Diabetes mellitus is the most common endocrine disorder in the US. The prevalence of diabetes among adults in the US has been reported to be between 8 and 11%. It has been noted that diabetes causes more deaths than breast cancer and AIDS combined each year in the US.

Insulin, which is produced by the pancreas, is the hormone responsible for blood sugar regulation. It circulates in the bloodstream and enables sugar to enter the cells, storing glucose as glycogen, fats, and protein, thus lowering the concentration of sugar in the bloodstream. When the blood sugar is low, insulin secretions are lowered by the pancreas. In diabetes, insulin production is either limited or absent, which results in elevated blood sugar. It can lead to serious complications affecting multiple body organs, such as kidney failure, neurological disorders, blindness, vascular damage, limb amputation, heart disease, and stroke.

Glucagon is another hormone secreted by the pancreas. Opposite to insulin, glucagon helps break down glycogen by the liver and increases blood glucose levels. Glucagon can be given intramuscularly to hypoglycemic patients to oppose the effects of insulin, especially if IV or IO access cannot be established.

There are two types of diabetes mellitus:

Type 1 diabetes is characterized by the lack of insulin production by the pancreas and has a genetic predisposition with onset in childhood. The immune system destroys insulin-producing cells in the pancreas, leading to a lack of insulin production. It accounts for 5-10% of diabetes in adults.

Type 2 diabetes occurs later in life during adulthood and is the more common type (> 90% in adults). It is characterized by the progressive loss of insulin secretion from the pancreas superimposed on a background of insulin resistance, resulting in relative insulin deficiency. Type 2 diabetes may be related to obesity, hypertension, and hyperlipidemia. The majority of patients are asymptomatic at the time of presentation, with hyperglycemia noted on routine lab evaluation, leading to further testing.

Classic symptoms of hyperglycemia include:

• Polyuria (i.e., increased urination)

• Polydipsia (i.e., increased thirst)

• Nocturia

• Blurred vision

• Weight loss. 

Polyuria occurs when the renal threshold for glucose reabsorption is exceeded, usually above 180 mg/dL, leading to increased urinary glucose excretion. Osmotic diuresis (i.e., polyuria) and hypovolemia then occur, which leads to polydipsia. Patients then try to replete their volume losses, and if they use sugar drinks to do so, hyperglycemia and osmotic diuresis is exacerbated.

There are several complications with diabetes. One is neuropathy, which leads to the patient experiencing numbness, tingling, burning, and/or pain, typically in the extremities. However, neuropathy can also occur in the chest, which is why a silent myocardial infarction is associated with diabetic patients. Therefore, it is important to perform a 12-lead ECG in diabetic patients, especially if they are in extremis and even if they have no complaints of chest pain because they may not be feeling pain due to neuropathy in the nerves of their chest.

Diabetes is also the leading cause of kidney failure, which can lead to dialysis and/or kidney transplant. Other complications include heart disease, stroke, amputation of limbs, bacterial and fungal infections of the skin and mouth, and retinopathy, which is damage to the blood vessels of the eyes, leading to blindness.

Next week we will discuss the different types of diabetic emergencies, signs and symptoms, and treatment for each.

Jeffrey Luk, MD

Diabetes Part 2 - May 8, 2023

In the prehospital setting, diabetic emergencies account for 3-4% of all EMS calls. The two most common types of diabetic emergencies encountered by EMS are hypoglycemia and hyperglycemia. Patients with a history of diabetes should have their blood sugar checked in the prehospital setting, as abnormal blood sugar levels can present in various ways.

Hypoglycemia is the most common endocrine emergency and is defined per our protocols as a blood glucose less than 70. Low blood sugar is usually caused by too much insulin, or the patient eats too little. The brain uses glucose as its sole energy source, so if glucose levels fall, mental status changes occur. Therefore, it is critical to obtain blood sugar in all altered mental status patients. Other signs of hypoglycemia include:

• confusion

• headache

• diaphoresis

• shaking

• tachycardia

• feeling extreme hunger

The patient can be semi-conscious, unconscious, and/or experience seizures due to hypoglycemia. In addition, the patient can be combative, aggressive, display slurred speech, and lack coordination. Therefore, a blood glucose should be performed in all patients with stroke symptoms. Hypoglycemia can also occur in non-diabetic patients, such as those with chronic alcohol disorders, cancer, liver disease, and kidney disease. 

Treatment for hypoglycemia involves giving the patient glucose in some form. If the patient is awake, alert, and can tolerate PO, oral glucose or food containing glucose (e.g., juice, candy bar) can be given. If the patient is altered or unconscious, IV/IO glucose should be given, or IM Glucagon if an IV or IO cannot be established. Consider airway management if the patient does not respond to glucose administration. After the patient’s mental status improves, the patient may refuse transport to the hospital. Following your agency’s protocol for refusal of transport. general guidelines for a safe refusal after hypoglycemia treatment include:

• a history of insulin-dependent diabetes

• return to normal mental status within 10 minutes of dextrose administration

• pretreatment glucose < 80; post-treatment glucose > 80

• patient tolerated food by mouth

• no other complicating factors or comorbid conditions

• ability to follow up with a physician

• not on oral sulfonylureas or long-acting insulins

• normal vital signs 

Hyperglycemia is defined as a blood glucose > 250. Symptoms include the 3 P’s: 

1. Polydipsia

2. Polyuria

3. Polyphagia

Diabetic patients usually experience hyperglycemia due to:

• medication non-compliance

• insufficient insulin dosages

• eating too much food or sugar-containing food

• infection

• illness

• surgery

• and/or emotional stress

By itself, hyperglycemia is not a medical emergency but can progress to diabetic ketoacidosis (DKA) if not treated. DKA causes the body to produce acids called ketones due to breaking down fat or protein for energy and carries a mortality of 9-14%. Patients in DKA usually experience nausea, vomiting, abdominal pain, fatigue, and altered mental status. A fruity smell due to the ketones produced by the body may be smelled on the patient’s breath. DKA patients may be unconscious and demonstrate deep, rapid respirations (AKA Kussmual’s respirations) due to the body’s attempt to rid itself of the excessive acid in the form of CO2 with breathing. DKA patients can also undergo osmotic diuresis and pass large amounts of urine. 

A hyperglycemic patient can also suffer from hyperglycemic hyperosmolar syndrome (HHS), which does not usually involve ketone production by the body. Hyperosmolarity is a condition in which the blood has a high sodium and glucose concentration, causing water to move out of the cells into the bloodstream. Severe dehydration occurs, and unconsciousness can occur. HHS carries a mortality of 10-50%. 

There is no way to know if a hyperglycemic patient is in DKA or HHS in the prehospital setting. Additional hospital labs are needed to diagnose these conditions. However, treatment should include IV fluids since patients are typically severely dehydrated. Some electrolytes can be affected by DKA, so it is recommended to obtain an ECG along with placing the patient on a cardiac monitor. Transporting the patient to the ED as soon as possible is vitally important in case they worsen.  

Jeffrey Luk, MD

GI Bleeding - May 15, 2023

This week we will discuss gastrointestinal (GI) bleeding, which can be divided into two broad categories: upper GI bleeding and lower GI bleeding.

Upper GI bleeding is defined as bleeding from an area of the GI tract proximal to the ligament of Treitz, which is the suspensory muscle of the duodenum located in the fourth section. Upper GI bleeding is more common in males and the elderly. Peptic ulcer disease (PUD) is the most cause of upper GI bleeding, followed by erosive gastritis, esophagitis, esophageal and gastric varies, and Mallory-Weiss tears. Alcohol, salicylates, and NSAIDs increase the risk of upper GI bleeding. 

One mnemonic that can be used to remember the causes of upper GI bleeding is “GUM BLEED:”

• Gastritis Ulcers

• Mallory-Weiss tears

• Biliary

• Large esophageal varies

• Esophagitis

• Enteric-aortic fistula

• Dieulafoy lesions (i.e., gastric vessel aneurysms)

The clinical features of upper GI bleeding include hematemesis (i.e., “coffee ground emesis”). Melena (i.e., dark black stools) is seen in 70% of patients with upper GI bleeding and may result from as little as 60 ml of blood in the upper GI tract. Blood must remain in the GI tract for about 8 hours before turning black. 

When suspicious of upper GI bleeding, the provider should evaluate for signs of hypovolemia, which include hypotension, tachycardia, tachypnea, decreased peripheral perfusion, and altered mental status. Signs of liver disease leading to coagulopathy as a cause of upper GI bleeding include jaundice, telangiectasia, bruises, petechiae, and/or hemangiomas. Organomegaly, ascites, and abdominal tenderness may also be present in patients with upper GI bleeding.

Prehospital treatment for upper GI bleeding includes two large bore intravenous lines (or intraosseous lines if necessary for vascular access), volume resuscitation with crystalloid solution, and blood if available, and two liters of crystalloid solution fails to achieve adequate resuscitation. Patients on Warfarin or with liver dysfunction require coagulation replacement with Vitamin K and/or fresh frozen plasma (FFP) if available. Proton pump inhibitors are indicated for presumed ulcer or variceal hemorrhage. H2 blockers (e.g., famotidine) have demonstrated no benefit with upper GI bleeds. In patients with cirrhosis or varices, IV octreotide, and IV antibiotics (such as a 3rd generation cephalosporin or fluoroquinolone) may be helpful. 

Lower GI bleeding is defined as bleeding originating from a location in the GI tract distal to the ligament of Tretiz. The annual incidence is 20 per 100,000. Lower GI bleeding is more common in the elderly. The most common cause of lower GI bleeding is diverticular disease, followed by colitis, adenomatous polyps, and malignancies. Of note, lower GI bleeding may be due to an upper GI source about 10-14% of the time. Approximately 80% of lower GI bleeding will resolve spontaneously. 

The mnemonic to assist with remembering the causes of lower GI bleeding is “DRAIN:” 

• Diverticulosis

• Radiation or Ischemic Colitis

• Arteriovenous malformations

• Inflammatory bowel disease (e.g., Crohn’s disease)

• Neoplasms 

Clinical features of lower GI bleeding include:

• Hematochezia (i.e., bright red or maroon-colored stools)

• Dizziness

• Weakness

• Syncope, and other signs of hypovolemia

Note that hematochezia can also be caused by a brisk upper GI bleed. 

Prehospital treatment for lower GI bleeding is very similar to that for upper GI bleeding: two large bore intravenous lines (or intraosseous lines if necessary for vascular access), volume resuscitation with crystalloid solution, and blood if available and two liters of crystalloid solution fails to achieve adequate resuscitation. If available, Vitamin K and/or fresh frozen plasma (FFP) is indicated for patients with an elevated international normalized ratio (INR).

A special note about aorto-enteric fistulas: This condition occurs when there is direct communication between the aorta and the GI tract. It occurs commonly in patients with prosthetic aortic grafts and may result from aortic aneurysms, aortitis, radiation treatment, tumors, or trauma. The third or fourth portion of the duodenum is most involved. Symptoms include GI bleeding, and in fact, mild bleeding may signify an impending rupture with massive bleeding. Other symptoms include abdominal pain, back pain, and fever. Treatment is like that for other GI bleeds, plus emergency surgical consultation. Post-operative hypotension is the strongest predictor of mortality, and emergent laparotomy is the only life-saving treatment for massive bleeding. 

Jeffrey Luk, MD

OB/GYN Emergencies - May 22, 2023

For the last week of May, we will discuss ob/gyn emergencies. Remember that normal physiological changes occur in pregnant females. Blood volume increases by at least 50%; baseline heart rate and respiratory rate increase 10-15%; and blood pressure can be lower or normal but should NEVER be hypertensive. 

Pre-eclampsia is one complication of pregnancy or even those females who have recently been pregnant, typically up to 8 weeks postpartum. These patients are hypertensive (SBP > 140 and/or DBP <110) and can have pedal edema, headache and/or visual disturbances, and epigastric/RUQ pain. Even marginal increases in BP are abnormal in pregnancy. When a seizure occurs, and eclampsia becomes the diagnosis, there is 14% maternal mortality. These patients absolutely need IV access.

 Treatment of pre-eclampsia or postpartum hypertension < 6 weeks with the above symptoms minus seizure includes magnesium sulfate 4-6 grams IV/IO over 20-60 minutes and with medical command orders, Labetalol 20 mg slow IVP if SBP > 160 and/or DBP>110. For eclampsia (i.e., the patient is seizing), treatment includes the aforementioned magnesium sulfate and then midazolam if magnesium fails. BP control within the above parameters with a medical command order is also advised. 

Bleeding in and around pregnancy is another potential complication. Important information to obtain includes:

• The time of onset

• The amount of bleeding (pads per hour; note that blood in the toilet bowl is a horrible estimation

• LMP (Last Menstrual Period)

• How many weeks of gestation

• Complications during pregnancy

• Membrane rupture

• Other children with their birthing history

• Medications

• Allergies

• Recent drug use

• The presence or absence of abdominal pain

Placenta previa and placenta abruption both occur in the mid to late second trimester or in the third trimester. Placenta previa is when the placenta partially or completely covers the cervical openings and presents as spontaneous PAINLESS copious vaginal bleeding. 

Placenta abruption is when the placenta separates from the uterine wall and presents as copious vaginal bleeding in the setting of trauma. It takes a surprisingly small amount of force to abrupt a placenta. Drugs, smoking, and hypertension in the setting of abdominal pain can also lead to placental abruption. Do NOT perform digital exams on pregnant patients who complain of vaginal bleeding. Prehospital treatment for both of these conditions is fluid resuscitation. Do NOT minimize the pregnant patient’s complaint of vaginal bleeding or abdominal pain; they all need IV access and close monitoring. 

Postpartum hemorrhage is another complaint that prehospital providers will encounter. More than 500 ml of bleeding is diagnostic for postpartum hemorrhage and may occur as late (i.e., more than 24 hours). Causes include:

• uterine atony

• lacerations

• retained products of conception

• uterine inversion/rupture

• coagulopathy

Treatments include: 

• IV fluid resuscitation

• external uterine massage

• oxytocin IM

• If hemorrhage persists or is uncontrolled, tranexamic acid can also be considered

Delivery complications can also occur, for example, Umbilical cord prolapse. This is a condition when the cord presents before the head of the fetus. Occult cord prolapse is when the cord drops alongside the baby but may not be seen in advance. Overt cord prolapse is when the cord comes before the baby’s head can come out. These patients need you to wrap the exposed cord in a sterile saline gauze and to get your digits onto the presenting portion of the neonate (NOT THE CORD) to elevate the presenting part, and thereby prevent cord hypoperfusion and neonatal hypovolemic shock. Also, position mom’s head down with feet elevated as best as you can.

For a breech presentation, transport the patient unless delivery is imminent. If a single limp is presenting, transport immediately. Do NOT encourage the mother to push. Support but do not pull presenting parts. If delivery is in process and the head is clamped against the vagina, create an air passage by supporting the body of the infant and placing 2 gloved fingers forming a “V” and push away from the face to facilitate an airway passage. If unable to deliver, transport the mother with hips elevated and knees to the chest.

If shoulder dystocia is found, transport the mother with hips elevated and knees to the chest. Insert fingers to relieve pressure on the cord, and place pressure above the symphysis pubis. Risk factors for shoulder dystocia include:

• maternal diabetes (2-4 fold increase)

• mother's age >35 years old

• short stature

• small/abnormal pelvis

• > 42 weeks gestation age and > 4500-gram fetus

Shoulder dystocia can lead to paralysis, cerebral palsy, fetal death, maternal postpartum hemorrhage, lacerations, and uterine rupture. Signs of distress include Turtle Sign (i.e., the head comes out and then goes back in), facial flushing (i.e., the baby has a red, puffy face on head emergence), and descent delay. 

This concludes our discussion on ob-gyn emergencies and the potential complications. Thank you to those in EMS for making a difference as we honor your work during National EMS Week May 21-27!

Jeffrey Luk, MD

Memorial Day - May 30, 2023

Good Morning,

It's Memorial Day. Today we honor and remember those who died in our armed services. We also want to thank all the past and present service men and women. Thank you for all that you do every day.

We encourage you to register for our regular email blasts including our Monday Morning Medical Director's Message, PharmPhriday, and the Prehospital Paraigm Podcast.

As we continue with our Monday morning messages, our goal is to communicate solid, helpful information. Next week, Dr. Joseph Posluszy, Trauma Surgeon at UH Cleveland Medical Center, will be addressing the topic of thoracic trauma the deadly dozen.

Every Monday, there is a new episode of the Prehospital Paradigm Podcast with our group talking about local, regional, and national EMS issues. Physicians, nurses, and EMS providers gain professional knowledge from the podcast. You can listen on your favorite podcast app and uhems.org. You can watch the video podcast on YouTube. On the fourth Monday of every month, we present a LIVE show where you can interact and ask questions on Facebook and YouTube.

Fridays expect PharmPhriday which highlights a specific drug from the drug box including its history, usage, and side effects.

Lastly, continue to utilize our website uhems.org for the latest courses, events, and updates.

Have a happy and safe Memorial Day.

Sincerely,

The UH EMS-I Team

University Hospitals