Diabetic Emergencies

Diabetes for the EMS Diabetes for the EMS ProviderProvider

Developed ByDeveloped By Kevin McGee, D.O., EMT-PKevin McGee, D.O., EMT-P

Emergency Medicine ResidentEmergency Medicine ResidentSUNY at BuffaloSUNY at Buffalo

DefinitionsDefinitions Diabetes:Diabetes:

– Derived from the Greek a word that literally means Derived from the Greek a word that literally means ""passing throughpassing through," or "siphon“. ," or "siphon“.

Diabetes Mellitus:Diabetes Mellitus:– Diabetes mellitus is a group of metabolic diseases Diabetes mellitus is a group of metabolic diseases

characterized by characterized by high blood sugar levelshigh blood sugar levels, which result , which result from from defects in insulin secretion, action, or bothdefects in insulin secretion, action, or both

Gestational Diabetes:Gestational Diabetes:– Increased Blood Sugar during Pregnancy. Increased Blood Sugar during Pregnancy.

Diabetes Insipidus:Diabetes Insipidus:– Diabetes insipidus is caused by the inability of the Diabetes insipidus is caused by the inability of the

kidneys to conserve water, which leads to frequent kidneys to conserve water, which leads to frequent urination and pronounced thirst.urination and pronounced thirst.

Glucose MetabolismGlucose Metabolism

GlucoseGlucose (Dextrose) (Dextrose) is the is the primary primary energyenergy source for source for the body.the body.

IngestedIngested or or convertedconverted from from dietary sourcesdietary sources

ProducedProduced in body in body by the liver.by the liver.– GluconeogenesisGluconeogenesis

Glucose TransportGlucose Transport

Due to its shape, Glucose cannot Due to its shape, Glucose cannot diffuse through cell walls without diffuse through cell walls without assistanceassistance

Cell walls are equipped with Cell walls are equipped with glucose glucose specific transport proteinsspecific transport proteins

These are located throughoutThese are located throughout all cells all cells of the bodyof the body

InsulinInsulin

Produced inProduced in PancreasPancreas by B-Cells by B-Cells of islets of of islets of langerhanlangerhan

Activates the Activates the Glucose transport Glucose transport proteins located in proteins located in 2/32/3 of the body’s of the body’s cellscells..– Skeletal Muscle and Skeletal Muscle and

Adipose tissue (Fat)Adipose tissue (Fat)

InsulinInsulin Stimulates Fat Stimulates Fat

Production and Production and Sugar storageSugar storage

Decreases Glucose Decreases Glucose ProductionProduction

Decreases Decreases Protein/Muscle Protein/Muscle break downbreak down

Diabetes MellitusDiabetes Mellitus

Type 1 DiabetesType 1 Diabetes– The body The body stops producing insulinstops producing insulin or or

produces too little insulin to regulate produces too little insulin to regulate blood glucose levelblood glucose level

Type 2 DiabetesType 2 Diabetes– The pancreas secretes insulin, but the The pancreas secretes insulin, but the

body is partially or completely body is partially or completely unable to unable to useuse the insulinthe insulin (Insulin Resistance) (Insulin Resistance)

Type 1 DiabetesType 1 Diabetes

Decreased Insulin ProductionDecreased Insulin Production Comprises Comprises 10%10% of all Diabetic Patients of all Diabetic Patients 15/100,000 population15/100,000 population Early onsetEarly onset

– Childhood/ AdolecenceChildhood/ Adolecence 1.5 times more likely to develop in 1.5 times more likely to develop in

American whitesAmerican whites than in American than in American blacks or Hispanics blacks or Hispanics


All patients are All patients are Insulin DependantInsulin Dependant Increased risk of Infections, Kidney Increased risk of Infections, Kidney

Disease, Ocular Disease, Nerve Disease, Ocular Disease, Nerve injury, HTN, CAD, CVAinjury, HTN, CAD, CVA

Type 2 DiabetesType 2 Diabetes Insulin resistanceInsulin resistance Comprises Comprises 90%90% of all of all

Diabetic PatientDiabetic Patient 6.2% population in 6.2% population in

20022002 Related to ObesistyRelated to Obesisty Affects Affects All AgesAll Ages

– Becoming more common Becoming more common among adolescentsamong adolescents

More prevalent among More prevalent among Hispanics, Native Hispanics, Native Americans, African Americans, African Americans, and AsiansAmericans, and Asians


Increased risk of infections, Kidney Increased risk of infections, Kidney Disease, Ocular Disease, Nerve Disease, Ocular Disease, Nerve injury, HTN, CAD, CVAinjury, HTN, CAD, CVA

Can Be Controlled with Can Be Controlled with Diet, Diet, Exercise, Weight LoseExercise, Weight Lose

Patients frequently take Patients frequently take Oral Oral Medications and/or InsulinMedications and/or Insulin..

Serum Glucose LevelsSerum Glucose Levels

– Normal: Normal: 100 mg/dL 100 mg/dL This fluctuates from 70-150 mg/dL This fluctuates from 70-150 mg/dL

– Pre-Diabetic Pre-Diabetic 100-125mg/dL Fasting Serum Glucose test100-125mg/dL Fasting Serum Glucose test

– Fasting indicates no oral intake for 6 hours prior Fasting indicates no oral intake for 6 hours prior to testto test

– Diabetic Diabetic >125mg/dL for Fasting Serum Glucose Test>125mg/dL for Fasting Serum Glucose Test

– Fasting indicates no oral intake for 6 hours prior Fasting indicates no oral intake for 6 hours prior to testto test

Diabetic EmergenciesDiabetic Emergencies

HyperglycemicHyperglycemic– HHNC: HHNC:

Hyperosmolar Hyperosmolar Hyperglycemic Hyperglycemic Nonketotic Coma Nonketotic Coma

– DKA: Diabetic DKA: Diabetic KetoacidosisKetoacidosis

HypoglycemicHypoglycemic– Diabetic Coma or Diabetic Coma or

Insulin ReactionInsulin Reaction

HHNC: Hyperosmolar HHNC: Hyperosmolar Hyperglycemic Nonketotic Hyperglycemic Nonketotic

ComaComa Effects Type 2 DiabeticsEffects Type 2 Diabetics Prominent later in lifeProminent later in life Elevated Blood Glucose lead to Elevated Blood Glucose lead to

increases serum osmolarityincreases serum osmolarity This results in Diuresis and Fluid Shift.This results in Diuresis and Fluid Shift. Increased Urination causes body wide Increased Urination causes body wide

depletion of Water and Electrolytes.depletion of Water and Electrolytes.– Extreme DehydrationExtreme Dehydration


ComaComa Physical Signs Physical Signs

– TachycardiaTachycardia– Orthostatic VitalsOrthostatic Vitals– Poor Skin TurgorPoor Skin Turgor– Drowsiness and Drowsiness and

lethargylethargy– DeliriumDelirium– ComaComa

SymptomsSymptoms– Nausea/vomitingNausea/vomiting– Abdominal painAbdominal pain– PolydipsiaPolydipsia– PolyuriaPolyuria


ComaComa TreatmentTreatment

– IV FLUIDS !!!!!IV FLUIDS !!!!! Bolus of Normal Saline will help to reverse Bolus of Normal Saline will help to reverse

the overwhelming dehydrationthe overwhelming dehydration EMS provides important early interventionEMS provides important early intervention

– Insulin?Insulin? Treatment of elevated glucose is Treatment of elevated glucose is NotNot Always Always

NecessaryNecessary

DKA: Diabetic KetoacidosisDKA: Diabetic Ketoacidosis

Dereased Insulin or Insulin resistance Dereased Insulin or Insulin resistance leads to leads to Elevated Blood GlucoseElevated Blood Glucose levels levels

However, Cellular Glucose is Low However, Cellular Glucose is Low without insulinwithout insulin– Equivalent to Equivalent to StarvationStarvation

As a result the body attempts to As a result the body attempts to CompensateCompensate– Uses Uses Glucose storesGlucose stores– Breaks Down FatBreaks Down Fat and and ProteinProtein


In an attempt to save the Heart and In an attempt to save the Heart and Brain, the body produces Brain, the body produces Ketone Ketone Bodies Bodies from fatty acidsfrom fatty acids– Acetoacetate, Beta-hydroxybutyrate, Acetoacetate, Beta-hydroxybutyrate,

And AcetoneAnd Acetone Excessive Ketones lead to Excessive Ketones lead to AcidosisAcidosis

– Beta-hydroxybutyrate is a carboxylic Beta-hydroxybutyrate is a carboxylic AcidAcid

DKA: Diabetic KetoacidosisDKA: Diabetic Ketoacidosis Physical SignsPhysical Signs

– Altered mental status Altered mental status without evidence of head without evidence of head traumatrauma

– TachycardiaTachycardia– Tachypnea or Tachypnea or

hyperventilation (Kussmaul hyperventilation (Kussmaul respirations)respirations)

– Normal or low blood Normal or low blood pressurepressure

– Increased capillary refill timeIncreased capillary refill time– Poor perfusionPoor perfusion– Lethargy and weaknessLethargy and weakness– FeverFever– Acetone odor of the breath Acetone odor of the breath

reflecting metabolic acidosisreflecting metabolic acidosis

SymptomsSymptoms– Often insidiousOften insidious– Fatigue and malaiseFatigue and malaise– Nausea/vomitingNausea/vomiting– Abdominal painAbdominal pain– PolydipsiaPolydipsia– PolyuriaPolyuria– PolyphagiaPolyphagia– Weight lossWeight loss– FeverFever


TreatmentTreatment– Fluids!!!!!Fluids!!!!!

It is important for EMS to initiate Fluid It is important for EMS to initiate Fluid Ressusitation prior to arrival in the HospitalRessusitation prior to arrival in the Hospital

Begin With Noramal SalineBegin With Noramal Saline

– InsulinInsulin This Will This Will Start in the Emergency Dept.Start in the Emergency Dept. Must Control Electrolyte Problems FirstMust Control Electrolyte Problems First

DKA vs. HHNCDKA vs. HHNC

No Difference in Treatment for EMSNo Difference in Treatment for EMS– Will Present as Will Present as Altered Mental StatusAltered Mental Status

ABC’sABC’s Supplemental OxygenSupplemental Oxygen IV FluidsIV Fluids Vitals / MonitorVitals / Monitor GlucometryGlucometry

HypoglycemiaHypoglycemia

Effects Type 1 & 2 DiabeticEffects Type 1 & 2 Diabetic Secondary to Insulin or Oral Secondary to Insulin or Oral

Hypoglycemic MedicationHypoglycemic Medication– More Common with Insulin UseMore Common with Insulin Use

Serum Glucose Levels Fall Serum Glucose Levels Fall Below Below Normal LevelsNormal Levels


Serum Glucose Levels Serum Glucose Levels – Normal: Normal:

100 mg/dL 100 mg/dL

– Hypoglycemia:Hypoglycemia: <50gmg/dL in men<50gmg/dL in men <45 mg/dL in women<45 mg/dL in women <40 mg/dL in infants and children<40 mg/dL in infants and children

– Protocol: <80 mg/dlProtocol: <80 mg/dl


Physical SignsPhysical Signs– SweatingSweating– TremulousnessTremulousness– TachycardiaTachycardia– Respitory Distress Respitory Distress – Abdominal PainAbdominal Pain– VomitingVomiting– Combative or Combative or

agitatedagitated – ComaComa

SymptomsSymptoms– Anxiety Anxiety – NervousnessNervousness– ConfusionConfusion– Personality changesPersonality changes– NauseaNausea


TreatmentTreatment– Patient’s will present with Patient’s will present with Altered Mental Altered Mental

StatusStatus– ABC’sABC’s– Supplemental OxygenSupplemental Oxygen– VitalsVitals– IV Fluids MonitorIV Fluids Monitor– GlucometryGlucometry

Glucose < 80 mg/dL, Considered Glucose < 80 mg/dL, Considered Hypoglycemia by ALS ProtocolHypoglycemia by ALS Protocol

HypoglycemiaHypoglycemia TreatmentTreatment

– Glucose SupplementationGlucose Supplementation Oral GlucoseOral Glucose

– Juice, Non- Diet Soda Juice, Non- Diet Soda – Oral Glucose SolutionOral Glucose Solution

D10D10– 250cc Bolus250cc Bolus

D50 D50 – 25 gram glucose in 50ml water, IV25 gram glucose in 50ml water, IV

– GlucagonGlucagon Naturally Occurring Hormone, From Pancreas Alpha-Naturally Occurring Hormone, From Pancreas Alpha-

CellsCells Breaks Down Stored Glycogen to GlucoseBreaks Down Stored Glycogen to Glucose 1U = 1mg Given IM/SC1U = 1mg Given IM/SC

– Pediatric 0.025 mg/kg IM/SC to max dose 1mgPediatric 0.025 mg/kg IM/SC to max dose 1mg

Is it Diabetes?Is it Diabetes?

Several Conditions Mimic Diabetic EmergenciesSeveral Conditions Mimic Diabetic Emergencies– Present with Present with Altered Mental StatusAltered Mental Status

Poisoning/ OverdosePoisoning/ Overdose– Some Chemicals and Medication Cause Some Chemicals and Medication Cause

HypoglycemiaHypoglycemia– Alcoholics frequently has Low Blood GlucoseAlcoholics frequently has Low Blood Glucose

Stroke/ CVAStroke/ CVA SeizuresSeizures

– Todd’s ParalysisTodd’s Paralysis HypoxiaHypoxia

Review of ProtocolReview of Protocol BLSBLS

– Altered Mental Status (M-2)Altered Mental Status (M-2) ABC’sABC’s Supplemental OxygenSupplemental Oxygen Vitals/ GCSVitals/ GCS If Known Diabetic on MediciationIf Known Diabetic on Mediciation

– ConsciousConscious and Able to Drink, and Able to Drink, No Head injuryNo Head injury Oral Glucose SupplementationOral Glucose Supplementation

– Blood GlucometryBlood Glucometry If < 80 mg/dl and Symptomatic, ALS protocols state If < 80 mg/dl and Symptomatic, ALS protocols state

totoTreat Patient for HypoglycemiaTreat Patient for Hypoglycemia

– Possible Stroke (M-17)Possible Stroke (M-17) Must Consider other Causes of Altered Mental/ Must Consider other Causes of Altered Mental/

Neurological StatusNeurological Status

Review of ProtocolReview of Protocol

ALS ProtocolsALS Protocols– Seizures Seizures – Altered Mental Altered Mental

Status Status – Possible StrokePossible Stroke– Overdose/ Toxic Overdose/ Toxic

ExposureExposure

All Consider All Consider Diabetic Diabetic Emergencies in Emergencies in DifferentialDifferential– If < 80 mg/dl, Treat If < 80 mg/dl, Treat

the Patientthe Patient 100mg Thiamine IV/ 100mg Thiamine IV/

IM (IM (Suspected Suspected Alcohol AbuseAlcohol Abuse))

D50 IVD50 IV Glucagon 1mg IM (Glucagon 1mg IM (If If

no IV no IV ))

Refusing Medical Aid (SC-5)Refusing Medical Aid (SC-5) Common with Diabetic PatientsCommon with Diabetic Patients

– Resolved HypoglycemiaResolved Hypoglycemia Patient Must Be:Patient Must Be:

– 18 yr or Older18 yr or Older– Emancipated/ Married MinorEmancipated/ Married Minor– Parent of MinorParent of Minor

No Limiting Medical/ Physical ConditionsNo Limiting Medical/ Physical Conditions– Psychiatric/ BehavioralPsychiatric/ Behavioral– Danger to Themselves/ OthersDanger to Themselves/ Others– Alcohol/ DrugsAlcohol/ Drugs– DementiaDementia– AbuseAbuse

GCS 15GCS 15

Refusing Medical Aid (SC-5)Refusing Medical Aid (SC-5)

Contact Medical ControlContact Medical Control– Questions For DiabeticsQuestions For Diabetics

Current or Recent IllnessCurrent or Recent Illness Oral Medication Vs. InsulinOral Medication Vs. Insulin

– Oral Meds More Difficult to ControlOral Meds More Difficult to Control

Medication Dose ChangesMedication Dose Changes Oral IntakeOral Intake Family / FriendsFamily / Friends GlucometryGlucometry

Refusing Medical Aid (SC-5)Refusing Medical Aid (SC-5)

If still Wishing to Refuse Treatment If still Wishing to Refuse Treatment or Transport:or Transport:– Inform of consequencesInform of consequences– Fill out PCRFill out PCR

Document Risk/ Consequences ExplainedDocument Risk/ Consequences Explained

– Document Medical Control Physician/ Document Medical Control Physician/ Law Enforcement involvedLaw Enforcement involved

– Patient / Guardian Signs RefusalPatient / Guardian Signs Refusal

Why Consider GlucometryWhy Consider Glucometry

Help with Early Differentiation of Help with Early Differentiation of Altered Mental StatusAltered Mental Status– HypoglycemiaHypoglycemia

Allows for Appropriate Early Allows for Appropriate Early TreatmentTreatment

Blood GlucometryBlood Glucometry

Measurement of Measurement of Blood Glucose levelsBlood Glucose levels– Hospital labs evaluate Hospital labs evaluate

Serum Glucose (Serum Glucose (10-10-

15% higher15% higher)) Requires a small Requires a small

sample of bloodsample of blood– No IV’s or PhlebotomyNo IV’s or Phlebotomy

Only seconds to Only seconds to obtain resultsobtain results

http://pennhealth.com/health_info/diabetes1/diabetes_step8.html

Blood GlucometryBlood Glucometry

Multiple TechnologiesMultiple Technologies– Colormetric, Amperometric, or Colormetric, Amperometric, or

CoulometricCoulometric Accuracy Accuracy

– Frequent Testing and CalibrationFrequent Testing and Calibration– Effected by Multiple FactorsEffected by Multiple Factors

Available to General PublicAvailable to General Public– Daily Monitoring for DiabeticsDaily Monitoring for Diabetics– EMSEMS

NYSDOHNYSDOH

PS 05-04PS 05-04– Available to Available to All BLS All BLS

EMS services EMS services ifif Approved by REMACApproved by REMAC Limited Laboratory Limited Laboratory

LicenseLicense Approved TrainingApproved Training

– Technique needs to Technique needs to be tailored to the be tailored to the specific glucometer specific glucometer usedused

Glucometry TechniqueGlucometry Technique

1. Wash hands with soap and warm water 1. Wash hands with soap and warm water and dry completely or clean the area with and dry completely or clean the area with alcohol and dry completely.alcohol and dry completely.

2. Prick the fingertip with a lancet.2. Prick the fingertip with a lancet. 3. Hold the hand down and hold the finger 3. Hold the hand down and hold the finger

until a small drop of blood appears; catch until a small drop of blood appears; catch the blood with the test strip.the blood with the test strip.

4. Follow the instructions for inserting the 4. Follow the instructions for inserting the test strip and using the SMBG meter.test strip and using the SMBG meter.

5. Record the test result. 5. Record the test result.

http://www.fda.gov/diabetes/glucose.html#6

What to Do with Results?What to Do with Results?

If < 80 mg/dl, Treat the PatientIf < 80 mg/dl, Treat the Patient– Glucose SupplementationGlucose Supplementation

Oral GlucoseOral Glucose– Juice, Non- Diet Soda Juice, Non- Diet Soda – Oral Glucose SolutionOral Glucose Solution

– 100mg Thiamine IV/ IM (100mg Thiamine IV/ IM (Suspected Suspected Alcohol AbuseAlcohol Abuse))

– D50 IVD50 IV– Glucagon 1mg IM (Glucagon 1mg IM (If no IV If no IV ))

SummarySummary

Diabetes Mellitus is a Common DiseaseDiabetes Mellitus is a Common Disease Controlled by Diet, Oral Medicine, or Controlled by Diet, Oral Medicine, or

InsulinInsulin Diabetic Emergencies Frequently Present Diabetic Emergencies Frequently Present

as as Altered Mental StatusAltered Mental Status Know Which Patients to Treat Know Which Patients to Treat

– Oral Vs. IV/IM treatmentOral Vs. IV/IM treatment Understand Patient RefusalsUnderstand Patient Refusals Appropriate use of GlucometryAppropriate use of Glucometry

Questions?Questions?

Documents

Diabetic Emergencies