Diabetes: The highs, lows, and "When Can They Go's"
Diabetic emergencies come in a variety of types and causes, but the tools available to EMS professionals allow excellent evaluation and initial treatment of the patient.
For most EMS professionals, the evaluation of emergency patients with diabetes is built around a protocol for "Patients with Mental Status Changes who are Known or Suspected Diabetic." A good history from the patient or knowledgeable bystanders, an assessment of the vital signs, and a physical evaluation that looks for all potential causes of altered mental status, are the first elements of managing patients with this problem.
The information then provided by testing a very small amount of blood will provide the approximate level of glucose in the patient's vascular system, and treatment can then be targeted to restore the patient's normal level of functioning. At the hospital, further testing may need to be done to establish the cause of the blood sugar abnormality, or whether there are other significant medical problems.
The process begins with the request by a patient or others who have noted the person acting abnormally. This can be family, friends, co-workers, teachers, police officers, or just a passerby. Beginning with the history and examination, the EMS professional can make a decision that the patient has a medical presentation consistent with an abnormal blood sugar.
In a known diabetic, the patient, family, or friends may describe the patient as having symptoms that are consistent with high or low blood sugar (usually when they have seen this patient act like this in the past). The medic will then make proper use of the blood glucose evaluation tool utilized by the EMS organization.
It is probably unnecessary for EMS to test for blood sugar if the patient has had a valid blood sugar test done with an appropriate glucose measuring device in the last 15 minutes. This may occur in a health care facility (nursing home, dialysis center, urgent care center, etc) or in the patient's home or worksite.
The blood glucose measuring device must be maintained as the critical and delicate piece of medical equipment that it is. Disposable portions of the blood sugar testing system must be maintained, and should be rotated to insure that they have not passed an expiration date. Most EMS systems specify an equipment-maintenance program that includes inspection and care to keep the monitor system clean, to regularly verify the accuracy of the monitor, and to maintain the monitor in working order. The process should be accomplished per the manufacturer's instructions, and should include an inspection of the condition and expiration date of the lancets and monitor strips.
With the blood sugar measuring device in functional status, EMS professionals caring for the patient will inform the patient and/or family member(s) that the medic will be testing a small amount of blood. It is appropriate for the medic performing the test to utilize Personal Protective Equipment (PPE), and if there is a concern that the patient will be difficult to control, then the whole crew will use PPE.
Whole blood is used for sugar testing. It can be obtained by lancing the fingertip of the patient, or by using a drop of blood when an intravenous line is started.
There are a variety of levels that are used to define low and high blood sugars, but for EMS professionals, simple levels should be established. Many emergency systems define elevated blood sugar as a value over 300 in persons without a known history of diabetes, or over 400 in the diabetic patient with an altered level of consciousness or other symptoms.
The patient with altered mental status and high blood sugar typically has treatment started by administering fluids and, in the EMS patient, establishing an intravenous line and administering a bolus (250cc or 500cc are common amounts) of normal saline. The patient has routine care provided and is transported to the emergency department in a position of comfort, maintaining an airway, and avoiding complications such as vomiting and aspiration. Document the assessment and treatment of the patient, the result of the blood glucose test, and the response of the patient to treatment.
The most common problem in diabetic patients with altered levels of consciousness is low blood sugar, typically defined as less then 60 to 80. If the sugar reading is low, the patient needs to have the protocol for low blood sugar followed, typically with the administration of oral glucose, intravenous dextrose, or glucagon. The choice of agent to increase the patient's blood sugar is based on a number of factors. Oral glucose is part of many EMS protocols when the patient is awake enough to cooperate, has an intact gag reflex that will protect the patient from aspirating the substance, and is not nauseated or vomiting.
Many patients do not fulfill this set of factors, particularly being awake enough to cooperate. In this case the patient protocol will call for the administration of sugar in the form of intravenous glucose. The medic must obtain excellent venous access to give intravenous dextrose. Note that dextrose solutions accidentally leaving the vein will cause severe skin loss. The administration of a 50% or 25% solution of sugar is given carefully, making sure there is no extravasation of the fluid outside the vein.
Most EMS systems use intramuscular or intranasal glucagon, if the crew is unable to establish vascular access. Glucagon is a medicine that counteracts the effects of insulin, and causes the patient to mobilize stores of glucose that are stored in the liver and other sites. Glucagon administration produces a much more gradual increase in blood glucose and, since the patient has already proven to have inadequate sugar to maintain consciousness, it will still be necessary to give the patient some sugar when they can tolerate it.
So, after glucagon is given and the patient awakens and is not nauseated, he or she will need to have oral fluid or food to provide a sustained source of calories and prevent recurrence of low blood sugar.
Most EMS systems have removed thiamine from the protocols for routine administration in the hypoglycemic patient. Thiamine 100mg by intravenous or intramuscular route is still used before glucose is given by some systems for suspected alcoholic patients who have low blood sugar, or in the presence of obvious malnutrition or chronic debilitating disease (e.g., cancer, or AIDS).
In a diabetic patient with an insulin pump and a glucose <60, disconnect the pump from the patient or have a knowledgeable family member "suspend" the device if he/she is familiar with its operation. If a patient does not awaken after administration of sugar, and the return of a blood sugar over 100 on repeat testing, consider other source for altered level of consciousness.
Diabetic emergencies: Refusal of transport
Many EMS organizations have developed policies that allow patients to refuse transportation. A conservative approach to patients treated for acute hypoglycemic reactions due to insulin would include these elements:
There are several patient types to exclude from a "treat and no transport" policy. In these situations, the underlying issue causing low blood sugar can't be adequately treated in a short time by EMS personnel, and blood glucose is likely to drop again without ongoing treatment. These groups include:
For some complicated diabetic patients, it may be appropriate to have the patient or family contact the patient's personal physician to get their advice. Many are happy to see the patient in their office if the patient does not want to go to the hospital. Local medical direction should be followed so that consistent approaches are in place for your group of providers.
Waking diabetics can be challenging, and all EMS professionals have memorable occasions related to the struggle to get patients treated and back to his/her baseline. A few of my memorable patients:
EMS professionals must be expert at dealing with patients who have high and low blood sugar, and be experts at managing the tools used for blood sugar measurement and treatment.
James J Augustine, M.D., is medical advisor for Washington Township Fire Department in the Dayton, Ohio, area. He is Director of Clinical Operations at EMP Management in Canton, Ohio, and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He formerly served as Assistant Fire Chief and Medical Director for Washington, DC Fire EMS. He has served 29 years as a firefighter, and was the first Chair of the Ohio EMS Board.
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