Please note! This essay has been submitted by a student.
This essay will be investigating the endocrine system and its relationship with diabetic hypoglycaemia. It will explore the assessment and management of this condition within the pre-hospital setting and discuss the ethical issues clinicians have to consider when treating patients.
The endocrine system comprises of glands that create and secrete hormones to regulate a range of functions within the body (Hormone Health Network, 2019). Hormones (chemical messengers) enter the bloodstream through an extensive network of capillaries by facilitated diffusion where they are transported to their target cells (Waugh and Grant, 2018). Here they bind to cellular receptors which trigger responses that can have a lag period of seconds up to days (Marieb and Hoehn, 2012).
Organs of the endocrine system are small and unimpressive in comparison to organs of other systems; they are not grouped together but dispersed around the body (Marieb and Hoehn, 2012). The pancreas is an endocrine organ located within the abdomen, behind the stomach (Johns Hopkins Medicine, 2019).
NHS resources are under ever increasing pressure as the number of people with diabetes increases (Fitzpatrick and Duncan, 2008). According to Diabetes UK (2019) 3.8 million people have been diagnosed with diabetes, with Type 2 accounting for 90%. However this statistic could be as high as 4.7 million due to people living with undiagnosed diabetes. In the UK thousands of emergency call outs are made by ambulance services to treat diabetic people with hypoglycaemia (Diabetes UK, 2019).
Hypoglycaemia or low blood sugar/glucose is where the level of glucose in the blood drops too low which can be dangerous if it’s not treated promptly (NHS, 2017). Hypoglycaemia is most common in diabetics, it occurs due to a compromised physiological and behavioural reaction to lowering blood glucose levels and an excess of insulin in the blood. Diabetic patients should ideally keep their blood sugar between 4-7mmol/L; if it drops below 4mmol/L then the patient could become hypoglycaemic (Pilbery and Lethbridge, 2019).
Caroline (2014) stated patients who have an endocrine condition often present with different signs and symptoms that “require a thorough assessment and immediate treatment to interrupt life-threatening emergencies” (Caroline, 2014, p. 597). Early signs of hypoglycaemia include; hunger, sweating, shaking, palpitations, tiredness, turning pale and becoming easily irritated. If untreated the patient can become confused, have difficulties concentrating, can get blurred vision/ headaches and may find it hard to speech. Finally if their blood glucose stays low for too long they could convulse/ become unconsciousness (NHS UK, 2017).
A rapid initial assessment of the patient must be conducted starting with a primary survey. This should be completed within 60-90 seconds to identify how to treat any life-threatening conditions in order of priority. This consists of DRABCDE (Danger, Response, Catastrophic haemorrhage/ C-spine injury, Airway, Breathing, Circulation, Disability and Exposure). Before approaching any patient a scene assessment must be conducted, checking for any dangers and ensuring the safety of yourself, your colleagues and the public (Caroline, 2014). The clinician should work through the primary survey in a logical sequence as described and any abnormalities managed as soon as they are encountered, the patient being re-assessed every time an intervention is performed (Brown et al, 2019).
As part of the disability assessment blood glucose levels must be checked to eliminate hypoglycaemia as the cause (Crouch et al, 2009). If a patient is presenting with hypoglycaemia then obtaining blood glucose is very important. Firstly appropriate personal protective equipment (PPE) i.e. gloves must be worn. A suitable site should be selected; typically the side of a finger. Clean the area with water or water-soaked gauze and dry to remove traces of glucose which will affect the test. The finger is then pricked; making sure any sharps are disposed of into a sharps bin. Wait for blood to appear and touch it to the test strip of the meter. The blood sugar result will appear, all results should be documented (Pilbery and Lethbridge, 2019).
After completing the primary survey the clinician should move onto the secondary survey. This is a more in depth head-to-toe assessment including patient history. Vital signs should continue to be monitored and recorded (Brown et al, 2019). Roper (2014) states “history-taking is the most important in leading you to the cause of illness” (Roper, 2014, p.10). To help gather critical information from the patient, history of the presenting complaint should be recorded first. The clinician can use SOCRATES (Site, Onset, Character, Radiation, Associations, Time, Exacerbating/relieving factors and Severity) to help determine the current condition. Medical, family and social history must also be asked about, including current medication (Caroline, 2014). If the patient is having a severe glycaemic emergency then they may have an altered level of consciousness. In this situation medical history can be collected from relatives, carers or friends, alternatively consider looking for alert bracelets etc. A neurological assessment should also be conducted when consciousness is altered; the Glasgow Coma Scale (GCS) can be used, any changes should be documented (Brown et al, 2019).
The management for this condition can vary depending on the patient’s level of consciousness when the paramedics arrive. In a mild to moderate glycaemic emergency the patient should be conscious, orientated and able to swallow. Fifteen to twenty grams of quick-acting carbohydrate must be administered; this can be one of the following: 4-5 Glucotabs, 60ml bottle of Glucojuice, 3-4 teaspoons of sugar/water solution or 150-200ml of pure fruit juice (Brown et al, 2019). Alternatively foods with a high glycaemic index (GI) or foods that are broken down quickly in the body can be eaten; this includes sugary foods and drinks. GI is a rating system for carbohydrate foods which indicates how quickly your blood sugar level is affected by certain foods (NHS, 2018). Fifteen minutes after quick-acting carbohydrates are consumed blood glucose must be re-tested to see if it has improved. If blood glucose persists at 4mmol/L is achieved. However if it does not rise after 45 minutes or three cycles of oral medication then intramuscular (IM) glucagon should be injected (Brown et al, 2019). Glucagon effectively manages severe hypoglycaemia in insulin-treated patients with diabetes as it helps restore blood glucose levels (Kedia, 2011). In a moderate glycaemic emergency, however the patient may be disorientated, confused and/or combative (Brown et al, 2019). If they are uncooperative but still able to swallow, 1-2 tubes of 40% glucose gel can be administered to the patient’s buccal mucosa instead of quick-acting carbohydrates, providing them with a fast source of energy (Caroline, 2014).
If the patient is having a severe glycaemic emergency then immediate action is needed to raise their blood glucose. They will be unconscious (GCS ≤8), convulsing or very aggressive meaning there is an increased risk of them aspirating/choking. Firstly check the patient’s ABC, correcting where necessary. A paramedic can administer 10% IV glucose over 15 minutes to raise blood glucose; IM glucagon can be given if IV access is not available. However IM glucagon takes 15 minutes to work and is given only once (Brown et al, 2019). Due to aspiration/chocking there should always be someone near the patient’s head watching their airway (Caroline, 2014). Glucose levels must be re-assessed after 10 minutes, if still 4mmol/L is obtained. If there is no improvement the patient must be conveyed to the nearest hospital while constantly monitoring their condition.
If blood sugars return to 4mmol/L or above after hypoglycaemia a starchy snack should be consumed. If glucagon has been administered a large portion of long-acting carbohydrates must be given to replenish glucagon stores. Most patients will not require a visit to hospital as long as they have fully recovered and can maintain their glucose levels >4mmol/L (Brown et al, 2019).
Before any assessment is carried out every clinician should think about the ethical guidelines and regulations they have to follow. Individuals have the right to make their own decisions, this is known as autonomy. Valid consent must be given to all healthcare providers before any care, treatment or other services are provided to respect a patient’s autonomy (Blaber, 2012). Three criteria must be met for valid consent to be obtained; consent must be given voluntarily, must be informed and the patient giving consent must have mental capacity to do so. They must not feel pressured by relatives or ambulance staff and must understand what they are consenting too (the course of action, what benefits and potential risks there are, alternatives and consequences of doing nothing) (Pilbery and Lethbridge, 2019). Informed consent can only be given if the patient has capacity to understand the procedure explained to them by the clinician. All adults are assumed to have capacity unless proved otherwise at the time decisions need to be made (Blaber, 2012). A diabetic suffering from a severe hypoglycaemic event may have a potential impairment therefore may lack capacity. In this case guidelines such as the Mental Capacity Act 2005 should be followed and the clinician should act in the best interest of the patient (Pilbery and Lethbridge, 2019). Professional standards set out by the Health and Care Professions Council (HCPC) is essential for paramedics to follow, they protect the public and outline what they should expect from healthcare providers. The standards include; working within your scope of practice, communication, respecting confidentiality reporting concerns, being honest, trustworthy and keeping records (HCPC, 2016).
To conclude this essay has been about the endocrine system and how patients with diabetic hypoglycaemia are assessed and treated.