EMS News in Focus
by Arthur Hsieh
06/01/2013

The sweet spot: Differentiating and managing the acute diabetic patient


Diabetes is a major disease in the United States; At least 18.8 million people are diagnosed with the disease, with another 7 million people who have not been diagnosed.[1] It is a major comorbidity factor for heart disease, stroke, high blood pressure, kidney disease and blindness.

Recent trends in diet, along with advancements in chronic diabetes management have been very promising in reducing the incidence of diabetes and its problems.[2] However, EMS providers will continue to see diabetic patients who are acutely ill as part of their practice.

How does diabetes occur?

The human body uses glucose as its main power source. Glucose is released from the normal breakdown of food as it passes through the digestive tract. The liver can also manufacture glucose as one of its many functions.

Glucose is a very large molecule, and does not pass through the cell membrane by itself. The pancreas makes a hormone known as insulin, which acts like a "key" that changes the permeability of the membrane in such a way as to allow glucose to enter the cell.

The body is constantly balancing the amount of glucose in the body to its demand through the continuous release of insulin. If this balance is disrupted, glucose levels will either rise or fall to levels that are unhealthy for the body. This is diabetes.

Forms of diabetes

There are several forms of diabetes. Type I occurs when the body is unable to manufacture insulin, and must depend upon external sources of the hormone to function. Type I diabetes comprise of 5 percent of the overall diabetes population.[3]

Type II diabetes is the most common form. While the pancreas' beta cells do secrete insulin, it is not enough to maintain an optimal balance.  Diet and various types of oral medications are used to bring the glucose-insulin ratio back in balance.[4] 

Gestational diabetes can occur during pregnancy. The female body changes quite a bit during pregnancy; one of them is a rising level of glucose in the bloodstream. Normally the body adjusts by also increasing the amount of insulin it makes; in some cases that does not occur, resulting in a diabetic condition. In most cases, this condition self resolves once the pregnancy is over and the body returns to its original state.[5]

Diabetic states

Patients and health care providers monitor the level of glucose in the bloodstream, using a glucometer and a small drop of blood from a finger prick. During a fasting test, the normal amount of blood glucose ranges from 70 to 100 milligrams per deciliter (mg/dcl).[6]

In day-to-day living the blood glucose levels rise and fall, but generally stay within this range. Blood glucose amounts in excess of 125 mg/dcl indicates hyperglycemia, while any amount below normal is called hypoglycemia.

Of the different diabetic conditions, there are three conditions that affect the care provided by EMS providers. One involves acute hypoglycemia; the other two represent hyperglycemic conditions.

Hypoglycemia

If blood glucose levels fall below normal, the body will react in several ways. Since the brain is particularly sensitive to glucose levels, it will be affected early. Restlessness, anxiety, and as levels continue to fall, confusion, altered level of consciousness, and unconsciousness will set in.

As hypoglycemia progresses, circulation is shunted away from the periphery, causing the skin to pale, cool and become diaphoretic. This is the same presentation as someone experiencing hypoperfusion, or shock; in fact serious cases of hypoglycemia are often called "insulin shock."

It is not unusual for hypoglycemic patients to present with stroke-like symptoms, such as hemiparesis, facial droop or slurred speech. It is essential that EMS providers check for glucose levels in any patient with altered mental status.

In mild cases of hypoglycemia, where the patient is cooperative and can follow commands, oral glucose is indicated. A highly concentrated form of glucose in gel form, a tube of oral glucose is given to the patient, who is instructed to self administer the entire amount. The patient should be encouraged to hold the gel in the mouth for as long as possible to allow rapid absorption of glucose by the oral mucosa.[7]

Management for severe insulin shock begins with preservation of airway patency, adequate ventilation and circulation. After testing for glucose levels, 25 grams of Dextrose 50% in water (D50W or simply "D50") is administered intravenously.

D50 has a significant osmotic pressure; in another words, it is quite caustic to the inside of the vein. It must be slowly administered, over several minutes, to minimize damage to the vein. Extrasavation (leakage into the surrounding tissues) of D50 will cause tissue necrosis or death. Because of this and other factors, several EMS systems have been using Dextrose 10% in water (D10) with favorable results.

An alternative to dextrose is the administration of glucagon. If glucose is not used by the body, it is stored in a variety of locations in the body as glycogen (glyconeogensis). This creates a reserve of sorts, which the body taps into when not enough food enters to the body to create glucose. The body secretes a hormone called glucagon that causes glycogen to be released back into the blood stream as glucose (glycogenolysis).  

EMS providers can inject a manufactured form of glucagon subcutaneously, intramuscularly or intravenously, usually 1 mg (1 unit).[8] If injected IM or SQ, it may take several minutes for results.

Be aware that patients with suspected malnutrition (i.e. elderly, alcoholics or drug abusers) may have low stores of glycogen and may not respond to glucagon injection. Very young patients will also have low or no levels of glycogen in their bodies.

It is not unusual for hypoglycemic patients to refuse further care or transport after regaining consciousness. The care that is provided is a temporizing measure only, and may only last for a brief period of time.  Carefully evaluate whether the patient is capable of continuing to eat after EMS leaves and whether the patient will follow up with their primary care provider to determine the underlying cause of the hypoglycemia.[9]

Hyperglycemia

At the other end of the spectrum, a high level of blood glucose causes the body to react differently. It is difficult to pump blood through the vascular system when it becomes thicker than normal; the kidneys attempts to filter the excess glucose as much as possible by creating more urine. This is a condition known as polyuria.

In order to "flush" out the large glucose molecules, the kidneys allow more water than normal to leave the body. The body senses this oncoming dehydration condition, and triggers a thirst signal. An excessive thirst is called polydipsia.

While the body struggles to remove glucose from the blood stream, the cells are paradoxically "starving" for glucose. Recall that the problem isn't enough glucose; it's the relative lack of insulin that is keeping glucose from entering the cells. The body will do what it normally does when it thinks there's not enough glucose to free itself – it triggers a hunger signal. This is also known as polyphasia.

Polyuria, polydipsia, and polyphasia are collectively known as the "Three Polly's." These signs manifest themselves slowly over a period of days, weeks, even months as the body struggles to maintain glucose levels. The patient may complain of gaining weight, general malaise and general flu-like symptoms as they become increasingly hyperglycemic.

In the absence of glucose, the body's metabolism will switch over to other materials to create energy. Free fatty acids are released from adipose tissue and are converted by the liver into ketone bodies acetoacetate and β-hydroxybutyrate. β-hydroxybutyrate can be used by the cells instead of glucose for energy production.

However ketone bodies make the blood stream very acidic, creating a condition called diabetic ketoacidosis or DKA. This interferes with other parts of the body, and body attempts to compensate the acidosis by releasing more carbon dioxide than normal along with the ketone bodies through the respiratory track. The patient's breathing pattern begins to shift, with longer exhalation phases than normal. These "sighing" breathing pattern is known as Kussmaul respirations.

In DKA blood glucose levels tend to rise above 300 mg/dcl. In rare situations glucose levels will rise far above that, often 600 mg/dcl or more. Simultaneously ketone bodies are not produced as just enough insulin exists to prevent it from happening. This super high level of glucose is known as hyperosmotic hyperglycemic nonketotic syndrome, or HHNS. This is a very dangerous condition.

The key to hyperglycemia is time – it takes a while for the condition to form, as opposed to hypoglycemia.  Carefully evaluate the longer-term history of the present illness; go back a few weeks or more to see if there have been any signs of the three poly's.

The patient may be confused, altered or unresponsive. Skin signs may be flush, warm and dry; the patient may have a fever. A faint fruity or acetone-like odor may be detected. Look for signs of Kussmaul respirations. If the patient is dehydrated, tachycardia and borderline or low blood pressure may be present.

Ensure airway, breathing and circulation. Establish an IV, using a larger angiocatheter. EMS providers may need to administer large volumes of crystalloid solution such as normal saline quickly to dilute the blood and restore perfusion pressure. One to two liters of fluid may be administered.

At this time there are no prehospital direct treatment for hyperglycemia; hospital management will include emergency insulin infusion, and correction of any electrolyte and acid-base balance.[10]

Summary

Prompt, accurate assessment of the acute diabetic patient by the EMS provider will direct the actions need to reverse or stabilize the condition. Establishing the history of the present illness, combine with bedside glucose testing will provide the necessary information for correct treatment.

References

[1] American Diabetes Association. Diabetes statistics: Data from the 2011 National Diabetes Fact Sheet. http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Retrieved 10 May 2013.

[2] Wood D. Trends in diabetes care and prevention. Nursezone.com. http://www.nursezone.com/nursing-news-events/more-news/Trends-in-Diabetes-Care-and-Prevention_38390.aspx. Retrieved 24 May 2013.

[3] National Diabetes Information Clearinghouse (NDIC). Your guide to diabetes: Type 2 and Type 2. http://diabetes.niddk.nih.gov/dm/pubs/type1and2/index.aspx. Retrieved 24 May 2013.

[4] Ibid.

[5] Kühl C, Hornnes PJ, Andersen O. Etiology and pathophysiology of gestational diabetes mellitus. Diabetes. 1985 Jun;34 Suppl 2:66-70.

[6] National Institutes of Health. Glucose test – blood. http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm. Retrieved 10 May 2013.

[7] Kurosaki Y, Yano K, Kimura T. Perfusion cells for studying regional variation in oral mucosal permeability in humans. 2. A specialized transport mechanism in D-glucose absorption exists in dorsum of tongue. J Pharm Sci. 1998 May;87(5):613-5.

[8] Drugs.com. Glucagon dosage. http://www.drugs.com/dosage/glucagon.html. Retrieved 19 May 2013.

[9] Carter AJE, Keane PS, Dreyer JF. Transport Refusal by Hypoglycemic Patients after On-scene Intravenous Dextrose. Acad Emerg Med. 2002 August;9(8): 855-7.

[10] Raghaven VA et al. Diabetic Ketoacidosis Treatment & Management. http://emedicine.medscape.com/article/118361-treatment. Retrieved 17 May 2013.

Art Hsieh, MA, NRP teaches in Northern California at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. An EMS provider since 1982, Art has served as a line medic, supervisor and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. Art is a textbook writer, author of "EMT Exam for Dummies," has presented at conferences nationwide and continues to provide direct patient care regularly. Art is a member of the EMS1 Editorial Advisory Board. Contact Art at Art.Hsieh@ems1.com and connect with him on Facebook or Twitter.

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