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Diabetic Emergencies: Part 2

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Editor's Note: This is a follow-up article to "Diabetic Emergencies."

The dispatch information sounds like another case of the flu. "Respond to care for a patient complaining of abdominal pain and general weakness." As you and your partner arrive on the scene and put on your face masks and gloves, you're met at the door by the patient's mother, who leads you to a back bedroom. You find 17-year-old Devon, a moderately obese male patient, supine in his bed. He appears to be sleeping as you enter the room. Walking up to him, you call his name and reach to feel his pulse. He slowly opens his eyes, looks at you, and says, "Hey." Then, his eyes close again. Still considering the flu as a possible cause of your patient's symptoms, you turn to your partner and comment, "He doesn't feel like he has a fever."

You're able to obtain a history from the patient and his mother. Devon began feeling weak several days ago. The abdominal pain began this morning. But he's been eating and drinking normally. In fact, his mother remarks that he's always thirsty. He denies having diarrhea but claims he has to urinate all the time. He also tells you he becomes dizzy when he stands.

Your secondary assessment reveals no signs of trauma, and he has no past medical history. His skin is warm and dry to the touch, but you notice his skin has areas of darkened tissue in the folds around the back of his neck. His vital signs are within normal ranges with the exception of his breathing, which is fast and deep. Your partner comments that the patient's breath smells of fruity gum.

The Diagnosis
You place the patient on oxygen via nasal cannula, transfer him onto your cot and transport him to the hospital. His level of responsiveness remains unchanged during transport. At the emergency department, the physician performs a finger stick blood glucose test (BGL), which reads 380 mg/dL. Other lab test results confirmed the physician's suspicion of diabetic ketoacidosis. You later learn Devon was discharged from the hospital with Type 2 diabetes.

Causes of Types 2 Diabetes
Type 2 diabetes isn't caused by an absence of insulin as seen with Type 1 diabetes, but rather the body's inability to use its insulin. Type 2 diabetics have insulin in their body, but the cells are either no longer responsive to the insulin or there isn't enough insulin to manage all of the glucose in the blood stream.

This results in the body's failure to move blood glucose into the cells. The cells begin to starve in the absence of glucose. Patients will feel hungry. They have plenty of glucose in their body but they just can't move it into their cells where it can be used. Patients begin to increase their food intake (polyphagia). In turn, this will increase the amount of unusable glucose in the blood. Because of this, some patients may experience weight loss even though consumption of food has increased.

Needing to rid itself of the excess glucose in the blood stream, the body begins to filter the glucose out into the urine (osmotic diuresis). Glucose is a large molecule and thus draws lots of water as it leaves the blood. This increases the amount of urine produced. Patients urinate more frequently than normal (polyuria). The increased fluid loss from the body creates dehydration, and the patient becomes excessively thirsty (polydipsia).

The cells will eventually turn to other energy sources in the body, such as lipids. This is an inefficient process and results in the increase of ketone bodies, which are a primary cause a metabolic acidosis. The metabolic acidosis causes a domino effect of changes in the body. Patients will develop electrolyte imbalances, cellular damage and organ malfunction. This is diabetic ketoacidosis.

The Early Signs
The onset of Type 2 diabetes may take several months. It's sometimes discovered during routine blood tests. Patients with Type 2 diabetes are commonly obese and will initially present with aches and lethargy. They'll present with the "poly" triad: polyphagia, polydipsia and polyuria. The developing acidosis and other changes will eventually cause other symptoms, such as abdominal pain. This may be severe. The osmotic diuresis can cause profound dehydration and hypotension. The brain doesn't require insulin to use glucose, so changes in mental status develop later and occur secondary to other changes in blood chemistry.

Respiratory rates will increase in rate and depth (Kussmaul breathing) in an attempt to regulate blood chemistry. The patient's breath may have a sweet odor. The increased blood glucose levels cause damage to small blood vessels. This will cause damage to internal organs and in some patients will cause dark, shiny areas of skin (known as acanthosis nigricans) seen on the back of the neck, under the arms and on the groin.

Treatment
Emergent treatment for patients with Type 2 diabetes includes airway management and fluid resuscitation. Further treatment is based on lab test results. Long-term treatment begins with exercise, changes in diet and weight loss. If unresponsive to these lifestyle changes, patients will be placed on oral antihyperglycemics drugs. Depending on the drug prescribed, they'll stimulate the pancreas to secrete more insulin, decrease the release of glucose into the blood stream or increase cellular sensitivity to the body's insulin.

As the disease progresses, patients may eventually require insulin injections. Type 2 diabetes has historically been a disease seen in the adult population. It was once referred to as "adult onset diabetes". There has been an increase in the development of Type 2 diabetes in the pediatric population over the last several years. This disease isn't just for grown-ups anymore, so consider it for all patients exhibiting these symptoms.

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