Quick and Dirty Guide to Diabetic Emergencies

MedicTests.com Quick and Dirty to Diabetic Emergencies

Diabetes Mellitus

Diabetes Mellitus is a systemic disease of the endocrine system resulting from the insufficiency/dysfunction of the pancreas. It is a complex disorder of fat, carbohydrates, and protein metabolism. Diabetes mellitus is potentially lethal, putting the patient at risk for several types of medical emergencies. It is characterized by a lack of insulin, or a persons inability to use insulin. In order to properly manage the numerous calls for diabetics, it is important for EMS professionals to have a basic knowledge of diabetes (DM) before dealing with the associated emergencies that may arise as a result of the disease. Diabetes is the seventh leading cause of  death in the US, as well as, it is estimated that 5 + million US citizens become diabetic annually and don't realize they have the disease until an emergency arises. To truly understand the signs and symptoms of the various related conditions, we must first, comprehend some basic pathophysiology.
The primary energy fuel for cells is glucose. Glucose is a simple sugar that accounts for approximately 95 percent of the sugar in the bloodstream after gastrointestinal absorption. Thus, it is the blood glucose level that EMS and other health care practitioners are most interested in determining.

Glucose absorption

The key function of insulin (A hormone secreted by the beta cells in the pancreas) is to move glucose from the blood into the cells, where it can be used for energy. However, insulin does not directly carry glucose into the cell, it triggers a receptor on the plasma membrane to open a channel allowing a protein helper (through the process of facilitated diffusion), to carry the glucose molecule into the cell. As long as any insulin is available in the blood, is active, is effective, and is able to stimulate the receptor; it will continue to move glucose into cells, even if the blood glucose level falls below the normal range. When this occurs, a large amount of glucose exits the blood, leaving an inadequate supply for the brain cells. If the pancreas is functioning normally, insulin secretion will decrease as the blood glucose level drops.

The bodies use of insulin

Type I Insulin Dependent Diabetes Mellitus (IDDM)

You guessed it, IDDM Type I is characterized by the bodies inadequate insulin production by the pancreas. This type of diabetic presentation is somewhat rare, afflicting 1 in every 10 diabetic patients. It normally begins in the teens and young adult years but, can occur anytime after the patient is born. The disease is a autoimmune phenomenon resulting from genetic abnormalities that cause the body to destroy its own insulin producing beta cells. Patients with IDDM require life long insulin treatments, special diet , and exercise in order to lead a normal, healthy life.
The symptoms of Type I IDDM will usually appear suddenly without warning and includes:

  • Polyuria (Urinating often)
  • Polydipsia (Drinking a lot of fluids)
  • Dizziness
  • Blurred vision
  • Rapid, unexplained weight loss

Type I Diabetes

Type II Non-Insulin Dependent Diabetes Mellitus (NIDDM)

Type II non-insulin dependent diabetes is characterized by a decrease in the bodies natural production of insulin by the beta cells within the pancreas and/or diminished tissue sensitivity to insulin. NIDDM type II  diabetes usually afflicts adults over the age of 40 and/or those patients that are overweight. Obese patients are predisposed to type II diabetes because a larger amount of insulin is routinely needed for metabolic control in obese patients compared to those who are not overweight.
Most patients with type II diabetes, requires a daily intake of oral hypoglycemic medications, exercise and dietary regulations to control their blood sugar levels. A small percentage of these patients will require daily insulin injections. The onset of symptoms is usually gradual with type II diabetes and includes the following signs and symptoms:

  • Polyuria (Urinating often)
  • Polydipsia (Drinking a lot of fluids)
  • Dizziness
  • Blurred vision
  • Rapid, unexplained weight loss
  • Fatigue
  • Loss of appetite
  • Numbness/tingling in extremities
  • Pain (especially lower legs)

Type II


Adverse Effects of Diabetes Mellitus

Most adverse effects of Diabetes can be associated with one of the following effects of decreased insulin levels:

  1. Decreased use of insulin by the cells of the body, with a marked increase in the patients blood glucose levels.
  2. Excessive increased mobilization of fats from the fat storage areas, causing abnormal fat metabolism. In the short term this may cause ketoacidosis and in the long run; atherosclerosis.
  3. Protein depletion and severe muscle wasting.

Diabetic Emergencies

MedicTests.com Quick and Dirty Guide to Diabetic Emergencies

There are 3 life threatening conditions that may afflict a diabetic at anytime. The EMS professional must be prepared to manage them at any given time:

  • Hypoglycemia (low blood sugar)-Insulin shock
  • Hyperglycemia (High blood sugar)-Diabetic Ketoacidosis
  • Hyperosmolar hyperglycemic nonketotic (HHNK) coma

Hypoglycemia/Insulin Shock

Hypoglycemia is a syndrome of diabetes relating to blood glucose levels below 80 mg/dl but, symptoms usually won't begin until the 60 mg/dl range unless the fall  occurs rapidly. Hypoglycemia can occur in non-diabetic patients that have a low food intake, excessive exertion, drug and alcohol ingestion, or pregnancy. In diabetic patients, hypoglycemia reactions are usually caused by:

  • Too much Insulin
  • Decreased dietary intake
  • Vigorous physical activity
  • Certain antibiotics

Less common causes and factors include:

  • Chronic alcoholism
  • Adrenal gland dysfunction
  • Liver disease
  • Malnutrition
  • Pancreatic tumors
  • Cancer
  • Hypothermia
  • Sepsis
  • Beta blocker administration

Signs & Symptoms of Hypoglycemia

The signs and symptoms of hypoglycemia usually appear quickly and are related to the release of epinephrine as the body tries to compensate for the drop in blood glucose levels. In the beginning stages the patient may complain of severe hunger. The following signs and symptoms are normally associated with the decreased availability of glucose to the brain:

  • Nervousness/trembling
  • Irritability
  • Combative/psychotic behavior
  • Weakness/uncoordinated movements
  • Confusion
  • Appearance of intoxication
  • Weak, rapid pulse
  • Cold, clammy skin
  • Drowsiness
  • Seizures
  • Coma in severe cases

Also hypoglycemia should be suspected in any diabetic patients with acute behavioral changes, abnormal neurological signs or unconsciousness with no apparent reason. Hypoglycemia is a true medical emergency and must be aggressively treated with glucose to prevent permanent brain damage or death.

Hyperglycemia/Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA) results from an absence or resistance to use the available insulin. The low insulin level prevents glucose from entering the bodies cells therefore accumulating in the bloodstream. When this occurs the cells become "starved" for glucose and begin to use other sources of energy, mainly from the fat stores in the body. This metabolism causes fatty acids and glycerol; glycerol provides some energy for the starved cells. The fatty acids  are further metabolized to form ketoacids, resulting in acidosis.
Acidosis increases the loss of potassium from the cells of the body into the bloodstream resulting in high potassium concentration in the urine, and a total loss of body potassium levels. In addition the sodium concentrations outside the cells decrease and are replaced by increased amounts of hydrogen ions, greatly adding to the acidosis. As blood sugar levels rise, the patient undergoes a massive osmotic diuresis. This coupled with vomiting causes dehydration and profound shock. The associated electrolyte imbalances may cause cardiac dysrhythmias and altered neuromuscular activity, including seizures.

Signs and symptoms of DKA are usually related to diuresis and acidosis. The onset of symptoms are normally slow in onset (> 12-48 hours) and Include:

  • Diuresis
  • Warm dry skin
  • Dry mucous membranes
  • Tachycardia (thready pulse)
  • Postural hypotension
  • Weight loss
  • Polyuria
  • Polydipsia
  • Acidosis
  • Abdominal pain
  • N/V
  • Acetone Breath odor
  • Kussmaul respiration's in an attempt to reduce carbon dioxide levels
  • ALOC

DKA patients are seldom deeply comatose. Patients that are truly unresponsive should be assessed for the possibility of other causes such as, head injury and stroke.

Hyperosmolar Hyperglycemic Nonketotic Coma

HHNK is a true medical emergency, it usually occurs in older patients with type II or non-diagnosed diabetes. The syndrome is easily mistaken for diabetic ketoacidosis. But, HHNK differs from DKA in that their may be enough insulin present to prevent fat metabolism and the development of ketocacidosis as seen with DKA. However the amount of insulin may not be enough to prevent  glucose use by the peripheral tissues or reduce glycogenesis by the liver.
HHNK develops from sustained hyperglycemia that produces a hyperosmolar state. This is followed by an osmotic diuresis that results in marked dehydration and electrolyte losses. These patients often have an excessively high blood sugar level, up to 1000 mg/dl. This is considerably higher than DKA, simply because patients with HHNK are more dehydrated and have less ketone formation. HHNK tends to develop slowly, often over the course of several days and has a higher mortality rate than other diabetic conditions.
The early signs and symptoms  of HHNK include:

  • Volume depletion including polydipsia and polyuria
  • Orthostatic hypotension
  • Dry mucous membranes
  • Tachycardia
  • Lethargy
  • Confusion
  • Coma

Precipitating factors of HHNK coma may include:

  • Advanced age
  • Pre-existing heart disease
  • Renal disease
  • Inadequate insulin secretion (Type II)
  • Increased insulin requirements (stress, AMI, infection, trauma)
  • Certain medication (Thiazide, Thiazide diuretics, glucocoticoids, phenytoin, sympathomimetics, propranolol, immunosuppressants)

Diabetic Assessments

MedicTests.com Quick and Dirty Guide to Diabetic Emergencies

A patient experiencing a diabetic emergency may have a wide range of signs and symptoms; many of which mimic other more common conditions. But, EMS professionals must have a high degree of suspicion for diabetes related illnesses. In addition, to  a proper patient assessment, treatment of life threatening conditions, the EMT must search for signs such as medical alert tags, information, syringes, and diabetic medications (hint: Insulin is usually found in the fridge).
Important components of the patient assessment of diabetic patients include:

  • Onset of symptoms
  • Recent food intake
  • Insulin/oral hypoglycemic medication use
  • Alcohol or drug consumption

Managing a Conscious Diabetic

If the patient is conscious and able to talk, a pertinent history should be obtained while assessing the patients airway, breathing, and circulation. If appropriate the patient should be given glucose. Protocol may include drawing blood before the administration of glucose. Most EMS agencies use field glucose testing with a portable glucometer. Any patient regardless of history with a blood glucose reading below 80 mg/dl with signs and symptoms of hypoglycemia should receive oral glucose, promptly. Known diabetics may refuse transport after the administration of glucose and their levels return to normal. Contact medical command for guidance.
The methods of glucose administration vary from region to region. If the patient is conscious and alert, has a gag reflex and is able to swallow properly, sugar may be administered orally. It may given in the form of a candy bar, orange juice with sugar, sublingual or buccal administration of glucose gel. An alternate method is to slowly administer 50% Dextrose through a stable vein. If D50 is administered, it is advised to transport the patient for evaluation.

Managing an Unconscious Diabetic

The pre-hospital management of an unconscious patient is clear; properly manage the airway and providing ventilatory and circulatory support. Depending on local protocol, the initiation of an IV of lactated Ringers solution or saline to replenish electrolytes and fluid. The flow rate should depend on the patients BP and heart rate. Before glucose is administered, a blood sample should be drawn for the hospital lab.
If alcoholism or other drug abuse is suspected then medical command may recommend the administration of thiamine, naloxone, or both before the administration of glucose.
If IV access is unobtainable, subcutaneous or intramuscular injection of glucagon, may help raise serum glucose levels by stimulating the breakdown of liver glucagon. Glucagon is not effective on alcoholics and those with liver disease.
Determining the cause of a diabetic emergency is sometimes difficult in the pre-hospital setting. When the EMS professional isn't sure of the cause, all patients should receive glucose, if confirmed by field glucose testing.
The difference in the signs and symptoms of the different diabetic emergencies should help determine the cause.

Findings

Hypoglycemia

Hyperglycemia

HHNK Coma

History
Food Intake
Insulin Dosage
Onset
Infection
Insufficient
Excessive
Rapid
Uncommon
Excessive
Insufficient
Gradual
Common
Excessive
Insufficient
Gradual
Common
Gastrointestinal Tract
Thirst
Hunger
Vomiting
Absent
Intense
Uncommon
Intense
Absent
Common
Intense
Intense
Uncommon
Respiratory System
Breathing
Breath Odor
Normal or Rapid
Normal
Deep or Rapid
Acetone smell
Shallow/Rapid
Normal
Cardiovascular System
Blood Pressure
Pulse
Skin
Normal
Normal, rapid, or full
Cool, Pale or moist
Low
Rapid or weak
Warm and/or dry
Low
Rapid or weak
warm and/or dry
Nervous System
Headache
Consciousness
Present
Irritability
Seizure or coma
Absent
Restless
Coma (rare)
Irritable
Seizure or coma

 

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