Overview of endocrine

1. Section 6
Chapter 18:
Diabetic Emergencies
CWI AEMT Course
Robert S. Cole

2. Endocrine Glands
 Controls many body functions
› exerts control by releasing special chemical
substances into the blood called hormones
› Hormones affect other endocrine glands or body
systems
 Ductless glands
 Secrete hormones directly into bloodstream
› Hormones are quickly distributed by bloodstream
throughout the body

3. Hormones
 Chemicals produced by endocrine glands
 Act on target organs elsewhere in body
 Control/coordinate widespread processes:
• Homeostasis
• Reproduction
• Growth & Development
• Metabolism
• Response to stress
• Overlaps with the Sympathetic Nervous System

4. Hormones
 Hormones are classified as:
› Proteins
› Polypeptides (amino acid derivatives)
› Lipids (fatty acid derivatives or steroids)

5. Hormones
 Amount of hormone reaching target tissue
directly correlates with concentration of
hormone in blood.
› Constant level hormones
 Thyroid hormones
› Variable level hormones
 Epinephrine (adrenaline) release
 Insulin
› Cyclic level hormones
 Reproductive hormones

6. The Endocrine System
 Consists of several glands located in various
parts of the body
 Specific Glands
› Hypothalamus
› Pituitary
› Thyroid
› Parathyroid
› Adrenal
› Kidneys
› Pancreatic Islets
› Ovaries
› Testes

7. Endocrine Disorders
and Emergencies
 Primarily consist of:
› Disorders of the Pancreas
› Disorders of the Thyroid Gland
› Disorders of the Adrenal Glands

8. The Endocrine System is the control mechanism for the
autonomic functions of the body.

9. Disorders of the Pancreas

10. What is the Pancreas?
 The pancreas is a dual purpose gland organ in the
digestive system and endocrine system of
vertebrates.
 It is both an endocrine gland producing several
important hormones, including insulin, glucagon,
somatostatin, and pancreatic polypeptide, and a
digestive organ, secreting pancreatic juice
containing digestive enzymes that assist the
absorption of nutrients and the digestion in the
small intestine.
 These enzymes help to further break down the
carbohydrates, proteins, and lipids in the chyme.

13. The Pancreas

14. Pancreas
 Produces 3 types of cells:
› Alpha (α)
› Beta (β)
› Delta (δ)

15. Alpha Cells (α)
 Alpha () cells release glucagon to RAISE
blood glucose level and stimulate
glycogenolysis
› When blood glucose levels fall,  cells  the amount
of glucagon in the blood
› The surge of glucagon stimulates liver to release
glucose stores by the breakdown of glycogen into
glucose (glycogenolysis)
› Also, glucagon stimulates the liver to produce glucose
(gluconeogenesis)

16. Beta Cells (β)
 Stimulate the release of insulin to
Lower the blood glucose level
 Beta Cells () release insulin (antagonistic to
glucagon) to control blood glucose level
› Insulin  the rate at which various body cells take up
glucose  insulin lowers the blood glucose level
› Promotes glycogenesis - storage of glycogen in the
liver
› Insulin is rapidly broken down by the liver and must
be secreted constantly

17. Delta Cells (δ)
 Delta Cells () produce somatostatin, which
inhibits both glucagon and insulin
› inhibits insulin and glucagon secretion by the
pancreas
› inhibits digestion by inhibiting secretion of digestive
enzymes
› inhibits gastric motility
› inhibits absorption of glucose in the intestine

18. The Role of Glucose and Insulin
 Glucose is a major source of energy for the
body.
 Insulin is needed to allow glucose to enter
cells (except for brain cells).
› A “cellular key”

19. The Role of Glucose and Insulin

20. The Role of Glucose and Insulin
 When glucose is unavailable, the body turns
to other energy sources.
› Fat is most abundant.
› Using fat for energy results in buildup of ketones
and fatty acids in blood and tissue.

21. The Role of Glucose and Insulin
 Diabetic ketoacidosis (DKA)
› A form of acidosis seen in uncontrolled diabetes
› Without insulin, certain acids accumulate.
› More common in type 1 diabetes
› Signs and symptoms:
 Weakness
 Nausea

22. Diabetes
 Diabetes affects the body’s ability to use
glucose (sugar) for fuel.
 Occurs in about 7% of the population
 Complications include blindness,
cardiovascular disease, and kidney failure.

23. The central problem in diabetes is lack, or ineffective action, or
resistance to, of insulin.
Hypoglycemia, the most common diabetic emergency seen in
EMS, is simply the result of over-correction of this problem, the
result of loss of balance in the endocrine system, but is not the
key problem with diabetes.

24. Diabetes
 As an EMT, you need to know signs and
symptoms of blood glucose that is:
› High (hyperglycemia)
› Low (hypoglycemia)
 Central problem in diabetes is lack, or
ineffective action, of insulin.

25. Types of Diabetes Mellitus
 Type I
 Type II
 Secondary
 Gestational

26. The term “Insulin Dependent” and “non-Insulin Dependent” are
no longer accurate definitions of Type I and Type II Diabetes.
Type I diabetics are now being occasionally prescribed anti-
hyperglycemics as well as insulin; and Type 2 diabetics are
(occasionally) being prescribed insulin in addition to their oral
meds.

27. Type 1 Diabetes Mellitus
 Type 1 patients do not produce insulin at all.
› Need daily injections of insulin
› Typically develops during childhood
› Patients more likely to have metabolic problems
and organ damage
› Considered an autoimmune problem

28. Type 1 Diabetes
 More than 90% of children with diabetes
suffer from Type 1 diabetes (previously
known as insulin-dependent diabetes).
 The body loses the ability to make insulin.
This occurs when the immune system
destroys the insulin-producing cells.
 As a result of this attack, these cells stop
making insulin over time.

29. Type 2 Diabetes Insipidus
 Type 2 patients produce inadequate
amounts of insulin, or normal amount that
does not function effectively.
› Usually appears later in life
› Treatment may be diet, exercise, oral
medications, or insulin.

30. Key Point:
 Type 1 and type 2 diabetes both:
› Are equally serious
› Affect many tissues and functions
› Require life-long management.

31. New Onset Diabetes?
 About 25% of new onset Diabetes (Type I)
are discovered due to a DKA type event.
 Type 2 Diabetes, by contrast is typically
discovered during health screenings or other
routine medical evaluations.
 This DOES NOT IMPLY that Type 2 is less
severe than Type 1.
› Both can be fatal if untreated/unrecognized.

32. Types of Diabetes
 Secondary Diabetes : Pre-existing condition
affects pancreas and its function
› Pancreatitis
› Trauma
› Shock States
› Cystic Fibrosis
 Occurs during pregnancy
› Usually resolves after delivery

33. Types of Diabetes
 Definition: Onset of diabetes with pregnancy.
 Most women need two to three times more insulin when
they are pregnant than they usually do.
 In gestational diabetes, there are often no warning
symptoms. All pregnant women need to be tested for
diabetes during the second trimester. This is especially
important for women who are already at risk.
 After the baby is born, blood glucose levels usually return
to normal. A woman who has had gestational diabetes is
at risk for developing type 2 diabetes later in life.
 No Pregnant?
› Occurs rarely in non-pregnant women on BCPs
› Increased estrogen, progesterone from BCPs
antagonize endogenous insulin

34. New Onset Diabetes?
 Classic symptoms of uncontrolled diabetes
(“3 Ps”):
› Polyuria: frequent, plentiful urination
› Polydipsia: frequent drinking to satisfy
continuous thirst
› Polyphagia: excessive eating
 This is why we check a Bgon 90% of IV
starts….

35. Monitoring Blood Glucose
Source: Accu-Chek® Aviva used with permission of Roche Diagnostics.
Blood glucose monitoring kit

36. Monitoring Blood Glucose
 Perhaps the single most important factor in
a diabetics health is how well they monitor
their own BG.
 Severity of diabetic complications depends
on patient’s average blood glucose level.

37. Glucose Monitors Facts
 Personal use: Calibrated Monthly (rare)
 For EMS use: Calibrated WEEKLY
 Most have a chip which need to be changed
with EVRY BOTTLE OF NEW STRIPS
 Affected by temp
 Affected by time (samples must be applied
w/in 30 –60 seconds)

38. Blood Glucose Monitoring
 Should be done daily or more often.
 When done by EMS, should be done in the
opposite ext. as D50 was given.
 Venous blood usually runs about 10 mg/dl
higher than capillary blood.

39. Checking the Blood Glucose
Level (BG)
› Glucometers are commonly found on EMS units.
› Determines the amount of glucose in the blood, the
sample usually coming from a finger stick.
› Glucose is measured in milligrams per deciliter
(mg/dl).
› A normal range is 80-120 mg/dl.
› Hypoglycemia is a BGL <60 mg/dl.
› Hyperglycemia is a BGL >150 mg/dl.
 Typically not significant until greater than 250. Often not
symptomatic until greater than 400 (not always true)

40. Benefit Of Frequent Testing
Breakfast
100 (5.6)
200 (11)
400 (22)
300 (17)
DinnerLunch Bed
1 test versus 7 tests a day

41. Testing Frequency
 In a Kaiser study of actual prescription
fulfillment among 44,181 patients with
diabetes:
› 60% of Type 1s were not testing 3-4
times a day as recommended by the
ADA
› 67% of Type 2s were not testing
once a day as recommended by the
ADA
Diabetes Care 23:477-483, 2000

42. Why Aren’t People Testing?
 Lack of understanding
 No direct /immediate reward/benefit
 No mechanism for long-term benefit
 No link to cause of BG problems
 Finger-pricking required (NOT FUN)
 No guidance for lowering highs
 No easy way to record other things
$2,000 a year for 7 x a day
testing

43. LOG BOOKS:
 Can be very useful in reviewing a patients
control

44. What are the numbers?
 Low: <60mg/dl (<3.0 mmol/L)
 Normal: 60-150mg/dl (3.0-8.0 mmol/L)
› Some recommend 120 mg/dl
 Hyperglycemic: >150 (>8.0 mmol/L)
 DKA usually seen at 250-500mg/dl

45. mmol/L vs. mg/dl
 What is an MMOL?
 It is a unit of measurement commonly used
in chemistry based on the molecular weight
of the substance it pertains to.
 To convert mmol/l of glucose to mg/dl,
multiply by 18. To convert mg/dl of glucose to
mmol/l, divide by 18 or multiply by 0.055.

46. Hemoglobin A1c
 Hg A1c is a 3 month Average of blood glucose control
 In the normal 120-day lifespan of the red blood cell, glucose
molecules react with hemoglobin, forming glycated hemoglobin. In
individuals with poorly controlled diabetes, the quantities of these
glycated hemoglobins are much higher than in healthy people.
 Once a hemoglobin molecule is glycated, it remains that way. A
buildup of glycated hemoglobin within the red cell, therefore,
reflects the average level of glucose to which the cell has been
exposed during its life-cycle. Measuring glycated hemoglobin
assesses the effectiveness of therapy by monitoring long-term
serum glucose regulation. The HbA1c level is proportional to
average blood glucose concentration over the previous four weeks
to three months.
 Some researchers state that the major proportion of its value is
related to a rather shorter period of two to four weeks.

47. A1c: the Numbers
 In general, the normal range (that found in healthy
persons), is about 4%–5.9%
 The 2010 American Diabetes Association added the A1c
≥ 6.5% as another criterion for the diagnosis of diabetes,
but this is controversial and has not been universally
adopted.
 Target criteria for DM is typically 6-7%
 In diabetes , higher amounts of glycated hemoglobin,
indicating poorer control of blood glucose levels, have
been associated with cardiovascular
disease, nephropathy, and retinopathy.
 Monitoring the HbA1c in type-1 diabetic patients may
improve treatment.

48. Common Diabetic Emergencies

49. Hyperglycemia and Hypoglycemia
 Both lead to diabetic emergencies.
 Hyperglycemia: Blood glucose is above normal.
› Result of lack of insulin
› Untreated, results in DKA
 Hypoglycemia: Blood glucose is below normal.
› Untreated, results in unresponsiveness and hypoglycemic
crisis
 Signs and symptoms of hyperglycemia and
hypoglycemia are similar if your assessment is
shoddy…..

50. Hypoglycemia
 “Looks Shocky” used to be called Insulin
shock. Pale, diaphoretic, altered mental
tatus. May Vomit.
 BG <60mg/dl
 Reality is this is a hypoglycemic state, not a
shock state.

51. Hypoglycemia:
Definitions
 “Mild”: Adrenergic (BG<60) (<4mmol)
 “Moderate”: Cognitive (BG<50) (<3mmol)
 “Severe”: Neurologic Unconscious (BG
???)

52. Hypoglycemia
 More common with Type I diabetics
 Most common complication of diabetes
mellitus seen by EMS
› Most common cause of coma in the diabetic patient

53. Common Causes
 Common history is taking insulin:
› And then not eating a meal
› Eating a meal, but having heavier exertion than
normal
› Taking too much insulin and depleting the glucose
levels in the body
 Also caused by Medication Interactions
› Beta Blockers (High Blood Pressure Meds)
 Change in exercise
 Recent illness

54. Hypoglycemia

55. Treatment for Hypoglycemia
 Food (simple and Complex Carbs)
 Oral Glucose
 IV Dextrose
 Glucagon

56. Carbs!!!!!

58. Oral Glucose
 Class: Simple Carbohydrate
 MOA: A heavy sugar gel that is absorbed across the mucosal
membranes of the mouth and the GI tract, and enters the blood
stream.
› Increases the BGL by providing sugar available for the brain.
 Indications: Only administer if the following criteria are met (all
three must be met):
 The patient has an altered mental status.
 There is a history of diabetes controlled by medications.
 The patient is responsive enough to swallow and control their
own airway.
 DOSE: 15-45 GM’s PO

59. IV Dextrose
 IV Dextrose (D50)
12.5-25 GM IVP
 Consider mixing in a
bag of 250cc and run
in.
 Always administer
slowly….

60. Glucagon
 MOA: Enzyme that promotes/stimulates
gylcogenisis
 Works opposite of insulin.
› Primary action is to raise the BGL if it
becomes lower than normal
(<60mg/dl).
› Helps the liver to release stored
glycogen back into the bloodstream,
where it is again restored to the
simple sugar glucose (during a
process called glycogenolysis).
 DOSE: Glucagon 1-5 units IV or IM.
(Uses stores in liver)
› Sometimes patients have their own
glucagon.
 Route: IM or occasionally IV 1-5 units

61. OK…. their awake, NOW What?
 When awake: f/u with complex
carbohydrates (food)
 Ensure that someone will be with the pt.
 Assess for and treat hypothermia (common)
 R/O other problems (trauma). Pt must be
fully CA&O.
 Consider T/R if desired after contact with
medical control or per protocol

62. 11 Questions:
 1. Is there a clear reason for the hypoglycemic episode?
 2. Is the patient alert and oriented?
 3. Is the patient’s repeat BG above 80 mg/dl?
 4. Has the patient’s BG been well-controlled prior to this episode?
 5. Is the patient able to eat a complex carbohydrate meal?
 6. Does the patient have regular, on-going physician care?
 7. Is the patient comfortable with non-transport?
 8. Is the patient/guardian willing to sign a release form?
 9. Is there another responsible person with the patient?
 10. Is the patient’s temperature within normal limits? (95° to 100.4°
Fahrenheit)
 11. The patient is free of the influence of alcohol or other CNS-
altering drugs?

63. KEY POINTS:
 Hypoglycemia is an Altered LOC (ALOC)
emergency until proven to be hypoglycemia.
› In other words, don’t get surprised by other
causes, i.e. CVA, Alcohol, drugs, etc

65.  Patent issued
September 14, 1971
for the
Ames Reflectance
Meter

66.  More physiologic insulin
delivery to mimic the
pancreas
 Basal: steady background
insulin delivery to keep BG
from rising while fasting
 Bolus: spurts of insulin to
cover carbs or lower high
BGs

67.  Liberalization of diet —
timing & amount (by user)
 Increased control with
exercise (by user)
 Able to work shifts & through
lunch (by user)
 Less hassle with travel and
time zones (by user)
 Aid to weight control (by user)
 Less anxiety in trying to keep on schedule (by user)

68. •55.0
29.8
•23.9
•5.1
•13.413.0
7.9
16.4
5.02.5
0
10
20
30
40
50
60
Retinopathy
Progression
Laser Rx1 Micro-
albuminuria2
Albuminuria2
Clinical
Neuropathy3
Conventional
Intensive
76%
Risk Reduction
59%
Risk Reduction
39%
Risk Reduction
54%
Risk Reduction
64%
Risk Reduction
CumulativeIncidence(%)
1. DCCT Research Group, Ophthalmology. 1995;102:647-661
2. DCCT Research Group, Kidney Int. 1995;47:1703-1720
3. DCCT Research Group. Ann Intern Med. 1995;122:561-568.

70.  Carb boluses
 Accuracy improved with personal
carb factor adjusted for different
times of day
 Personal carb database
 Correction boluses
 Personalized correction factors for different times
of day
 Safer correction of high BGs
 Reports amount of correction bolus used (ie, over
8% of TDD)
An accurate TDD --> accurate basals & boluses

71. Each manufacturer provides bolus dose recommendations differently.

72.  As bolus size
increases, so
too does
duration of
action.
Woodworth et al. Diabetes. 1993;42(Suppl. 1):54A

73.  Bolus On Board (BOB)
› Discounts bolus for residual
BOB
› Improves accuracy
› Avoids stacking of bolus insulin
› Acts as guide to whether carbs
or insulin are needed, ie, BG is
130 mg/dl but
BOB = 5 u
 Requires a blood sugar test, an
accurate duration of insulin action,
and BG targets
Prevents hypoglycemia!

74.  Reminders (alarms) to
› test glucose following a bolus
› test glucose after a low
reading
› test glucose after a high
reading
› give a bolus at certain time of
day
› warn when bolus delivery was
not completed, etc.
› change infusion site

75. 108

76.  Direct glucose entry into database eliminates data
errors and offers optimum use of glucose/insulin data
• AccuChek Spirit + meter
• CozMore System +
Therasense CoZmonitor
• Soill Diabecare III pump +
meter
• Medtronic 515/715 +
BD Paradigm Link
• Soon: Animas + ? Lifescan
or Glucowatch

77.  A watch type device worn for about 13
hours/day.
 Uses a disposable pad and minute bioelectric
charge to read glucose readings as often as
every 10 minutes.
 Is effected by sweat (poor readings)
 Is a supplement to (not a replacement for )
normal glucometer readings.
 Downloadable info.

80.  Real time readings
 Add-on to routine BG
monitoring
 Radio communication
from sensor to monitor
 High and low glucose
alarms
 FDA pending
Caution: Investigational Device.Limited by U.S. Law to Investigational Use

81.  Silicon microneedles can be used to infuse insulin or allow glucose
measurements in interstitial fluid. This needle array could replace
the AutoSensor in a GlucoWatch for effective continuous
monitoring.

82. Caution: Investigational Device.Limited by U.S. Law to Investigational Use
Meter replacement

83.  Open-flow Microperfusion
System
 Inserted into the
subcutaneous adipose
tissue
 Double lumen catheter
 Acquires glucose
readings every 30
minutes
 Goal – subcutaneous
glucose sensing/insulin
delivery system

84. An intelligent pump would
alert the user when the BG
is likely to cross a selected
threshold value, such as
120 mg/dl (6.7 mmol).
This safe meal delay
reduces glucose exposure,
especially when combined
with a Super Bolus
Max. drop ~4-5 mg/dl per min

85.  Generally speaking, Insulin used in insulin
pumps should not be used for standard
injection!
 Most insulin pump pt’s only take one type of
insulin (fast acting)
 When encountering a pump in a
hypoglycemic patient, do not try to adjust it!
› Remove it from the patient.

88.  Usually presents as either DKA or HHNC
› DKA more common to Type I diabetics
› HHNC more common to Type II diabetics
 Both syndromes have elevated BGL in the
body.
 Altered physiology leads to dehydration and
acidosis.
› Usually a slower onset than that of hypoglycemic
episodes.

89.  Also known as
“Diabetic Coma”
 DKA usually > 350
mg/dl (occasionally
as low as 250 mg/dl)
 More common in type
I diabetics
› More common in
the 40’s (can be
seen at all ages)
 The body in an attempt to
compensate for hyperglycemia,
develops an acidosis state.
 Dehydration
 Vomiting
 Loss of weight
 Kussmaul respirations
 Acetone smell
 Impaired sensorium
 Shock
(hypovolemic/dehydration)

90.  Oxygen, Airway Control, Rapid Transport
 ALS Intercept!
› EKG (look out for hyperK)
› IV fluids (may require 4-6 liters over time) Monitor
B/P.
› Recheck BG
 Hospital Care:
› Insulin
› ICU Admission

91.  Hyperglycemic Hyper-Osmolar Non-ketotic Coma
 Only 10% actually severe enough for coma
 HHNC usually > 600 mg/dl
 More common in type 2 diabetics
 Slightly more common than DKA
 More common in very elderly (can be seen at all ages)
 Some insulin still being produced is enough to prevent
Lactic metabolism. Thus no Ketones and no acidosis.
 Just profound dehydration.
 Treated with lots of saline as well as glycemic correction
 High chance of severe electrolyte imbalances.
 Mortality 10-20%

92. One third of patients with HHNC do
not have a prior (known) history of
diabetes.
-Emedicine.com

93.  Protect the ABC’s
 High Flow O2
 Call ALS
 Rapid Transport
 Look for other causes also.

94.  All BLS care AND :
› 2 Large Bore IV’s
› Fluid Resuscitation
 Watch for fluid overload though
› Shock management
› Airway Management

95.  The classical symptoms of
child presenting with (new
onset) Type 1 diabetes:
› increasing thirst
› increased drinking and
› polyuria for some time
(May start having
accidents)
› Weight Loss
› Abd Pain
› Tired and listless

96.  More Severe complaints:
› Vomiting
› Altered Mental Status
› Kussmal Respirations
› Coma
› Profound dehydration
 25-40% go untreated long enough to develop DKA
 5-10% in diabetic coma from DKA.
 The condition is severe and is still the major cause of
death in children with diabetes.
 Consider abuse and/or neglect.

97. Hypoglycemia
 “Insulin Shock”
 BG <60
 They Look Shocky!
 Pale, Diaphoretic,
 HR is normal or mildly
increased
 BP typically normal.
 Breathing is shallow
 Sudden Onset
 No real shock
Hyperglycemia: DKA & HHNC
 “Diabetic Coma”
 Deep Respirations and fruity
Breath (DKA)
 BP decreased
 HR is very increased (120-150 or
more)
 Hypotension and severe
dehydration
 Very Dry skin, Flushed or pale.
 Slower onset.
 Real Shock

98.  Infection
› Especially on feet and hands
 Atypical Heart Attacks
 Strokes
 Renal Failure
 Hypertension
 Poor recovery from major insults to the body,
prolonged healing.

99.  After you obtain a good grasp of various
diabetic conditions, you may want to learn
about:
› Graves Disease
› Addison's Disease
› Thyrotoxic Crisis (Thyroid Storm)
› Hypothyroidism
› Cushing's Syndrome
 (not Cushing's response, which is different)

100.  The endocrine system maintains stability in
the body’s internal environment
(homeostasis).
 Type 1 and type 2 diabetes involve
abnormalities in the body’s ability to use
glucose (sugar) for fuel.

101.  Polyuria (frequent, plentiful urination),
polydipsia (frequent drinking to satisfy
continuous thirst), and polyphagia
(excessive eating due to cellular hunger)
are common symptoms, or the “3 Ps,” of
uncontrolled diabetes.

102.  Patients with diabetes have chronic
complications that place them at risk for
other diseases.
 Hyperglycemia is the result of a lack of
insulin, causing high blood glucose levels.

103.  Hypoglycemia is a state in which the blood
glucose level is below normal. Without
treatment, permanent brain damage and
death can occur.
 DKA is the buildup of ketones and fatty
acids in the blood and body tissue that
results when the body relies upon fat for
energy.

104.  Hyperglycemic crisis (diabetic coma) is a
state of unconsciousness resulting from
DKA, hyperglycemia, and/or dehydration
due to excessive urination.

105.  Hypoglycemic crisis (insulin shock) is
caused by insufficient blood glucose levels.
Treat quickly, by giving oral glucose (if
protocols allow), to avoid brain damage.

106.  When assessing diabetic emergencies, err
on the side of giving oral glucose (if
protocols allow). Do not give oral glucose to
patients who are unconscious or who
cannot swallow properly and protect the
airway. In all cases, provide rapid transport.

107.  Problems associated with diabetes include
seizures, altered mental status, “intoxicated”
appearance, and loss of a gag reflex, which
affects airway management.
 Hematology is the study and prevention of
blood-related disorders.

108.  Sickle cell disease is a blood disorder the
affects the shape of red blood cells.
Symptoms include joint pain, fever,
respiratory distress, and abdominal pain.

109.  Hemoglobin A is considered normal
hemoglobin. Hemoglobin S is considered an
abnormal type of hemoglobin and is
responsible for sickle cell crisis.

110.  Patients with sickle cell disease have
chronic complications that place them at
risk for other diseases, such as heart attack,
stroke, and infection.

111.  Patients with hemophilia are not able to
control bleeding.
 Emergency care in the prehospital setting is
supportive for patients with sickle disease or
a clotting disorder such as hemophilia.