1	Endocrine Emergency Pharmacology
2	Diabetes Mellitus
3	Diabetes Mellitus A hormone is a chemical substance produced by an organ or specialized cells that regulates or controls the activities of another organ. The pancreas is located in the retroperitoneal space, within the folds of the small intestine.
4	Diabetes Mellitus (cont.) Within the pancreas is an area called the islets of Langerhans. The islets secretes three hormones: The α cells secrete the hormone glucagon. The β cells secrete insulin. The δ cells secrete somatostatin.
5	Diabetes Mellitus (cont.) Insulin is required for the passage of glucose into the cells. Glucagon causes stored carbohydrates to be broken down to glucose. Diabetes mellitus is caused when β cells of the pancreas reduce the amount of insulin secreted.
6	Diabetes Mellitus (cont.) Type I diabetes mellitus Possibly caused by a viral infection that attacks the pancreatic β cells Possibly caused by the immune system targeting the pancreatic β cells Heredity is a factor Patient must take a daily dose of insulin
7	Diabetes Mellitus (cont.) Type II diabetes mellitus Occurs more commonly than type I Usually begins later in life Pancreas is less responsive to stimulation from increased blood glucose levels Usually does not require insulin injections Does not usually result in DKA Can develop nonketotic hyperosmolar coma
8	Diabetes Mellitus (cont.) Diabetic ketoacidosis Insulin levels decrease Blood glucose levels increase Individual cells become glucose-depleted Ketones and acids are produced Metabolic acidosis insues Left uncorrected, coma will follow
9	Diabetes Mellitus (cont.) Hypoglycemia Commonly referred to as “insulin shock” Usually has a rapid onset Insulin levels increase Blood glucose levels decrease Lack of glucose will cause brain injury
10	Insulin Humulin, Novolin, Iletin
11	Class Hormone and antihyperglycemic
12	Description In diabetics incapable of producing an adequate amount of insulin, supplemental insulin must be obtained by injection. Many patients develop antibodies to animal insulin, rendering it less effective. Genetically engineered insulin (Humulin, Novolin) is chemically identical to the insulin hormone secreted by the pancreas.
13	Mechanism of Action Combines with insulin receptors present on the cell membranes Promotes glucose entry into the cell Lowers the blood glucose level
14	Pharmacokinetics Onset 30-60 minutes Peak effects 2-3 hours Duration 5-7 minutes Half-life 13 hours
15	Indications Diabetic ketoacidosis Hyperglycemia Hyperkalemia
16	Contraindications Should be administered only when hyperglycemia or ketoacidosis has been confirmed Blood glucose approximation should be obtained in all diabetic emergencies Usually not used during the prehospital phase of emergency medical care
17	Precautions Repeated measurements of the blood glucose level, including possible administration of glucose, are necessary.
18	Side Effects Hypoglycemia Itching Swelling Redness Allergic reactions may occur following administration of animal-derived insulins.
19	Interactions Corticosteroids can increase the blood glucose level. Patients receiving these drugs may require a higher dose of insulin. Signs and symptoms of hypoglycemia may be masked in patients receiving β-blockers.
20	Dosage Dose for diabetic coma is 5-10 units of regular insulin IV Followed by an infusion at 0.1 unit/kg per hour 5-20 units of regular insulin SC/IM if there is not an immediate need for IV insulin
21	Glucagon
22	Class Hormone and antihypoglycemic
23	Description A protein secreted by the α cells of the pancreas Used to increase the blood glucose level in cases of hypoglycemia in which an IV cannot be immediately obtained
24	Mechanism of Action When released, causes a breakdown of stored glycogen to glucose Also inhibits the synthesis of glycogen from glucose Both actions tend to cause an increase in circulating blood glucose.
25	Pharmacokinetics Onset 5-20 minutes Peak effects 30 minutes Duration 1-2 hours Half-life N/A
26	Indications Hypoglycemia β-blocker overdose
27	Contraindications Glucagon is a protein, so hypersensitivity may occur. Known hypersensitivity to the drug
28	Precautions Only effective if there are sufficient stores of glycogen within the liver Drug of choice in the management of insulin-induced hypoglycemia is D₅₀W Should be administered with caution to patients with a history of cardiovascular or renal disease
29	Side Effects Hypotension Dizziness Headache Nausea and vomiting
30	Interactions Few interactions in the emergency setting
31	Dosage Standard initial dose is 0.25-0.5 units IVP If no IV, 1 mg IM Can be administered IV, IM, or SC
32	50% Dextrose in Water D₅₀W
33	Class Carbohydrate
34	Description Dextrose is used to describe the six-carbon sugar d-glucose. Principal form of carbohydrate used by the body
35	Mechanism of Action Dextrose supplies supplemental glucose in cases of hypoglycemia. Serious brain injury can occur if hypoglycemia is prolonged.
36	Pharmacokinetics Onset < 1 minute Peak effects Variable Duration Variable Half-life N/A
37	Indications Hypoglycemia Coma of unknown origin
38	Contraindications No major contraindications to the IV administration of D₅₀W to a patient with suspected hypoglycemia Should be used with caution in patients with increased intracranial pressure because the dextrose load may worsen cerebral edema
39	Precautions Obtain a Glucometer reading and draw a sample of blood before giving D₅₀W. Therapy should always be guided by objective data such as patient assessment findings and blood glucose determination. Extravasation may occur when smaller veins are used.
40	Side Effects Tissue necrosis and phlebitis at the injection site
41	Interactions None in the emergency setting
42	Dosage Standard dosage in hypoglycemia is 25 g (50 mL of a 50% solution) IVP A second dose of 25 g, if first dose is ineffective Pediatrics Dilute 1:1 with sterile water forming D₂₅W The dose is 0.5-1.0 g/kg slow IVP
43	Thiamine
44	Class Vitamin
45	Description An important vitamin commonly referred to as vitamin B₁ Required for the conversion of pyruvic acid to acetyl coenzyme A
46	Mechanism of Action A vitamin is a substance that the body cannot manufacture but that is required for metabolism. Without thiamine, a significant amount of the energy available in glucose cannot be obtained. Chronic alcohol intake interferes with the absorption, intake, and use of thiamine.
47	Mechanism of Action (cont.) The brain is extremely sensitive to thiamine deficiency. Wernicke’s encephalopathy Acute and reversible encephalopathy Characterized by an unsteady gait, eye muscle weakness, and mental derangement Korsakoff’s psychosis is a significant memory disorder and may be irreversible.
48	Pharmacokinetics Onset Rapid Peak effects Variable Duration Variable Half-life N/A
49	Indications Coma of unknown origin, especially if alcohol may be involved Delirium tremens
50	Contraindications None in the emergency setting
51	Precautions A few cases of hypersensitivity to thiamine have been reported. Therapy should always be guided by objective data such as patient assessment findings and blood glucose determination.
52	Side Effects Few side effects reported Rare reports of: Hypotension Dyspnea Respiratory failure
53	Interactions None in the emergency setting
54	Dosage 100 mg IVP or IM