
Regulation of Glucose <ul><li>Glucose must pass into the cell by binding to a special carrier protein on the cell’s surfac...
Regulation of Glucose <ul><li>Body strives to maintain blood glucose between 60 mg/dl and 120 mg/dl. </li></ul><ul><li>Glu...
Regulation of Glucose Insulin Glucagon Glucagon and Insulin are opposites (antagonists) of each other.
Regulation of Glucose <ul><li>Glucagon </li></ul><ul><ul><li>Released in response to: </li></ul></ul><ul><ul><ul><li>Sympa...
Regulation of Glucose <ul><li>Insulin </li></ul><ul><ul><li>Released in response to: </li></ul></ul><ul><ul><ul><li>Increa...
Diabetes Mellitus <ul><li>2 Types historically based on age of onset (NOT insulin vs. non-insulin) </li></ul><ul><ul><li>T...
Types of Diabetes Mellitus <ul><li>Type I </li></ul><ul><li>Type II </li></ul><ul><li>Secondary </li></ul><ul><li>Gestatio...
Pathophysiology of  Type I Diabetes Mellitus <ul><li>Characterized by inadequate or absent production of insulin by pancre...
Pathophysiology of  Type II Diabetes Mellitus <ul><li>Pancreas continues to produce some insulin however disease results f...
Secondary Diabetes Mellitus <ul><li>Pre-existing condition affects pancreas </li></ul><ul><ul><li>Pancreatitis </li></ul><...
Gestational Diabetes Mellitus <ul><li>Occurs during pregnancy </li></ul><ul><ul><li>Usually resolves after delivery </li><...
Presentation of New Onset Diabetes Mellitus <ul><li>3 Ps </li></ul><ul><ul><li>Polyuria </li></ul></ul><ul><ul><li>Polydip...
Long Term Treatment of  Diabetes Mellitus <ul><li>Diet regulation </li></ul><ul><ul><li>e.g . 1400 calorie ADA diet </li><...
Long Term Treatment of Diabetes Mellitus <ul><li>Insulin </li></ul><ul><ul><li>Available in various forms distinguished on...
Long Term Treatment of Diabetes Mellitus <ul><li>Insulin </li></ul><ul><ul><li>Must be given by injection as insulin is pr...
Long Term Treatment of  Diabetes Mellitus <ul><li>Oral Hypoglycemic Agents </li></ul><ul><ul><li>Stimulate the release of ...
Emergencies Associated Blood Glucose Level <ul><li>Hyperglycemia </li></ul><ul><ul><li>Diabetic Ketoacidosis (DKA) </li></...
Hyperglycemia <ul><li>Defined as blood glucose > 200 mg/dl  </li></ul><ul><li>Causes </li></ul><ul><ul><li>Failure to take...
Hyperglycemia <ul><li>Two hyperglycemic diabetic states may occur </li></ul><ul><ul><li>Diabetic Ketoacidosis (DKA) </li><...
Diabetic Ketoacidosis (DKA) <ul><li>Occurs in Type I diabetics (insulin dependency) </li></ul><ul><li>Usually  associated ...
Diabetic Ketoacidosis (DKA) <ul><li>Pathophysiology </li></ul><ul><ul><li>Results from absence of insulin </li></ul></ul><...
Diabetic Ketoacidosis (DKA) <ul><li>Pathophysiology (cont) </li></ul><ul><ul><li>Blood sugar rises above renal threshold f...
Diabetic Ketoacidosis (DKA) <ul><li>Presentation </li></ul><ul><ul><li>Gradual onset with progression </li></ul></ul><ul><...
Diabetic Ketoacidosis Increased Blood Sugar Osmotic   Diuresis Polyuria Cells Can’t Burn Glucose Cells Burn Fat Polyphagia...
Management of DKA <ul><li>Airway/Ventilation/Oxygen NRB mask </li></ul><ul><li>Assess blood glucose level & ECG </li></ul>...
Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) <ul><li>Usually occurs in type II diabetics </li></ul><ul><li>Typically ...
Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) <ul><li>Pathophysiology </li></ul><ul><ul><li>Some minimal insulin produ...
Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) Increased Blood Sugar Osmotic   Diuresis Polyuria Inadequate insulin Pol...
Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) <ul><li>Presentation </li></ul><ul><ul><li>Same as DKA but with greater ...
Management of HHNC <ul><li>Secure airway and assess ventilation </li></ul><ul><ul><li>Consider need to assist ventilation ...
Further Management of Hyperglycemia <ul><li>Insulin (regular) </li></ul><ul><ul><li>Correct hyperglycemia </li></ul></ul><...
Hypoglycemia <ul><li>True hypoglycemia defined as blood sugar  < 60 mg/dl </li></ul><ul><li>ALL hypoglycemia is NOT caused...
Hypoglycemia <ul><li>Causes  of hypoglycemia in diabetics </li></ul><ul><ul><li>Too much insulin </li></ul></ul><ul><ul><l...
Hypoglycemia <ul><li>Presentation </li></ul><ul><ul><li>Hunger (initially), Headache </li></ul></ul><ul><ul><li>Weakness, ...
Hypoglycemia: Pathophysiology Blood Glucose Falls Brain Lacks Glucose SNS Response Altered LOC Seizures Headache Dizziness...
Hypoglycemia Beta Blockers may mask symptoms by inhibiting sympathetic response
Management of Hypoglycemia  <ul><li>Secure airway manually  </li></ul><ul><ul><li>suction prn </li></ul></ul><ul><ul><li>V...
Management of Hypoglycemia <ul><li>Oral glucose </li></ul><ul><ul><li>ONLY if intact gag reflex, awake & able to sit up </...
Management of Hypoglycemia <ul><li>Glucagon </li></ul><ul><ul><li>Used if unable to obtain IV access </li></ul></ul><ul><u...
Management of Hypoglycemia  <ul><li>Have patient eat high-carbohydrate meal </li></ul><ul><li>Transport? </li></ul><ul><ul...
Long-term Complications of Diabetes Mellitus <ul><li>Blindness </li></ul><ul><ul><li>Retinal hemorrhages </li></ul></ul><u...
Long-term Complications of Diabetes Mellitus <ul><li>Diffuse Atherosclerois </li></ul><ul><ul><li>AMI </li></ul></ul><ul><...
Long-term Complications of Diabetes Mellitus 10% of all diabetics develop renal disease usually resulting in dialysis Diab...
Long-term Complications of Diabetes Mellitus <ul><li>Peripheral Neuropathy </li></ul><ul><ul><li>Silent MI </li></ul></ul>...
Diabetes in Pregnancy <ul><li>Early pregnancy (<24 weeks) </li></ul><ul><ul><li>Rapid embryo growth </li></ul></ul><ul><ul...
Diabetes in Pregnancy <ul><li>Late pregnancy (>24 weeks) </li></ul><ul><ul><li>Increased resistance to insulin effects </l...
Diabetes in Pregnancy <ul><li>Increased maternal risk for: </li></ul><ul><ul><li>Pregnancy-induced hypertension </li></ul>...
Diabetes in Pregnancy <ul><li>Increased fetal risk for: </li></ul><ul><ul><li>High birth weight </li></ul></ul><ul><ul><li...
Assessment of the Diabetic Patient <ul><li>Maintain high-degree of suspicion </li></ul><ul><li>Assess blood glucose level ...
Assessment of the Diabetic Patient <ul><li>History and Physical Exam includes </li></ul><ul><ul><li>Look for insulin syrin...
Blood Glucose Assessment <ul><li>Capillary vs. venous blood sample </li></ul><ul><ul><li>Depends on glucometer model </li>...
Case Study #1 <ul><li>You are dispatched to a college residence hall to see a 20-year-old female complaining of fever and ...
Case Study #1 <ul><li>You direct your partner to assess vital signs while you place the patient on Oxygen 15 lpm by NRB ma...
Case Study #1 <ul><li>The patient states this has occurred before but never lasted this long.  She has not been ill lately...
Case Study #2 <ul><li>You are dispatched to a residence to see a 44-year-old man who has fainted.  You arrive to find him ...
Case Study #2 <ul><ul><li>Your partner assesses vital signs while you obtain the following history: </li></ul></ul><ul><ul...
Case Study #2 <ul><ul><li>Vital signs are: </li></ul></ul><ul><ul><ul><li>Pulse: 110-126, irregular </li></ul></ul></ul><u...
Case Study #2 <ul><ul><li>Your partner is a brand new, naïve paramedic.  He comments to the patient, “That is a great tan ...
Case Study #3 <ul><li>Your last call (you hope) of the shift is to a manufacturing plant for a possible drug overdose.  Yo...
Case Study #3 <ul><li>Your partner quickly assesses the patient’s vital signs and relays the following: </li></ul><ul><ul>...
Case Study #3 <ul><li>A coworker now tells you that the patient is going through a difficult divorce and has not been eati...
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Training

  1. 1. The Endocrine System EMS Professions Temple College
  2. 2. Endocrine Glands <ul><li>Controls many body functions </li></ul><ul><ul><li>exerts control by releasing special chemical substances into the blood called hormones </li></ul></ul><ul><ul><li>Hormones affect other endocrine glands or body systems </li></ul></ul><ul><li>Ductless glands </li></ul><ul><li>Secrete hormones directly into bloodstream </li></ul><ul><ul><li>Hormones are quickly distributed by bloodstream throughout the body </li></ul></ul>
  3. 3. Hormones <ul><li>Chemicals produced by endocrine glands </li></ul><ul><li>Act on target organs elsewhere in body </li></ul><ul><li>Control/coordinate widespread processes: </li></ul><ul><ul><li>Homeostasis </li></ul></ul><ul><ul><li>Reproduction </li></ul></ul><ul><ul><li>Growth & Development </li></ul></ul><ul><ul><li>Metabolism </li></ul></ul><ul><ul><li>Response to stress </li></ul></ul><ul><ul><ul><li>Overlaps with the Sympathetic Nervous System </li></ul></ul></ul>
  4. 4. Hormones <ul><li>Hormones are classified as: </li></ul><ul><ul><li>Proteins </li></ul></ul><ul><ul><li>Polypeptides (amino acid derivatives) </li></ul></ul><ul><ul><li>Lipids (fatty acid derivatives or steroids) </li></ul></ul>
  5. 5. Hormones <ul><li>Amount of hormone reaching target tissue directly correlates with concentration of hormone in blood. </li></ul><ul><ul><li>Constant level hormones </li></ul></ul><ul><ul><ul><li>Thyroid hormones </li></ul></ul></ul><ul><ul><li>Variable level hormones </li></ul></ul><ul><ul><ul><li>Epinephrine (adrenaline) release </li></ul></ul></ul><ul><ul><li>Cyclic level hormones </li></ul></ul><ul><ul><ul><li>Reproductive hormones </li></ul></ul></ul>
  6. 6. The Endocrine System <ul><li>Consists of several glands located in various parts of the body </li></ul><ul><li>Specific Glands </li></ul><ul><ul><li>Hypothalamus </li></ul></ul><ul><ul><li>Pituitary </li></ul></ul><ul><ul><li>Thyroid </li></ul></ul><ul><ul><li>Parathyroid </li></ul></ul><ul><ul><li>Adrenal </li></ul></ul><ul><ul><li>Kidneys </li></ul></ul><ul><ul><li>Pancreatic Islets </li></ul></ul><ul><ul><li>Ovaries </li></ul></ul><ul><ul><li>Testes </li></ul></ul>
  7. 7. Pituitary Gland <ul><li>Small gland located on stalk hanging from base of brain - AKA </li></ul><ul><li>“ The Master Gland” </li></ul><ul><ul><li>Primary function is to control other glands. </li></ul></ul><ul><ul><li>Produces many hormones. </li></ul></ul><ul><ul><li>Secretion is controlled by hypothalamus in base of brain. </li></ul></ul>
  8. 8. Pituitary Gland <ul><li>Two areas </li></ul><ul><ul><li>Anterior Pituitary </li></ul></ul><ul><ul><li>Posterior Pituitary </li></ul></ul><ul><li>Structurally, functionally different </li></ul>
  9. 9. Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Thyroid-Stimulating Hormone (TSH) </li></ul></ul><ul><ul><ul><li>stimulates release of hormones from Thyroid </li></ul></ul></ul><ul><ul><ul><ul><li>thyroxine (T4) and triiodothyronine (T3): stimulate metabolism of all cells </li></ul></ul></ul></ul><ul><ul><ul><ul><li>calcitonin: lowers the amount of calcium in the blood by inhibiting breakdown of bone </li></ul></ul></ul></ul><ul><ul><ul><li>released when stimulated by TSH or cold </li></ul></ul></ul><ul><ul><ul><li>abnormal conditions </li></ul></ul></ul><ul><ul><ul><ul><li>hyperthyroidism: too much TSH release </li></ul></ul></ul></ul><ul><ul><ul><ul><li>hypothyroidism: too little TSH release </li></ul></ul></ul></ul>
  10. 10. Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Growth Hormone (GH) </li></ul></ul><ul><ul><ul><li>stimulates growth of all organs and increases blood glucose concentration </li></ul></ul></ul><ul><ul><ul><ul><li>decreases glucose usage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>increases consumption of fats as an energy source </li></ul></ul></ul></ul><ul><ul><li>Adreno-Corticotrophic Hormone (ACTH) </li></ul></ul><ul><ul><ul><li>stimulates the release of adrenal cortex hormones </li></ul></ul></ul>
  11. 11. Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Follicle Stimulating Hormone (FSH) </li></ul></ul><ul><ul><ul><li>females - stimulates maturation of ova; release of estrogen </li></ul></ul></ul><ul><ul><ul><li>males - stimulates testes to grow; produce sperm </li></ul></ul></ul><ul><ul><li>Luteinizing Hormone (LH) </li></ul></ul><ul><ul><ul><li>females - stimulates ovulation; growth of corpus luteum </li></ul></ul></ul><ul><ul><ul><li>males - stimulates testes to secrete testosterone </li></ul></ul></ul>
  12. 12. Pituitary Gland <ul><li>Anterior Pituitary </li></ul><ul><ul><li>Prolactin </li></ul></ul><ul><ul><ul><li>stimulates breast development during pregnancy; milk production after delivery </li></ul></ul></ul><ul><ul><li>Melanocyte Stimulating Hormone (MSH) </li></ul></ul><ul><ul><ul><li>stimulates synthesis, dispersion of melanin pigment in skin </li></ul></ul></ul>
  13. 13. Pituitary Gland <ul><li>Posterior Pituitary </li></ul><ul><ul><li>Stores, releases two hormones produced in hypothalamus </li></ul></ul><ul><ul><ul><li>Antidiuretic hormone (ADH) </li></ul></ul></ul><ul><ul><ul><li>Oxytocin </li></ul></ul></ul>
  14. 14. Pituitary Gland <ul><li>Posterior Pituitary </li></ul><ul><ul><li>Antidiuretic hormone (ADH) </li></ul></ul><ul><ul><ul><li>Stimulates water retention by kidneys </li></ul></ul></ul><ul><ul><ul><ul><li>reabsorb sodium and water </li></ul></ul></ul></ul><ul><ul><ul><li>Abnormal conditions </li></ul></ul></ul><ul><ul><ul><ul><li>Undersecretion: diabetes insipidus (“water diabetes”) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Oversecretion: Syndrome of Inappropriate Antidiuretic Hormone (SIADH) </li></ul></ul></ul></ul><ul><ul><li>Oxytocin </li></ul></ul><ul><ul><ul><li>Stimulates contraction of uterus at end of pregnancy (Pitocin®); release of milk from breast </li></ul></ul></ul>
  15. 15. Hypothalamus <ul><li>Produces several releasing and inhibiting factors that stimulate or inhibit anterior pituitary’s secretion of hormones. </li></ul><ul><li>Produces hormones that are stored in and released from posterior pituitary </li></ul>What are these two hormones?
  16. 16. Hypothalamus <ul><li>Also responsible for: </li></ul><ul><ul><li>Regulation of water balance </li></ul></ul><ul><ul><li>Esophageal swallowing </li></ul></ul><ul><ul><li>Body temperature regulation (shivering) </li></ul></ul><ul><ul><li>Food/water intake (appetite) </li></ul></ul><ul><ul><li>Sleep-wake cycle </li></ul></ul><ul><ul><li>Autonomic functions </li></ul></ul>
  17. 17. Pineal Gland <ul><li>Located within the Diencephalon </li></ul><ul><li>Melatonin </li></ul><ul><ul><li>Inhibits ovarian hormones </li></ul></ul><ul><ul><li>May regulate the body’s internal clock </li></ul></ul>
  18. 18. Thyroid <ul><li>Located below larynx and low in neck </li></ul><ul><ul><li>Not over the thyroid cartilage </li></ul></ul><ul><li>Thyroxine (T 4 ) and Triiodothyronine (T 3 ) </li></ul><ul><ul><li>Stimulate metabolism of all cells </li></ul></ul><ul><li>Calcitonin </li></ul><ul><ul><li>Decreases blood calcium concentration by inhibiting breakdown of bone </li></ul></ul>
  19. 19. Parathyroids <ul><li>Located on posterior surface of thyroid </li></ul><ul><li>Frequently damaged during thyroid surgery </li></ul><ul><li>Parathyroid hormone (PTH) </li></ul><ul><ul><li>Stimulates Ca 2+ release from bone </li></ul></ul><ul><ul><li>Promotes intestinal absorption and renal tubular reabsorption of calcium </li></ul></ul>
  20. 20. Parathyroids <ul><li>Underactivity </li></ul><ul><ul><li>Decrease serum Ca 2+ </li></ul></ul><ul><ul><ul><li>Hypocalcemic tetany </li></ul></ul></ul><ul><ul><ul><li>Seizures </li></ul></ul></ul><ul><ul><ul><li>Laryngospasm </li></ul></ul></ul>
  21. 21. Parathyroids <ul><li>Overactivity </li></ul><ul><ul><li>Increased serum Ca 2+ </li></ul></ul><ul><ul><ul><li>Pathological fractures </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Renal stones </li></ul></ul></ul><ul><ul><ul><li>Altered mental status </li></ul></ul></ul><ul><ul><li>“ Bones, stones, hypertones, abdominal moans” </li></ul></ul>
  22. 22. Thymus Gland <ul><li>Located in anterior chest </li></ul><ul><li>Normally absent by ~ age 4 </li></ul><ul><li>Promotes development of immune-system cells (T-lymphocytes) </li></ul>
  23. 23. Adrenal Glands <ul><li>Small glands located near (ad) the kidneys (renals) </li></ul><ul><li>Consists of: </li></ul><ul><ul><li>outer cortex </li></ul></ul><ul><ul><li>inner medulla </li></ul></ul>
  24. 24. Adrenal Glands <ul><li>Adrenal Medulla </li></ul><ul><ul><li>the Adrenal Medulla secretes the catecholamine hormones norepinephrine and epinephrine </li></ul></ul><ul><ul><li>Epinephrine and Norepinephrine </li></ul></ul><ul><ul><ul><li>Prolong and intensify the sympathetic nervous system response during stress </li></ul></ul></ul>
  25. 25. Adrenal Glands <ul><li>Adrenal Cortex </li></ul><ul><ul><li>Aldosterone (Mineralocorticoid) </li></ul></ul><ul><ul><ul><li>Regulates electrolyte (potassium, sodium) and fluid homeostasis </li></ul></ul></ul><ul><ul><li>Cortisol (Glucocorticoids) </li></ul></ul><ul><ul><ul><li>Antiinflammatory, anti-immunity, and anti-allergy effects. </li></ul></ul></ul><ul><ul><ul><li>Increases blood glucose concentrations </li></ul></ul></ul><ul><ul><li>Androgens (Sex Hormones) </li></ul></ul><ul><ul><ul><li>Stimulate sexual drive in females </li></ul></ul></ul>
  26. 26. Adrenal Glands <ul><li>Adrenal Cortex </li></ul><ul><ul><li>Glucocorticoids </li></ul></ul><ul><ul><ul><li>accounts for 95% of adrenal cortex hormone production </li></ul></ul></ul><ul><ul><ul><li> the level of glucose in the blood </li></ul></ul></ul><ul><ul><ul><li>Released in response to stress, injury, or serious infection - like the hormones from the adrenal medulla </li></ul></ul></ul>
  27. 27. Adrenal Glands <ul><li>Adrenal Cortex </li></ul><ul><ul><li>Mineralcorticoids </li></ul></ul><ul><ul><ul><li>work to regulate the concentration of potassium and sodium in the body </li></ul></ul></ul>
  28. 28. Ovaries <ul><li>Located in the abdominal cavity adjacent to the uterus </li></ul><ul><li>Under the control of LH and FSH from the anterior pituitary </li></ul><ul><li>Produce eggs for reproduction </li></ul><ul><li>Produce hormones </li></ul><ul><ul><li>estrogen </li></ul></ul><ul><ul><li>progesterone </li></ul></ul><ul><ul><li>Functions include sexual development and preparation of the uterus for implantation of the egg </li></ul></ul>
  29. 29. Ovaries <ul><li>Estrogen </li></ul><ul><ul><li>Development of female secondary sexual characteristics </li></ul></ul><ul><ul><li>Development of endometrium </li></ul></ul><ul><li>Progesterone </li></ul><ul><ul><li>Promotes conditions required for pregnancy </li></ul></ul><ul><ul><li>Stabilization of endometrium </li></ul></ul>
  30. 30. Testes <ul><li>Located in the scrotum </li></ul><ul><li>Controlled by anterior pituitary hormones FSH and LH </li></ul><ul><li>Produce sperm for reproduction </li></ul><ul><li>Produce testosterone - </li></ul><ul><ul><li>promotes male growth and masculinization </li></ul></ul><ul><ul><li>promotes development and maintenance of male sexual characteristics </li></ul></ul>
  31. 31. Pancreas <ul><li>Located in retroperitoneal space between duodenum and spleen </li></ul><ul><li>Has both endocrine and exocrine functions </li></ul><ul><ul><li>Exocrine Pancreas </li></ul></ul><ul><ul><ul><li>Secretes key digestive enzymes </li></ul></ul></ul><ul><ul><li>Endocrine Pancreas </li></ul></ul><ul><ul><ul><li>Alpha Cells - glucagon production </li></ul></ul></ul><ul><ul><ul><li>Beta Cells - insulin production </li></ul></ul></ul><ul><ul><ul><li>Delta Cells - somatostatin production </li></ul></ul></ul>
  32. 32. Pancreas <ul><li>Exocrine function </li></ul><ul><ul><li>Secretes </li></ul></ul><ul><ul><ul><li>amylase </li></ul></ul></ul><ul><ul><ul><li>lipase </li></ul></ul></ul>
  33. 33. Pancreas <ul><li>Alpha Cells </li></ul><ul><ul><li>Glucagon </li></ul></ul><ul><ul><ul><li>Raises blood glucose levels </li></ul></ul></ul><ul><li>Beta Cells </li></ul><ul><ul><li>Insulin </li></ul></ul><ul><ul><ul><li>Lowers blood glucose levels </li></ul></ul></ul><ul><li>Delta Cells </li></ul><ul><ul><li>Somatostatin </li></ul></ul><ul><ul><ul><li>Suppresses release of growth hormone </li></ul></ul></ul>
  34. 34. Disorders of the Endocrine System
  35. 35. Abnormal Thyroid Function <ul><li>Hypothyroidism </li></ul><ul><ul><li>Too little thyroid hormone </li></ul></ul><ul><li>Hyperthyroidism (Thyrotoxicosis / Thyroid Storm) </li></ul><ul><ul><li>Too much thyroid hormone </li></ul></ul>
  36. 36. Hypothyroidism <ul><li>Thyroid hormone deficiency causing a decrease in the basal metabolic rate </li></ul><ul><ul><li>Person is “slowed down” </li></ul></ul><ul><li>Causes of Hypothyroidism : </li></ul><ul><ul><li>Radioactive iodine ablation </li></ul></ul><ul><ul><li>Non-compliance with levothyroxine </li></ul></ul><ul><ul><li>Hashimoto’s thyroiditis - autoimmune destruction </li></ul></ul>
  37. 37. Hypothyroidism <ul><li>Confusion, drowsiness, coma </li></ul><ul><li>Cold intolerant </li></ul><ul><li>Hypotension, Bradycardia </li></ul><ul><li>Muscle weakness </li></ul><ul><li>Decreased respirations </li></ul><ul><li>Weight gain, Constipation </li></ul><ul><li>Non-pitting peripheral edema </li></ul><ul><li>Depression </li></ul><ul><li>Facial edema, loss of hair </li></ul><ul><li>Dry, coarse skin </li></ul>Appearance of Myxedema
  38. 38. Hypothyroidism <ul><li>Myxedema Coma </li></ul><ul><ul><li>Severe hypothyroidism that can be fatal </li></ul></ul><ul><li>Management of Myxedema Coma </li></ul><ul><ul><li>Control airway </li></ul></ul><ul><ul><li>Support oxygenation, ventilation </li></ul></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Later </li></ul></ul><ul><ul><ul><li>Levothyroxine (Synthroid®) </li></ul></ul></ul><ul><ul><ul><li>Hydrocortisone </li></ul></ul></ul>
  39. 39. Hyperthyroidism <ul><li>Excessive levels of thyroid levels cause hypermetabolic state </li></ul><ul><ul><li>Person is “sped up”. </li></ul></ul><ul><li>Causes of Hyperthyroidism </li></ul><ul><ul><li>Overmedication with levothyroxine (Synthroid®) - Fad diets </li></ul></ul><ul><ul><li>Goiter (enlarged, hyperactive thyroid gland) </li></ul></ul><ul><ul><li>Graves Disease </li></ul></ul>
  40. 40. Hyperthyroidism <ul><li>Nervousness, irritable, tremors, paranoid </li></ul><ul><li>Warm, flushed skin </li></ul><ul><li>Heat intolerant </li></ul><ul><li>Tachycardia - High output CHF </li></ul><ul><li>Hypertension </li></ul><ul><li>Tachypnea </li></ul><ul><li>Diarrhea </li></ul><ul><li>Weight loss </li></ul><ul><li>Exophthalmos </li></ul><ul><li>Goiter </li></ul>
  41. 41. Hyperthyroidism <ul><li>Treatment </li></ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul><ul><ul><li>ECG monitor </li></ul></ul><ul><ul><li>IV access - Cautious IV fluids </li></ul></ul><ul><ul><li>Acetaminophen for fever </li></ul></ul><ul><ul><li>Beta -blockers </li></ul></ul><ul><ul><li>Consider benzodiazepines for anxiety </li></ul></ul><ul><ul><li>PTU (propylthiouracil) </li></ul></ul><ul><ul><ul><li>Usually short-term use prior to more definitive treatment </li></ul></ul></ul><ul><ul><li>SSKI® (potassium iodide) </li></ul></ul>
  42. 42. Thyroid Storm/Thyrotoxicosis <ul><li>Severe form of hyperthyroidism that can be fatal </li></ul><ul><ul><li>Acute life-threatening hyperthyroidism </li></ul></ul><ul><li>Cause </li></ul><ul><ul><li>Increased physiological stress in hyperthyroid patients </li></ul></ul>
  43. 43. Thyroid Storm/Thyrotoxicosis <ul><li>Severe tachycardia </li></ul><ul><li>Heart Failure </li></ul><ul><li>Dysrhythmias </li></ul><ul><li>Shock </li></ul><ul><li>Hyperthermia </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Restlessness, Agitation, Delirium, Coma </li></ul>
  44. 44. Thyroid Storm/Thyrotoxicosis <ul><li>Management </li></ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul><ul><ul><li>ECG monitor </li></ul></ul><ul><ul><li>IV access - cautious IV fluids </li></ul></ul><ul><ul><li>Control hyperthermia </li></ul></ul><ul><ul><ul><li>Active cooling </li></ul></ul></ul><ul><ul><ul><li>Acetaminophen </li></ul></ul></ul><ul><ul><li>Inderal (beta blockers) </li></ul></ul><ul><ul><li>Consider benzodiazepines for anxiety </li></ul></ul><ul><ul><li>Potassium iodide (SSKI®) </li></ul></ul><ul><ul><li>Propylthiouracil (PTU) </li></ul></ul>
  45. 45. Abnormal Adrenal Function <ul><li>Hyperadrenalism </li></ul><ul><ul><li>Excess activity of the adrenal gland </li></ul></ul><ul><ul><li>Cushing’s Syndrome & Disease </li></ul></ul><ul><ul><li>Pheochromocytoma </li></ul></ul><ul><li>Hypoadrenalism (adrenal insufficiency) </li></ul><ul><ul><li>Inadequate activity of the adrenal gland </li></ul></ul><ul><ul><li>Addison’s disease </li></ul></ul>
  46. 46. Hyperadrenalism <ul><li>Primary Aldosteronism </li></ul><ul><ul><li>Excessive secretion of aldosterone by adrenal cortex </li></ul></ul><ul><ul><ul><li>Increased Na + /H 2 O </li></ul></ul></ul><ul><ul><li>Presentation </li></ul></ul><ul><ul><ul><li>headache </li></ul></ul></ul><ul><ul><ul><li>nocturia, polyuria </li></ul></ul></ul><ul><ul><ul><li>fatigue </li></ul></ul></ul><ul><ul><ul><li>hypertension, hypervolemia </li></ul></ul></ul><ul><ul><ul><li>potassium depletion </li></ul></ul></ul>
  47. 47. Hyperadrenalism <ul><li>Adrenogenital syndrome </li></ul><ul><ul><li>“ Bearded Lady” </li></ul></ul><ul><ul><li>Group of disorders caused by adrenocortical hyperplasia or malignant tumors </li></ul></ul><ul><ul><li>Excessive secretion of adrenocortical steroids especially those with androgenic or estrogenic effects </li></ul></ul><ul><ul><li>Characterized by </li></ul></ul><ul><ul><ul><li>masculinization of women </li></ul></ul></ul><ul><ul><ul><li>feminization of men </li></ul></ul></ul><ul><ul><ul><li>premature sexual development of children </li></ul></ul></ul>
  48. 48. Hyperadrenalism <ul><li>Cushing’s Syndrome </li></ul><ul><ul><li>Results from increased adrenocortical secretion of cortisol </li></ul></ul><ul><ul><li>Causes include: </li></ul></ul><ul><ul><ul><li>ACTH-secreting tumor of the pituitary (Cushing’s disease) </li></ul></ul></ul><ul><ul><ul><li>excess secretion of ACTH by a neoplasm within the adrenal cortex </li></ul></ul></ul><ul><ul><ul><li>excess secretion of ACTH by a malignant growth outside the adrenal gland </li></ul></ul></ul><ul><ul><ul><li>excessive or prolonged administration of steroids </li></ul></ul></ul>
  49. 49. Hyperadrenalism <ul><li>Cushing’s Syndrome </li></ul><ul><ul><li>Characterized by: </li></ul></ul><ul><ul><ul><li>truncal obesity </li></ul></ul></ul><ul><ul><ul><li>moon face </li></ul></ul></ul><ul><ul><ul><li>buffalo hump </li></ul></ul></ul><ul><ul><ul><li>acne, hirsutism </li></ul></ul></ul><ul><ul><ul><li>abdominal striae </li></ul></ul></ul><ul><ul><ul><li>hypertension </li></ul></ul></ul><ul><ul><ul><li>psychiatric disturbances </li></ul></ul></ul><ul><ul><ul><li>osteoporosis </li></ul></ul></ul><ul><ul><ul><li>amenorrhea </li></ul></ul></ul>
  50. 50. Hyperadrenalism <ul><li>Cushing’s Disease </li></ul><ul><ul><li>Too much adrenal hormone production </li></ul></ul><ul><ul><ul><li>adrenal hyperplasia caused by an ACTH secreting adenoma of the pituitary </li></ul></ul></ul><ul><ul><li>“ Cushingoid features” </li></ul></ul><ul><ul><ul><li>striae on extremities or abdomen </li></ul></ul></ul><ul><ul><ul><li>moon face </li></ul></ul></ul><ul><ul><ul><li>buffalo hump </li></ul></ul></ul><ul><ul><ul><li>weight gain with truncal obesity </li></ul></ul></ul><ul><ul><ul><li>personality changes, irritable </li></ul></ul></ul>
  51. 51. Hyperadrenalism <ul><li>Cushing’s Syndrome </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul></ul><ul><ul><ul><li>Supportive care </li></ul></ul></ul><ul><ul><ul><li>Assess for cardiovascular event requiring treatment </li></ul></ul></ul><ul><ul><ul><ul><li>severe hypertension </li></ul></ul></ul></ul><ul><ul><ul><ul><li>myocardial ischemia </li></ul></ul></ul></ul>
  52. 52. Hyperadrenalism <ul><li>Pheochromocytoma </li></ul><ul><ul><li>Catecholamine secreting tumor of adrenal medulla </li></ul></ul><ul><ul><li>Presentation </li></ul></ul><ul><ul><ul><li>Anxiety </li></ul></ul></ul><ul><ul><ul><li>Pallor, diaphoresis </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Tachycardia, Palpitations </li></ul></ul></ul><ul><ul><ul><li>Dyspnea </li></ul></ul></ul><ul><ul><ul><li>Hyperglycemia </li></ul></ul></ul>
  53. 53. Hyperadrenalism <ul><li>Pheochromocytoma </li></ul><ul><ul><li>Management </li></ul></ul><ul><ul><ul><li>Supportive care based upon presentation </li></ul></ul></ul><ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul></ul><ul><ul><ul><li>Calm/Reassure </li></ul></ul></ul><ul><ul><ul><li>Assess blood glucose </li></ul></ul></ul><ul><ul><ul><li>Consider beta blocking agent - Labetalol </li></ul></ul></ul><ul><ul><ul><li>Consider benzodiazepines </li></ul></ul></ul>
  54. 54. Hypoadrenalism <ul><li>Adrenal Insufficiency </li></ul><ul><ul><li>decrease production of glucocorticoids, mineralcorticoids and androgens </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Primary adrenal failure (Addison’s Disease) </li></ul></ul><ul><ul><li>Infection (TB, fungal, Meningococcal) </li></ul></ul><ul><ul><li>AIDS </li></ul></ul><ul><ul><li>Prolonged steroid use </li></ul></ul>
  55. 55. Hypoadrenalism <ul><li>Presentation </li></ul><ul><ul><li>Hypotension, Shock </li></ul></ul><ul><ul><li>Hyponatremia, Hyperkalemia </li></ul></ul><ul><ul><li>Progressive Muscle weakness </li></ul></ul><ul><ul><li>Progressive weight loss and anorexia </li></ul></ul><ul><ul><li>Skin hyperpigmentation </li></ul></ul><ul><ul><ul><li>areas exposed to sun, pressure points, joints and creases </li></ul></ul></ul><ul><ul><li>Arrhythmias </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>N/V/D </li></ul></ul>
  56. 56. Hypoadrenalism <ul><li>Management </li></ul><ul><ul><li>Airway/Ventilation/Oxygen </li></ul></ul><ul><ul><li>ECG monitor </li></ul></ul><ul><ul><li>IV fluids </li></ul></ul><ul><ul><li>Assess blood glucose - D50 if hypoglycemic </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><ul><li>hydrocortisone or dexamethasone </li></ul></ul></ul><ul><ul><ul><li>florinef (mineralcorticoid) </li></ul></ul></ul><ul><ul><li>Vasopressors if unresponsive to IV fluids </li></ul></ul>
  57. 57. Diabetes Mellitus
  58. 58. Diabetes Mellitus <ul><li>Chronic metabolic disease </li></ul><ul><li>One of the most common diseases in North America </li></ul><ul><ul><li>Affects 5% of USA population (12 million people) </li></ul></ul><ul><li>Results in </li></ul><ul><ul><li> insulin secretion by the Beta (  ) cells of the islets of Langerhans in the pancreas, AND/OR </li></ul></ul><ul><ul><li>Defects in insulin receptors on cell membranes leading to cellular resistance to insulin </li></ul></ul><ul><li>Leads to an  risk for significant cardiovascular, renal and ophthalmic disease </li></ul>
  59. 59. Regulation of Glucose <ul><li>Dietary Intake </li></ul><ul><ul><li>Components of food : </li></ul></ul><ul><ul><ul><li>Carbohydrates </li></ul></ul></ul><ul><ul><ul><li>Fats </li></ul></ul></ul><ul><ul><ul><li>Proteins </li></ul></ul></ul><ul><ul><ul><li>Vitamins </li></ul></ul></ul><ul><ul><ul><li>Minerals </li></ul></ul></ul>
  60. 60. Regulation of Glucose <ul><li>The other 3 major food sources for glucose are </li></ul><ul><ul><li>carbohydrates </li></ul></ul><ul><ul><li>proteins </li></ul></ul><ul><ul><li>fats </li></ul></ul><ul><li>Most sugars in the human diet are complex and must be broken down into simple sugars: glucose, galactose and fructose - before use </li></ul>
  61. 61. Regulation of Glucose <ul><li>Carbohydrates </li></ul><ul><ul><li>Found in sugary, starchy foods </li></ul></ul><ul><ul><li>Ready source of near-instant energy </li></ul></ul><ul><ul><li>If not “burned” immediately by body, stored in liver and skeletal muscle as glycogen (short-term energy) or as fat (long-term energy needs) </li></ul></ul><ul><ul><li>After normal meal, approximately 60% of the glucose is stored in liver as glycogen </li></ul></ul>
  62. 62. Regulation of Glucose <ul><li>Fats </li></ul><ul><ul><li>Broken down into fatty acids and glycerol by enzymes </li></ul></ul><ul><ul><li>Excess fat stored in liver or in fat cells (under the skin) </li></ul></ul>
  63. 63. Regulation of Glucose <ul><li>Pancreatic hormones are required to regulate blood glucose level </li></ul><ul><ul><li>glucagon released by Alpha (  ) cells </li></ul></ul><ul><ul><li>insulin released by Beta Cells (  ) </li></ul></ul><ul><ul><li>somatostatin released by Delta Cells (  ) </li></ul></ul>
  64. 64. Regulation of Glucose <ul><li>Alpha (  ) cells release glucagon to control blood glucose level </li></ul><ul><ul><li>When blood glucose levels fall,  cells  the amount of glucagon in the blood </li></ul></ul><ul><ul><li>The surge of glucagon stimulates liver to release glucose stores by the breakdown of glycogen into glucose (glycogenolysis) </li></ul></ul><ul><ul><li>Also, glucagon stimulates the liver to produce glucose (gluconeogenesis) </li></ul></ul>
  65. 65. Regulation of Glucose <ul><li>Beta Cells (  ) release insulin (antagonistic to glucagon) to control blood glucose level </li></ul><ul><ul><li>Insulin  the rate at which various body cells take up glucose  insulin lowers the blood glucose level </li></ul></ul><ul><ul><li>Promotes glycogenesis - storage of glycogen in the liver </li></ul></ul><ul><ul><li>Insulin is rapidly broken down by the liver and must be secreted constantly </li></ul></ul>
  66. 66. Regulation of Glucose <ul><li>Delta Cells (  ) produce somatostatin, which inhibits both glucagon and insulin </li></ul><ul><ul><li>inhibits insulin and glucagon secretion by the pancreas </li></ul></ul><ul><ul><li>inhibits digestion by inhibiting secretion of digestive enzymes </li></ul></ul><ul><ul><li>inhibits gastric motility </li></ul></ul><ul><ul><li>inhibits absorption of glucose in the intestine </li></ul></ul>
  67. 67. Regulation of Glucose <ul><li>Breakdown of sugars carried out by enzymes in the GI system </li></ul><ul><ul><li>As simple sugars, they are absorbed from the GI system into the body </li></ul></ul><ul><li>To be converted into energy, glucose must first be transmitted through the cell membrane </li></ul><ul><ul><li>Glucose molecule is too large and does not readily diffuse </li></ul></ul>
  68. 68. Regulation of Glucose <ul><li>Glucose must pass into the cell by binding to a special carrier protein on the cell’s surface. </li></ul><ul><ul><li>Facilitated diffusion - carrier protein binds with the glucose and carries it into the cell. </li></ul></ul><ul><li>The rate at which glucose can enter the cell is dependent upon insulin levels </li></ul><ul><ul><li>Insulin serves as the messenger - travels via blood to target tissues </li></ul></ul><ul><ul><li>Combines with specific insulin receptors on the surface of the cell membrane </li></ul></ul>
  69. 69. Regulation of Glucose <ul><li>Body strives to maintain blood glucose between 60 mg/dl and 120 mg/dl. </li></ul><ul><li>Glucose </li></ul><ul><ul><li>brain is the biggest user of glucose in the body </li></ul></ul><ul><ul><li>sole energy source for brain </li></ul></ul><ul><ul><li>brain does not require insulin to utilize glucose </li></ul></ul>
  70. 70. Regulation of Glucose Insulin Glucagon Glucagon and Insulin are opposites (antagonists) of each other.
  71. 71. Regulation of Glucose <ul><li>Glucagon </li></ul><ul><ul><li>Released in response to: </li></ul></ul><ul><ul><ul><li>Sympathetic stimulation </li></ul></ul></ul><ul><ul><ul><li>Decreasing blood glucose concentration </li></ul></ul></ul><ul><ul><li>Acts primarily on liver to increase rate of glycogen breakdown </li></ul></ul><ul><ul><li>Increasing blood glucose levels have inhibitory effect on glucagon secretion </li></ul></ul>
  72. 72. Regulation of Glucose <ul><li>Insulin </li></ul><ul><ul><li>Released in response to: </li></ul></ul><ul><ul><ul><li>Increasing blood glucose concentration </li></ul></ul></ul><ul><ul><ul><li>Parasympathetic innervation </li></ul></ul></ul><ul><ul><li>Acts on cell membranes to increase glucose uptake from blood stream </li></ul></ul><ul><ul><li>Promotes facilitated diffusion of glucose into cells </li></ul></ul>
  73. 73. Diabetes Mellitus <ul><li>2 Types historically based on age of onset (NOT insulin vs. non-insulin) </li></ul><ul><ul><li>Type I </li></ul></ul><ul><ul><ul><li>juvenile onset </li></ul></ul></ul><ul><ul><ul><li>insulin dependent </li></ul></ul></ul><ul><ul><li>Type II </li></ul></ul><ul><ul><ul><li>historically adult onset </li></ul></ul></ul><ul><ul><ul><ul><li>now some morbidly obese children are developing Type II diabetes </li></ul></ul></ul></ul><ul><ul><ul><li>non-insulin dependent </li></ul></ul></ul><ul><ul><ul><ul><li>may progress to insulin dependency </li></ul></ul></ul></ul>
  74. 74. Types of Diabetes Mellitus <ul><li>Type I </li></ul><ul><li>Type II </li></ul><ul><li>Secondary </li></ul><ul><li>Gestational </li></ul>
  75. 75. Pathophysiology of Type I Diabetes Mellitus <ul><li>Characterized by inadequate or absent production of insulin by pancreas </li></ul><ul><li>Usually presents by age 25 </li></ul><ul><li>Strong genetic component </li></ul><ul><li>Autoimmune features </li></ul><ul><ul><li>body destroys own insulin-producing cells in pancreas </li></ul></ul><ul><ul><li>may follow severe viral illness or injury </li></ul></ul><ul><li>Requires lifelong treatment with insulin replacement </li></ul>
  76. 76. Pathophysiology of Type II Diabetes Mellitus <ul><li>Pancreas continues to produce some insulin however disease results from combination of: </li></ul><ul><ul><li>Relative insulin deficiency </li></ul></ul><ul><ul><li>Decreased sensitivity of insulin receptors </li></ul></ul><ul><li>Onset usually after age 25 in overweight adults </li></ul><ul><ul><li>Some morbidly obese children develop Type II diabetes </li></ul></ul><ul><li>Familial component </li></ul><ul><li>Usually controlled with diet, weight loss, oral hypoglycemic agents </li></ul><ul><ul><li>Insulin may be needed at some point in life </li></ul></ul>
  77. 77. Secondary Diabetes Mellitus <ul><li>Pre-existing condition affects pancreas </li></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Trauma </li></ul></ul>
  78. 78. Gestational Diabetes Mellitus <ul><li>Occurs during pregnancy </li></ul><ul><ul><li>Usually resolves after delivery </li></ul></ul><ul><li>Occurs rarely in non-pregnant women on BCPs </li></ul><ul><li>Increased estrogen, progesterone antagonize insulin </li></ul>
  79. 79. Presentation of New Onset Diabetes Mellitus <ul><li>3 Ps </li></ul><ul><ul><li>Polyuria </li></ul></ul><ul><ul><li>Polydipsia </li></ul></ul><ul><ul><li>Polyphagia </li></ul></ul><ul><li>Blurred vision, dizziness, altered mental status </li></ul><ul><li>Rapid weight loss </li></ul><ul><li>Warm dry skin, </li></ul><ul><li>Weakness, Tachycardia, Dehydration </li></ul>
  80. 80. Long Term Treatment of Diabetes Mellitus <ul><li>Diet regulation </li></ul><ul><ul><li>e.g . 1400 calorie ADA diet </li></ul></ul><ul><li>Exercise </li></ul><ul><ul><li>increase patient’s glucose metabolism </li></ul></ul><ul><li>Oral hypoglycemic agents </li></ul><ul><ul><li>Sulfonylureas </li></ul></ul><ul><li>Insulin </li></ul><ul><ul><li>Historically produced from pigs (porcine insulin) </li></ul></ul><ul><ul><li>Currently genetic engineering has lead to human insulin (Humulin) </li></ul></ul>
  81. 81. Long Term Treatment of Diabetes Mellitus <ul><li>Insulin </li></ul><ul><ul><li>Available in various forms distinguished on onset and duration of action </li></ul></ul><ul><ul><ul><li>Onset </li></ul></ul></ul><ul><ul><ul><ul><li>rapid (Regular, Semilente, Novolin 70/30) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>intermediate (Novolin N, Lente) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>slow (Ultralente) </li></ul></ul></ul></ul><ul><ul><ul><li>Duration </li></ul></ul></ul><ul><ul><ul><ul><li>short, 5-7 hrs (Regular) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>intermediate, 18-24 hrs (Semilente, Novolin N, Lente, NPH) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>long-acting, 24 - 36+ hrs (Novolin 70/30, Ultralente) </li></ul></ul></ul></ul>
  82. 82. Long Term Treatment of Diabetes Mellitus <ul><li>Insulin </li></ul><ul><ul><li>Must be given by injection as insulin is protein which would be digested if given orally </li></ul></ul><ul><ul><ul><li>extremely compliant patients may use an insulin pump which provides a continuous dose </li></ul></ul></ul><ul><ul><ul><li>current research studying inhaled insulin form </li></ul></ul></ul>
  83. 83. Long Term Treatment of Diabetes Mellitus <ul><li>Oral Hypoglycemic Agents </li></ul><ul><ul><li>Stimulate the release of insulin from the pancreas, thus patient must still have intact beta cells in the pancreas. </li></ul></ul><ul><ul><li>Common agents include : </li></ul></ul><ul><ul><ul><li>Glucotrol® (glipizide) </li></ul></ul></ul><ul><ul><ul><li>Micronase® or Diabeta® (glyburide) </li></ul></ul></ul><ul><ul><ul><li>Glucophage® (metformin) [Not a sulfonylurea] </li></ul></ul></ul>
  84. 84. Emergencies Associated Blood Glucose Level <ul><li>Hyperglycemia </li></ul><ul><ul><li>Diabetic Ketoacidosis (DKA) </li></ul></ul><ul><ul><li>Hyperglycemic Hyperosmolar Nonketotic Coma (HHNC) </li></ul></ul><ul><li>Hypoglycemia </li></ul><ul><ul><li>“ Insulin Shock” </li></ul></ul>
  85. 85. Hyperglycemia <ul><li>Defined as blood glucose > 200 mg/dl </li></ul><ul><li>Causes </li></ul><ul><ul><li>Failure to take medication (insulin) </li></ul></ul><ul><ul><li>Increased dietary intake </li></ul></ul><ul><ul><li>Stress (surgery, MI, CVA, trauma) </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Pregnancy (gestational diabetes) </li></ul></ul>
  86. 86. Hyperglycemia <ul><li>Two hyperglycemic diabetic states may occur </li></ul><ul><ul><li>Diabetic Ketoacidosis (DKA) </li></ul></ul><ul><ul><li>Hyperglycemic Hyperosmolar Non-ketotic Coma (HHNC) </li></ul></ul>
  87. 87. Diabetic Ketoacidosis (DKA) <ul><li>Occurs in Type I diabetics (insulin dependency) </li></ul><ul><li>Usually associated with blood glucose level in the range of 200 - 600 mg/dl </li></ul><ul><li>No insulin availability results in ketoacidosis </li></ul>
  88. 88. Diabetic Ketoacidosis (DKA) <ul><li>Pathophysiology </li></ul><ul><ul><li>Results from absence of insulin </li></ul></ul><ul><ul><ul><li>prevents glucose from entering the cells </li></ul></ul></ul><ul><ul><ul><li>leads to glucose accumulation in the blood </li></ul></ul></ul><ul><ul><li>Cells become starved for glucose and begin to use other energy sources (primarily fats) </li></ul></ul><ul><ul><ul><li>Fat metabolism generates fatty acids </li></ul></ul></ul><ul><ul><ul><li>Further metabolized into ketoacids (ketone bodies) </li></ul></ul></ul>
  89. 89. Diabetic Ketoacidosis (DKA) <ul><li>Pathophysiology (cont) </li></ul><ul><ul><li>Blood sugar rises above renal threshold for reabsorption (blood glucose > 180 mg/dl) </li></ul></ul><ul><ul><ul><li>glucose “spills” into the urine </li></ul></ul></ul><ul><ul><ul><li>Loss of glucose in urine causes osmotic diuresis </li></ul></ul></ul><ul><ul><li>Results in </li></ul></ul><ul><ul><ul><li>dehydration </li></ul></ul></ul><ul><ul><ul><li>acidosis </li></ul></ul></ul><ul><ul><ul><li>electrolyte imbalances (especially K+) </li></ul></ul></ul>
  90. 90. Diabetic Ketoacidosis (DKA) <ul><li>Presentation </li></ul><ul><ul><li>Gradual onset with progression </li></ul></ul><ul><ul><li>Warm, pink, dry skin </li></ul></ul><ul><ul><li>Dry mucous membranes (dehydrated) </li></ul></ul><ul><ul><li>Tachycardia, weak peripheral pulses </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Polyuria, polydipsia </li></ul></ul><ul><ul><li>Abdominal pain with nausea/vomiting </li></ul></ul><ul><ul><li>Altered mental status </li></ul></ul><ul><ul><li>Kussmaul respirations with acetone (fruity) odor </li></ul></ul>
  91. 91. Diabetic Ketoacidosis Increased Blood Sugar Osmotic Diuresis Polyuria Cells Can’t Burn Glucose Cells Burn Fat Polyphagia Ketone Bodies Metabolic Acidosis Fruity Breath Kussmaul Breathing Inadequate insulin Polydipsia Volume Depletion Shock
  92. 92. Management of DKA <ul><li>Airway/Ventilation/Oxygen NRB mask </li></ul><ul><li>Assess blood glucose level & ECG </li></ul><ul><li>IV access, large bore NS </li></ul><ul><ul><li>normal saline bolus and reassess </li></ul></ul><ul><ul><li>often requires several liters </li></ul></ul><ul><li>Assess for underlying cause of DKA </li></ul><ul><li>Transport </li></ul>How does fluid treat DKA?
  93. 93. Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) <ul><li>Usually occurs in type II diabetics </li></ul><ul><li>Typically very high blood sugar (>600mg/dl) </li></ul><ul><li>Some insulin available </li></ul><ul><li>Higher mortality than DKA </li></ul>
  94. 94. Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) <ul><li>Pathophysiology </li></ul><ul><ul><li>Some minimal insulin production </li></ul></ul><ul><ul><ul><li>enough insulin available to allow glucose to enter the cells and prevent ketogenesis </li></ul></ul></ul><ul><ul><ul><li>not enough to decrease gluconeogenesis by liver </li></ul></ul></ul><ul><ul><ul><li>no ketosis </li></ul></ul></ul><ul><ul><li>Extreme hyperglycemia produces hyperosmolar state causing </li></ul></ul><ul><ul><ul><li>diuresis </li></ul></ul></ul><ul><ul><ul><li>severe dehydration </li></ul></ul></ul><ul><ul><ul><li>electrolyte disturbances </li></ul></ul></ul>
  95. 95. Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) Increased Blood Sugar Osmotic Diuresis Polyuria Inadequate insulin Polydipsia Volume Depletion Shock
  96. 96. Hyperosmolar Hyperglycemic Nonketotic Coma (HHNC) <ul><li>Presentation </li></ul><ul><ul><li>Same as DKA but with greater severity </li></ul></ul><ul><ul><ul><li>Higher blood glucose level </li></ul></ul></ul><ul><ul><ul><li>Non-insulin dependent diabetes </li></ul></ul></ul><ul><ul><ul><li>Greater degree of dehydration </li></ul></ul></ul>
  97. 97. Management of HHNC <ul><li>Secure airway and assess ventilation </li></ul><ul><ul><li>Consider need to assist ventilation </li></ul></ul><ul><ul><li>Consider need to intubate </li></ul></ul><ul><li>High concentration oxygen </li></ul><ul><li>Assess blood glucose level & ECG </li></ul><ul><li>IV access, large bore NS </li></ul><ul><ul><li>normal saline bolus and reassess </li></ul></ul><ul><ul><li>often requires several liters </li></ul></ul><ul><li>Assess for underlying cause of HHNC </li></ul><ul><li>Transport </li></ul>
  98. 98. Further Management of Hyperglycemia <ul><li>Insulin (regular) </li></ul><ul><ul><li>Correct hyperglycemia </li></ul></ul><ul><li>Correction of acid/base imbalances </li></ul><ul><ul><li>Bicarbonate (severe cases documented by ABG) </li></ul></ul><ul><li>Normalization of electrolyte balance </li></ul><ul><ul><li>DKA may result in hyperkalemia 2 o to acidosis </li></ul></ul><ul><ul><ul><li>H + shifts intracellularly, K + moves to extracellular space </li></ul></ul></ul><ul><ul><li>Urinary K + losses may lead to hypokalemia once therapy is started </li></ul></ul>
  99. 99. Hypoglycemia <ul><li>True hypoglycemia defined as blood sugar < 60 mg/dl </li></ul><ul><li>ALL hypoglycemia is NOT caused by diabetes </li></ul><ul><ul><li>Can occur in non-diabetic patients </li></ul></ul><ul><ul><ul><li>thin young females </li></ul></ul></ul><ul><ul><ul><li>alcoholics with liver disease </li></ul></ul></ul><ul><ul><ul><li>alcohol consumption on empty stomach will block glucose synthesis in liver (gluconeogenesis) </li></ul></ul></ul><ul><li>Hypoglycemia causes impaired functioning of brain which relies on constant supply of glucose </li></ul>
  100. 100. Hypoglycemia <ul><li>Causes of hypoglycemia in diabetics </li></ul><ul><ul><li>Too much insulin </li></ul></ul><ul><ul><li>Too much oral hypoglycemic agent </li></ul></ul><ul><ul><ul><li>Long half-life requires hospitalization </li></ul></ul></ul><ul><ul><li>Decreased dietary intake (took insulin and missed meal) </li></ul></ul><ul><ul><li>Vigorous physical activity </li></ul></ul><ul><li>Pathophysiology </li></ul><ul><ul><li>Inadequate blood glucose available to brain and other cells resulting from one of the above causes </li></ul></ul>
  101. 101. Hypoglycemia <ul><li>Presentation </li></ul><ul><ul><li>Hunger (initially), Headache </li></ul></ul><ul><ul><li>Weakness, Incoordination ( mimics a stroke ) </li></ul></ul><ul><ul><li>Confusion, Unusual behavior </li></ul></ul><ul><ul><ul><li>may appear intoxicated </li></ul></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Weak, rapid pulse </li></ul></ul><ul><ul><li>Cold, clammy skin </li></ul></ul><ul><ul><li>Nervousness, trembling, irritability </li></ul></ul>
  102. 102. Hypoglycemia: Pathophysiology Blood Glucose Falls Brain Lacks Glucose SNS Response Altered LOC Seizures Headache Dizziness Bizarre Behavior Weakness Anxiety Pallor Tachycardia Diaphoresis Nausea Dilated Pupils
  103. 103. Hypoglycemia Beta Blockers may mask symptoms by inhibiting sympathetic response
  104. 104. Management of Hypoglycemia <ul><li>Secure airway manually </li></ul><ul><ul><li>suction prn </li></ul></ul><ul><ul><li>Ventilate prn </li></ul></ul><ul><li>High concentration oxygen </li></ul><ul><li>Vascular access </li></ul><ul><ul><li>Large bore IV catheter </li></ul></ul><ul><ul><li>Saline lock, D 5 W or NS </li></ul></ul><ul><ul><li>Large proximal vein preferred </li></ul></ul><ul><li>Assess blood glucose level </li></ul>
  105. 105. Management of Hypoglycemia <ul><li>Oral glucose </li></ul><ul><ul><li>ONLY if intact gag reflex, awake & able to sit up </li></ul></ul><ul><ul><li>15gm-30gm of packaged glucose, or </li></ul></ul><ul><ul><li>May use sugar-containing drink or food </li></ul></ul><ul><ul><li>Oral route often slower </li></ul></ul><ul><li>Intravenous glucose </li></ul><ul><ul><li>Adult: Dextrose 50% (D 50 ) 25gms IV in patent, free-flowing vein, may repeat </li></ul></ul><ul><ul><li>Children: Dextrose 25% (D 25 ) @ 2 - 4 cc/kg (0.5 - 1 gm/kg) [Infants - may choose Dextrose 10% @ 0.5 - 1 gm/kg or 5 - 10 cc/kg] </li></ul></ul>
  106. 106. Management of Hypoglycemia <ul><li>Glucagon </li></ul><ul><ul><li>Used if unable to obtain IV access </li></ul></ul><ul><ul><li>1 mg IM </li></ul></ul><ul><ul><li>Requires glycogen stores </li></ul></ul><ul><ul><li>slower onset of action than IV route </li></ul></ul>What persons are likely to have inadequate glycogen stores?
  107. 107. Management of Hypoglycemia <ul><li>Have patient eat high-carbohydrate meal </li></ul><ul><li>Transport? </li></ul><ul><ul><li>Patient Refusal Policy </li></ul></ul><ul><ul><ul><li>Contact medical control </li></ul></ul></ul><ul><ul><ul><li>Leave only with responsible family/friend for 6 hours </li></ul></ul></ul><ul><ul><ul><li>Must educate family/friend to hypoglycemic signs/symptoms </li></ul></ul></ul><ul><ul><ul><li>Advise to contact personal physician </li></ul></ul></ul><ul><ul><li>Transport </li></ul></ul><ul><ul><ul><li>Hypoglycemic patients on oral agents (long half life) </li></ul></ul></ul><ul><ul><ul><li>Unknown, atypical or untreated cause of hypoglycemia </li></ul></ul></ul>
  108. 108. Long-term Complications of Diabetes Mellitus <ul><li>Blindness </li></ul><ul><ul><li>Retinal hemorrhages </li></ul></ul><ul><li>Renal Disease </li></ul><ul><li>Peripheral Neuropathy </li></ul><ul><ul><li>Numbness in “stocking glove” distribution (hands and feet) </li></ul></ul><ul><li>Heart Disease and Stroke </li></ul><ul><ul><li>Chronic state of Hyperglycemia leads to early atherosclerosis </li></ul></ul><ul><li>Complications in Pregnancy </li></ul>
  109. 109. Long-term Complications of Diabetes Mellitus <ul><li>Diffuse Atherosclerois </li></ul><ul><ul><li>AMI </li></ul></ul><ul><ul><li>CVA </li></ul></ul><ul><ul><li>PVD </li></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Diabetic retinopathy/blindness </li></ul></ul><ul><ul><li>Gangrene </li></ul></ul>
  110. 110. Long-term Complications of Diabetes Mellitus 10% of all diabetics develop renal disease usually resulting in dialysis Diabetics are up to 4 times more likely to have heart disease and up to 6 times more likely to have a stroke than a non-diabetic
  111. 111. Long-term Complications of Diabetes Mellitus <ul><li>Peripheral Neuropathy </li></ul><ul><ul><li>Silent MI </li></ul></ul><ul><ul><ul><li>Vague, poorly-defined symptom complex </li></ul></ul></ul><ul><ul><ul><ul><li>Weakness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dizziness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Malaise </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Confusion </li></ul></ul></ul></ul><ul><ul><ul><li>Suspect MI in any diabetic with MI signs/symptoms with or without CP </li></ul></ul></ul>
  112. 112. Diabetes in Pregnancy <ul><li>Early pregnancy (<24 weeks) </li></ul><ul><ul><li>Rapid embryo growth </li></ul></ul><ul><ul><li>Decrease in maternal blood glucose </li></ul></ul><ul><ul><li>Episodes of hypoglycemia </li></ul></ul>
  113. 113. Diabetes in Pregnancy <ul><li>Late pregnancy (>24 weeks) </li></ul><ul><ul><li>Increased resistance to insulin effects </li></ul></ul><ul><ul><li>Increased blood glucose </li></ul></ul><ul><ul><li>Ketoacidosis </li></ul></ul>
  114. 114. Diabetes in Pregnancy <ul><li>Increased maternal risk for: </li></ul><ul><ul><li>Pregnancy-induced hypertension </li></ul></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><ul><li>Vaginal </li></ul></ul></ul><ul><ul><ul><li>Urinary tract </li></ul></ul></ul>
  115. 115. Diabetes in Pregnancy <ul><li>Increased fetal risk for: </li></ul><ul><ul><li>High birth weight </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Liver dysfunction-hyperbilirubinemia </li></ul></ul><ul><ul><li>Hypocalcemia </li></ul></ul>
  116. 116. Assessment of the Diabetic Patient <ul><li>Maintain high-degree of suspicion </li></ul><ul><li>Assess blood glucose level in all patients with </li></ul><ul><ul><li>seizure, neurologic S/S, altered mental status </li></ul></ul><ul><ul><li>vague history or chief complaint </li></ul></ul><ul><li>Blood glucose assessment IS NOT necessary in all patients with diabetes mellitus!! </li></ul>
  117. 117. Assessment of the Diabetic Patient <ul><li>History and Physical Exam includes </li></ul><ul><ul><li>Look for insulin syringes, medical alert tag, glucometer, or insulin (usually kept in refrigerator) </li></ul></ul><ul><ul><li>Last meal and last insulin dose </li></ul></ul><ul><ul><li>Missed med or missed meal? </li></ul></ul><ul><ul><li>Signs of infection </li></ul></ul><ul><ul><ul><li>Foot cellulitis / ulcers </li></ul></ul></ul><ul><ul><li>Recent illness or physiologic stressors </li></ul></ul>
  118. 118. Blood Glucose Assessment <ul><li>Capillary vs. venous blood sample </li></ul><ul><ul><li>Depends on glucometer model </li></ul></ul><ul><ul><li>Usually capillary preferred </li></ul></ul><ul><li>Dextrostick vs Glucometer </li></ul><ul><ul><li>Dextrostick - colorimetric assessment of blood provides glucose estimate </li></ul></ul><ul><ul><li>Glucometer - quantitative glucose measurement </li></ul></ul><ul><li>Neonatal blood </li></ul><ul><ul><li>Many glucometers are not accurate for neonates </li></ul></ul>
  119. 119. Case Study #1 <ul><li>You are dispatched to a college residence hall to see a 20-year-old female complaining of fever and a fluttering in her chest. You find her awake but she appears very anxious. </li></ul><ul><ul><li>Airway - Open without assistance </li></ul></ul><ul><ul><li>Breathing - Slightly increased ventilatory rate; No obvious abnormal sounds of breathing </li></ul></ul><ul><ul><li>Circulation - Rapid, strong, regular radial pulse; Skin warm and pink </li></ul></ul>
  120. 120. Case Study #1 <ul><li>You direct your partner to assess vital signs while you place the patient on Oxygen 15 lpm by NRB mask. Your physical exam findings are: </li></ul><ul><ul><li>trembling, nervous </li></ul></ul><ul><ul><li>warm, flushed skin </li></ul></ul><ul><ul><li>clear and equal lung sounds </li></ul></ul><ul><li>Your partner relays the following vital signs to you: </li></ul><ul><ul><li>Pulse - 120, regular, strong </li></ul></ul><ul><ul><li>BP - 144/88 </li></ul></ul><ul><ul><li>Ventilatory rate - 20, regular with adequate TV </li></ul></ul><ul><ul><li>Glucose - 110 mg/dl </li></ul></ul><ul><ul><li>ECG - Sinus tachycardia with occasional PACs </li></ul></ul>What additional information regarding her history would you like to know?
  121. 121. Case Study #1 <ul><li>The patient states this has occurred before but never lasted this long. She has not been ill lately other than some recurrent diarrhea and weight loss. She has attributed these to worrying about finals. She has no significant medical history and takes no meds. She denies use of any drugs. She has no family history of pulmonary disease, diabetes or heart disease. Her mother, however, does have a problem with something in her neck for which she takes medication. </li></ul>What are the two most probable diagnosis for this patient?
  122. 122. Case Study #2 <ul><li>You are dispatched to a residence to see a 44-year-old man who has fainted. You arrive to find him semi-reclined in bed. He is awake and very wide-eyed but appears very tired. </li></ul><ul><ul><li>Airway - Maintained without assistance </li></ul></ul><ul><ul><li>Breathing - No obvious distress; No obvious, unusual sounds </li></ul></ul><ul><ul><li>Circulation - Rapid, weak, irregular radial pulse </li></ul></ul>
  123. 123. Case Study #2 <ul><ul><li>Your partner assesses vital signs while you obtain the following history: </li></ul></ul><ul><ul><ul><li>Hx of Present Illness: For the past month, he has felt very weak and dizzy; He has not felt like eating and has been losing weight. He has also experienced N/V/D on a few days this month. </li></ul></ul></ul><ul><ul><ul><li>Past Medical Hx: Has been fairly healthy all of his life; Three months ago he became ill with bacterial meningitis for which he was successfully treated. </li></ul></ul></ul>
  124. 124. Case Study #2 <ul><ul><li>Vital signs are: </li></ul></ul><ul><ul><ul><li>Pulse: 110-126, irregular </li></ul></ul></ul><ul><ul><ul><li>BP: 92/62 </li></ul></ul></ul><ul><ul><ul><li>Ventilatory rate: 20, regular </li></ul></ul></ul><ul><ul><ul><li>Skin: cool, clammy </li></ul></ul></ul><ul><ul><ul><li>ECG: Atrial fibrillation </li></ul></ul></ul><ul><ul><ul><li>Blood glucose: 74 mg/dl </li></ul></ul></ul>What should you include in your differential diagnosis?
  125. 125. Case Study #2 <ul><ul><li>Your partner is a brand new, naïve paramedic. He comments to the patient, “That is a great tan you have. Have you been on a tropical vacation lately?” </li></ul></ul>Now, what do you believe is the most likely diagnosis for this patient? What is your treatment plan for this patient?
  126. 126. Case Study #3 <ul><li>Your last call (you hope) of the shift is to a manufacturing plant for a possible drug overdose. Your patient is a 24-year-old female. The patient’s supervisor states the woman seems very jittery and “out of it”. You find the patient to be a very thin female who is acting unusual. </li></ul><ul><ul><li>Airway - Maintained without assistance </li></ul></ul><ul><ul><li>Breathing - No distress or unusual sounds </li></ul></ul><ul><ul><li>Circulation - Rapid, strong, regular radial pulse with clammy skin </li></ul></ul><ul><ul><li>Disability - Confused and answers questions slowly </li></ul></ul>
  127. 127. Case Study #3 <ul><li>Your partner quickly assesses the patient’s vital signs and relays the following: </li></ul><ul><ul><li>Pulse - 110, regular, strong </li></ul></ul><ul><ul><li>BP - 108/76 </li></ul></ul><ul><ul><li>Ventilatory rate - 16 with clear and equal lung sounds </li></ul></ul><ul><ul><li>Skin - pale, cool, clammy </li></ul></ul><ul><ul><li>Pupils - dilated, equal and reactive to light </li></ul></ul><ul><ul><li>ECG - Sinus tachycardia without ectopy </li></ul></ul><ul><li>History </li></ul><ul><ul><li>No significant medical history; No recent illness; No meds </li></ul></ul>What would you like to include in your differential diagnosis for this patient?
  128. 128. Case Study #3 <ul><li>A coworker now tells you that the patient is going through a difficult divorce and has not been eating well lately </li></ul><ul><li>Your partner now tells you the patient’s blood glucose is 40 mg/dl </li></ul>Would this patient be a good candidate for Glucagon therapy if an IV can not be established quickly? What is your specific diagnosis now?
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