Hypoglycemia

Introduction
Hypoglycemia is a condition characterized by abnormally low blood glucose (blood sugar) levels, usually less than 70 mg/dl. However, it is important to talk to your health care provider about your individual blood glucose targets, and what level is too low for you.

Emergency complications

If blood sugar rises high enough or for a prolonged period of time, it can lead to two serious conditions.

·         Diabetic ketoacidosis. Diabetic ketoacidosis develops when patient don’t have enough insulin in body. When this happens, sugar (glucose) can't enter the cells for energy. Because of that blood sugar level rises, and body begins to break down fat for energy.

This process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually "spill over" into the urine. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and be life-threatening.

·         Hyperglycemic hyperosmolar syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high — greater than 600 mg/dL (33 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy.

Glucose is then spilled into the urine, causing increased urination. Left untreated, diabetic hyperglycemic hyperosmolar syndrome can lead to life-threatening dehydration and a coma. Prompt medical care is essential.

Presentation

Signs and Symptoms of Hypoglycemia (happen quickly)

·         Shakiness

·         Nervousness or anxiety

·         Sweating, chills and clamminess

·         Irritability or impatience

·         Confusion, including delirium

·         Rapid/fast heartbeat

·         Lightheadedness or dizziness

·         Hunger and nausea

·         Sleepiness

·         Blurred/impaired vision

·         Tingling or numbness in the lips or tongue

·         Headaches

·         Weakness or fatigue

·         Anger, stubbornness, or sadness

·         Lack of coordination

·         Nightmares or crying out during sleep

·         Seizures

·         Unconsciousness  (Mayoclinicorg, 2015)

Causes

·         Medications. One example is quinine (Qualaquin), which is used to treat malaria.

·         Excessive alcohol consumption

·         Some critical illnesses. Severe illnesses of the liver, such as severe hepatitis

·         Insulin overproduction

·         Fasting

·         Infection

·         Diet changes

·         Extrapancreatic causes

·         Insulinomas

·         Idiopathic causes 

·         Hormone deficiencies

·         Metabolic changes or activity changes

Investigations

Whipple’s triad gives indications of symptoms and signs of hypoglycaemia, a low plasma      glucose

concentration and resolution of symptoms and signs after plasma glucose returns to normal. 

HbA1c gives the assessment of glucose control.  

Liver function tests and thyroid function tests include any metabolic abnormalities regarding the low

level of glucose.  

Insulin radioimmunoassay is done to recognize islet cell tumor where it shows elevated insulin

levels.  

Blood and urine assays for sulfonylureas will detect factitious hypoglycaemia caused by these drugs

(Willacy 2013).

Management 

Treatment

1. Consume 15-20 grams of glucose or simple carbohydrates
2. Recheck your blood glucose after 15 minutes
3. If hypoglycemia continues, repeat.
4. Once blood glucose returns to normal, eat a small snack if your next planned meal or snack is more than an hour or two away.

15 grams of simple carbohydrates commonly used:

·         glucose tablets (follow package instructions)

·         gel tube (follow package instructions)

·         2 tablespoons of raisins

·         4 ounces (1/2 cup) of juice or regular soda (not diet)

·         1 tablespoon sugar, honey, or corn syrup

·         8 ounces of nonfat or 1% milk

·         hard candies, jellybeans, or gumdrops (see package to determine how many to consume) (Uptodatecom, 2015)

Glucagon

If left untreated, hypoglycemia may lead to a seizure or unconsciousness (passing out, a coma). In this case, someone else must take over.

Glucagon is a hormone that stimulates your liver to release stored glucose into your bloodstream when your blood glucose levels are too low. Injectable glucagon kits are used as a medication to treat someone with diabetes that has become unconscious from a severe insulin reaction. Glucagon kits are available by prescription. Speak with your health care provider about whether you should buy one, and how and when to use it.

The people you are in frequent contact with (for example, family members, significant others, and coworkers) should also be instructed on how to administer glucagon to treat severe hypoglycemic events. Have them call 911 if they feel they can't handle the situation (for example, if the hypoglycemic person passes out, does not regain consciousness, or has a seizure, if the care taker does not know how to inject glucagon, or if glucagon is not available).

If glucagon is needed:

1. Inject glucagon into the individual's buttock, arm or thigh, following the manufacturer's instructions.
2. When the individual regains consciousness (usually in 5-15 minutes), they may experience nausea and vomiting.
3. If you have needed glucagon, let your health care provider know, so they can discuss ways to prevent severe hypoglycemia in the future.  (Diabetesorg, 2015)

Medications uses are glucose supplements such IV dextrose, glucose elevating agents such as glucagon, inhibitors of insulin secretion such as diazoxide and Antineoplastic drugs such as streptozocin (Hamdy, Khardori & Vellore 2014). 

References

Uptodatecom. 2015. Uptodatecom. [Online]. [15 April 2015]. Available from: http://www.uptodate.com/contents/hypoglycemia-low-blood-sugar-in-diabetes-mellitus-beyond-the-basics

Hamdy, O, Khardori, R & Kenneth, J 2014, 'Hypoglyaemia', retrieved 16th of March 2015, http://emedicine.medscape.com/article/122122-overview

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [22 April 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/hypoglycemia/basics/symptoms/con-20021103

Diabetesorg. 2015. American Diabetes Association. [Online]. [29 April 2015]. Available from: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html

Hyperglycaemic emergencies

Introduction
Hyperglycemia doesn't cause symptoms until glucose values are significantly elevated — above 200 milligrams per deciliter (mg/dL), or 11 millimoles per liter (mmol/L). Symptoms of hyperglycemia develop slowly over several days or weeks. The longer blood sugar levels stay high, the more serious the symptoms become. However, some people who've had type 2 diabetes for a long time may not show any symptoms despite elevated blood sugars.

It's important to treat hyperglycemia, because if left untreated, hyperglycemia can become severe and lead to serious complications requiring emergency care, such as a diabetic coma. In the long term, persistent hyperglycemia, even if not severe, can lead to complications affecting to the eyes, kidneys, nerves and heart.

Presentation

Signs & symptoms

·         Frequent urination

·         BGL > 15mmol 

·         Increased thirst

·         Blurred vision

·         Fatigue

·         Headache

·         Fruity-smelling breath

·         Nausea and vomiting

·         Shortness of breath

·         Dry mouth

·         Weakness

·         Confusion

·         Coma

·         Abdominal pain  (Mayoclinic 2015)

Causes

·         Not using enough insulin or oral diabetes medication

·         Not injecting insulin properly or using expired insulin

·         Not following your diabetes eating plan

·         Being inactive

·         Having an illness or infection

·         Using certain medications, such as steroids

·         Being injured or having surgery

·         Experiencing emotional stress, such as family conflict or workplace challenges

Investigations

Collect blood for FBC 

Urinalysis for ketone bodies and glucose

ABGs/venous blood gas 

HbA₁C to detect the level of control with regard to high glucose levels (Mayoclinic 2015).

BGL 

Management

Assess airway patency.

Assess any breathing assess needed if so ventilation and oxygenation.

IV cannulation if signs of dehydration or if SBP less than 90 mmHg give IV 0.9% Sodium

Chloride 500 mL bolus stat. (repeat once if signs of dehydration persist or SBP remains less than 90 mmHg)

Monitor LOC frequently.

Capillary glucose levels every 30 minutes.

Consider insulin therapy but not before a serum potassium is known and not before advice from a Medical Officer (Rural Emergency clinical guidelines 2012). 

 

Emergency treatment for severe hyperglycemia

Emergency treatment can lower blood sugar to a normal range. Treatment usually includes:

·         Fluid replacement. 

·         Electrolyte replacement. 

·         Insulin therapy. 

References

Jeannette, G & Jeremy, G 2014, 'Hyperglycaemic emergencies inadults',retrieved 16th of March 2015, http://guidelines.diabetes.ca/browse/Chapter15

Mayoclinic 2015, 'Hyperglycaemia in diabetes' ,retrieved 16th of March 2015,http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/symptoms/con-20034795

Hypertensive emergencies

Introduction
A hypertensive emergency is high blood pressure with acute impairment of one or more organ systems (especially the central nervous system, cardiovascular system and/or the renal system) that can result in irreversible organ damage. In a hypertensive emergency, the blood pressure should be slowly lowered over a period of minutes to hours with an anti hypertensive agent.

Hypertensive emergency pathophysiology includes:

·         Abrupt increase in systemic vascular resistance, likely related to humoral vasoconstrictors 

·         Endothelial injury

·         Fibrinoid necrosis of the arterioles 

·         Deposition of platelets & fibrin

·         Breakdown of normal autoregulatory function  (Heartorg, 2015)

Terminology	Systolic Pressure (mm Hg)	Diastolic Pressure (mm Hg)
Normal	< 120	< 80
Hypertensive crisis - emergency	≥ 180	≥ 120

Uncontrolled high blood pressure can lead to:

• Loss of consciousness
• Memory loss
• Loss of kidney function
• Aortic dissection
• Angina (unstable chest pain)
• Pulmonary edema (fluid backup in the lungs)
• Eclampsia

·        Heart attack or stroke. 

·        Aneurysm. 

·        Heart failure. 

·        Weakened and narrowed blood vessels in your kidneys.

·        Thickened, narrowed or torn blood vessels in the eyes.This can result in vision loss.

·        Metabolic syndrome. 

Signs & symptoms

·         Headache.

·         Fits.

·         Nausea and vomiting.

·         Visual disturbance.

·         Chest pain.

·         Neurological deficit, eg CVE.

·         Bleeding due to disseminated intravascular coagulopathy (DIC).
(Mayoclinicorg, 2015)

Causes

·         Unilateral renovascular hypertension, e.g renal artery stenosis

·         Renin-secreting neoplasms.

·         Trauma to the kidneys.

·         Renal vasculitis, eg scleroderma, polyarteritis & systemic lupus erythematosus. 

·         Phaeochromocytoma.

·        Cocaine abuse

·         Drugs such as monoamine-oxidase inhibitors, combind oral contraceptives or the withdrawal of alcohol, alpha stimulants such as clonidine, or beta-blockers.

·         Sodium-volume overload and low renin levels, eg acute glomerulonephritis, primary aldosteronism. 

·         Eclampsia.

·        Hyperthyroidism or hypothyroidism

Investigations

·         Full history - including:

·         Past medical history.

·         Full systems review.

·         Drug history including over-the-counter, herbal remedies and recreational drugs.

·         Full examination - including:

·         Blood pressure measurements - lying, standing and in both arms (looking for coarctation or aortic dissection).

·         Fundoscopy - retinopathy, eg grade III (flame haemorrhages, dot and blot haemorrhages, hard and soft exudates) to grade IV (papilloedema).

·         Cardiovascular examination - lying and standing blood pressure; look for signs of cardiac failure or pulmonary oedema, carotid or renal bruits, left ventricular heave, cardiac murmurs, third or fourth heart sounds.

·         Neurological examination.

·         Blood tests:

·         FBC ± clotting screen.

·         U&Es, creatinine.

·         Liver and TFTs.

·         Blood sugar measurement.

·         ± Cardiac enzymes and fasting blood lipids.

·         Urine dip testing for protein and blood.

·         CXR - cardiac size, cardiac failure, etc.

·         ECG - left ventricular hypertrophy or left atrial enlargement.

Subsequent investigations may include:

·         CT/MRI scan of the head or kidneys.

·         Plasma renin activity.

·         Plasma aldosterone level.

·         24-hour urine for vanillylmandelic acid (VMA) and catecholamine levels.

·         Auto-antibody levels, eg antinuclear factor.

Management

·         IV Nitroprusside is the drug that most often use for hypertensive emergencies. Phentolamine is the drug of choice for a Pheochromocytoma crisis. Also available parenterally are diltiazem, verapamil and Enalapril. Hydralazine is reserved for use in pregnant patient 

Also using,

·         Thiazide diuretics. Diuretics are medications that act on kidneys to help the body to eliminate sodium and water, reducing blood volume.

·         Beta blockers. 

·         Angiotensin-converting enzyme (ACE) inhibitors. 

·         Angiotensin II receptor blockers (ARBs). 

·         Calcium channel blockers. 

·         Renin inhibitors. 

 Additional medications to treat high blood pressure

·         Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels.

·         Vasodilators. 

·          Aldosterone antagonists. Examples are spironolactone (Aldactone) and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure. (Uptodatecom, 2015)

References

Uptodatecom. 2015. Uptodatecom. [Online]. [8 May 2015]. Available from: http://www.uptodate.com/contents/drugs-used-for-the-treatment-of-hypertensive-emergencies

Mayoclinicorg. 2015. Mayoclinicorg. [Online]. [9 May 2015]. Available from: http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/causes/con-20019580

Heartorg. 2015. Heartorg. [Online]. [8 May 2015]. Available from: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Hypertensive-Crisis_UCM_301782_Article.jsp