This is a presentation given at the 2020 Grangeville EMTA Spring Fling

1. 6Tips and
Tricks
For Diabetic
Emergencies

2. Disclosures – This
lecture is NOT
sponsored by….

3. Objectives
• Discuss general approaches to assessing the patient with an altered
mental status
• Help to understand the causes, aid in assessment, and care of
diabetes and various diabetic emergencies in the adult and pediatric
patient
• Identify symptoms commonly associated with hypo/hyperglycemia
• Explain the management of hyperglycemia
• Explain the management of hypoglycemia

4. What is the Pancreas?
• The pancreas is a dual purpose gland organ in the
digestive system and endocrine system of
vertebrates.
• It is both an endocrine gland producing several
important hormones, including insulin, glucagon,
somatostatin, and pancreatic polypeptide, and a
digestive organ, secreting pancreatic juice
containing digestive enzymes that assist the
absorption of nutrients and the digestion in the
small intestine.
• These enzymes help to further break down the
carbohydrates, proteins, and lipids in the chyme.

6. The Role of Glucose and Insulin
• Glucose is a major source of energy for the body.
• Insulin is needed to allow glucose to enter cells (except for brain
cells).
• A “cellular key”
• When glucose is unavailable INSIDE THE CELL, the body turns to
other energy sources.
• Fat is most abundant.
• Using fat for energy results in buildup of ketones and fatty acids in blood and
tissue.

7. Put another way…
With Insulin
Using glucose to makes 36 ATP
ByProduct: Metabolic Heat CO2, H2O
Without Insulin
Burning Fat to Produce ATP
Byproduct: Acids, Keatones, low metabolic heat

8. KEY POINT
• The central problem in diabetes is
lack, or ineffective action, or
resistance to, of insulin.
• Hypoglycemia, the most common
diabetic emergency seen in EMS, is
simply the result of over-correction
of this problem, the result of loss of
balance in the endocrine system,
but is not the key problem with
diabetes.

9. Why is the brain so susceptible to low blood
sugar?
• The brain must have glucose for
metabolism.
• The brain cannot synthesize
glucose itself
• The brain cannot store glucose
• Therefore it is dependent on
glucose levels in the blood at all
times.

10. Diabetes Mellitus
• Different Types
• Type 1
• Non production of insulin by pancreas
• Typically manifests in young patients, but not always
• Can be caused by trauma/disease to the pancreas in
an adult
• Type 2
• Type 2 patients produce inadequate amounts of
insulin, or normal amount that does not function
effectively.
• Usually appears later in life
• Treatment may be diet, exercise, oral medications, or
insulin.

11. Key Points:
• Type 1 and type 2 diabetes both:
• Are equally serious
• Affect many tissues and functions
• Require life-long management.
• About 25% of new onset Diabetes (Type I) are discovered due to a
DKA type event.
• Type 2 Diabetes, by contrast is typically discovered during health
screenings or other routine medical evaluations.
• This DOES NOT IMPLY that Type 2 is less severe than Type 1.
• Both can be fatal if untreated/unrecognized.

12. KEY POINT
• The term “Insulin Dependent” and
“non-Insulin Dependent” are no longer
accurate definitions of Type I and Type
II Diabetes.
• Type I diabetics are now being
occasionally prescribed anti-
hyperglycemics as well as insulin; and
Type 2 diabetics are (occasionally)
being prescribed insulin in addition to
their oral meds.

13. Secondary
• Pre-existing or external condition affects pancreas and its function
• Pancreatitis
• Trauma
• Shock States
• Cystic Fibrosis
Gestational
• Occurs during pregnancy
• Typically resolved during pregnancy
• After the baby is born, blood glucose levels usually return to normal. A
woman who has had gestational diabetes is at risk for developing type 2
diabetes later in life.
• Not Pregnant?
• Occurs rarely in non-pregnant women on BCPs
• Increased estrogen, progesterone from BCPs antagonize endogenous insulin
• Not to be confused with pre-existing diabetes in a patient who gets pregnant

14. Diabetes Insipidus
• Not related to other forms of Diabetes
• Hormone problem with Anti-diuretic hormone and Vasopressin, NOT
insulin
• No problem with insulin or blood glucose
• Problem with extreme during production and dehydration
• Can mimic hyperglycemia, but without the hyperglycemia.
• Two types:
• Cerebral : Cranial diabetes insipidus
• Renal: Nephrogenic diabetes insipidus

15. Diabetic Emergencies Potential Causes:
Hypoglycemia (low blood sugar)
• Diabetic takes too much insulin
• Diabetic does not eat
• Diabetic over exercises or
overexerts
• Diabetic vomits
Hyperglycemia (high blood sugar)
• Decrease in insulin
• May be due to body’s inability to
produce insulin
• May exist because insulin
injections not given in sufficient
quantity
• Infection
• Stress
• Increasing dietary intake

16. Hypoglycemia Presentation
• Generally a rapid onset
• May present with abnormal behavior mimicking drunken stupor or
other altered mental status
• Pale, sweaty skin
• Tachycardia
• Potential seizures
• BG < 60 mg/dl with symptoms
• Newborn/Neonate BG < 40 mg/dl with symptoms

17. What is Relative Hypoglycemia?
• Well documented since 1954
• “RELATIVE hypoglycemia is a clinical syndrome in which patients develop
symptoms referable to any system of the body as the result of a relative
drop in blood sugar level…”
• - 1966 “Relative Hypoglycemia as a Cause of Neuropsychiatric Illness” Salzer MD
• First believed to be in response to a high carbohydrate food intake and
drinks containing caffeine.
• Now understood to be the result of ANY drop below “fasting” glucose
levels in the body by 20%, but BG still may be above 60 mg/dl.
• Dieting
• Medication effect
• Change in activity
• Absolutely occurs in the non-diabetic

18. Whipples Triad:
Hypoglycemia
• Whipples Triad:
• the presence of symptoms
consistent with hypoglycemia
• a low serum glucose level
• resolution of the symptoms and
signs of hypoglycemia with the
administration of glucose
• The real lesson here is that if it
does not respond to Dextrose,
look for other causes and
complicating factors.

19. Stages of Hypoglycemia
“Mild”: Adrenergic
(BG<60) (<4mmol)
Shockey Appearance without hypotension -
“Insulin Shock”
Tremors , Tachycardia - “Adrenalin Dump”
Head Ache
“Moderate”: Cognitive
(BG<40-50 ) (<3mmol)
Altered LOC
Anxiety
Confusion
Can mimic a stroke
“Severe”: Neurologic Unconscious
(BG ???)
Unconsciousness
Seizures
Hypothermia

20. Hyperglycemia
Presentation
• Develops slowly over days or weeks
• Chronic thirst and hunger from
dehydration caused by increased
urination (Can lead to shock)
• Nausea
• Excessive waste products released into
system
• Profoundly altered mental status
• Increased chance of developing bacterial
infections

21. Hyperglycemic Emergencies: DKA vs HHNC
Diabetic Keato Acidosis
• Aka dka
• Predominantly Type 1
• Kussmal Respirations and
Keatones
• Mortality 5-15%
• BG > 250 mg/dl
• Typically 400-800 mg/dl
Hyperglycemic Hyperosmolar
Non-Ketonic Coma
• AKA HHS: Hyperglycemic,
Hyperosmolar Syndrome
• No Kussmal Respirations, No
Keatones
• Predominantly Type 2
• Mortality 40-60%
• Typically 800-1400 mg/dl

22. DKA/HHNC
prehospital treatment
• Transfer to ICU capable facility if
possible
• Air medical Transport?
• Airway management
• EKG monitoring if available
• IV Access and fluid resuscitation
• Limited to 1-2 liters prior to
labs

23. New Onset Diabetes?
• Typically hyperglycemic emergencies
• Classic symptoms of uncontrolled
diabetes (“3 Ps”):
• Polyuria: frequent, plentiful
urination
• New onset bedwetting
• Polydipsia: frequent drinking to
satisfy continuous thirst
• Polyphagia: excessive eating
• Often mistaken for the flu
• This is why we check a BG on 90% of
IV starts….

24. Treatment

25. 1 Diabetics are Altered
Mental Status Patients
FIRST
Systematic approaches for every patient,
every time.
“ “

26. A-E-I-O-U-T-I-P-S
• A good memory aid to remind to to always look for
other causes.
• Always be wary when someone tells you the patient is
“just drunk”., “Just a diabetic” or “Just a Psych”

27. Do a Stroke Assessment
• Strokes are time sensitive
emergencies
• Hypoglycemia is a time sensitive
urgency
• Do one during initial assessment
(if possible) and one after
resuscitation.

28. 2 Confirm the Blood
Glucose
Trust, but Verify
- Ronald Reagan
Repeating an old Russian Proverb
“
“

29. Every altered patient should
have a BG done.

30. What if the patient has no known
history of Diabetes?
• New Onset diabetes
• Hepatic issues
• Medication Interactions
• Chronic alcohol abuse
• Sepsis
• Accidental or
intentional Insulin
Overdose

32. Blood Glucose Readings
• Blood glucose measurement
• Less than 60 mg/dL and
symptomatic: hypoglycemia par
ACCESS Protocol
• Over 250 mg/dL and symptomatic:
hyperglycemia per ACCESS
protocol
• Over 250 mg/dL for prolonged
time: dehydration, altered LOC or
shock
• Severe Hyperglycemia
• DKA/HHS/HHNC
• Special glucometer readings
• May display word instead of
number
• “HI”: indicates extremely high
level, greater than 600 mg/dL
• “LOW”: indicates extremely
low level, less than 10 mg/dl

33. mmol/L vs. mg/dl
• What is an MMOL?
• It is a unit of measurement commonly
used in chemistry based on the molecular
weight of the substance it pertains to.
• To convert mmol/l of glucose to mg/dl,
multiply by 18. To convert mg/dl of glucose
to mmol/l, divide by 18 or multiply by
0.055.

34. 2 GET A HISTORY
LOOK OR CAUSES
A good assessment can tell you what
is going wrong, a good history will tell
you why…
“ “

35. Things to ask
• A.M.P.L.E.
• Are they Diabetic?
• Type of Diabetes?
• What do they do to manage their
diabetes?
• Who do they see for their diabetes?
• Recent changes to:
• Medications
• Diet
• Activity
• Illness
• Schedule
• Meal History
Photo Credit : Brant Ward:
https://www.sfgate.com/health/article/Nevius-S-F-paramedic-says-homeless-people-3234137.php

36. Are they Brittle? Are they well controlled
• Ask their spouse
• Check their BG meter history
• Look for highs and lows
• Look at averages
• Look at frequency
• What is their A1C
• 3 month average in %
• Normal : <6
• Severe: >9

37. Benefit Of Frequent Testing
Breakfast
100 (5.6)
200 (11)
400 (22)
300 (17)
DinnerLunch Bed
1 test versus 7 tests a day

38. Do our patient’s test their BG
often?
In a Kaiser study of actual prescription fulfillment among 44,181
patients with diabetes:
60% of Type 1s were not testing 3-4 times a day as recommended by the ADA
67% of Type 2s were not testing once a day as recommended by the ADA
Diabetes Care 23:477-483, 2000

39. Check for Sepsis
• Check a temp!
• Examination
• Examine wounds
• Assess for UTI
• Burning or Difficult urination?
• Strong smelling urine
• Blood in Urine
• Assess for respiratory infection
• Productive Cough?
• Fever, Chills
• Listen to lung sounds
• Questions:
• S – Shiver, fever, or very cold
• E – Examine wounds
• P – new PAIN, Unusually Pale?
• S – Sleepy, difficult to rouse, confused
• I – “I feel ill”
• S – New Short of breath?

40. 3 Just enough Sugar
An amp of D50 provides five times the
amount of glucose in a normal adult’s
blood.
Dr. Paul Rostykus
“ “

41. Hypoglycemia: Eating
is OK!
• If the patient can hold a cup or plate
without assistance, and can swallow
on command, encourage the patient
to consume simple and complex
carbohydrates or oral glucose.
• Attempt to document volume of
food/liquid ingested.
• If grams of sugar are known,
document this as well

42. Hypoglycemia: Oral Glucose
• Second option to raise a patients BG.
• After absorption from GI tract, glucose is distributed in the
tissues and provides a prompt increase in circulating blood
sugar.
• Ascertain the patient's ability to swallow an oral preparation
of glucose without airway compromise Must be swallowed,
not absorbed sublingually, or buccally.
• Oral glucose tastes bad to many people. You may have better
results having them drink a Soda, Juice or other sugary food
instead.

43. D10% is superior to D50
• Discard 50 ml from a 250 ml IV bag
and replace with the full 50 ml of
D50.
• 25 GM/250 cc
• 1 GM/10CC
• Not as necrotic if it infiltrates
• Studies found:
• Less total glucose administered
• Less combativeness
• Similar times to wakefulness

44. Food for thought
• 25 GMS of D50% is FIVE TIMES what is
needed for an “normal adult” patient
• Pediatric Dose of 0.5-1 G/KG is 6-11 times
what is needed for a “normal child’s glucose
needs
• Post treatment HYPERGLYCEMIA can cause
problems too…

45. So what is the dose?
• Enough to return to
wakefulness
• Some agencies put a
minimum
• ACP 12.5 GM
dextrose for
adult

46. Glucagon/ GlucaGen
Pancreatic Hormone
Increases blood glucose by stimulating
glycogenolysis Inhibits conversion of
glucose to glycogen Stimulates
gluconeogenesis (metabolism of glucose
in the liver)
Glucagon is our last resort if IV access is
unavailable and patient is unable to take
oral glucose.

47. 4 Check a temperature on
all hypoglycemics
Hypothermia in diabetic patients is well
described, particularly in association with
hypoglycemic episodes and diabetic
ketoacidosis.
Applebaum & Kim, 2002
“ “

48. Hypoglycemia and
Hypothermia
• Occurs in about 25-50% of cases
• Insulin
• Sulfonylureas
• Beta-Blockers
• Neuropathies
• Environmental
• Conduction – cold surface/floor
• Radiation – Wind, A/C
• Evaporation – Sweating
• Decreased heat production due to hypoglycemia

49. Mild hypothermia may be an
early warning symptom of
impending hypoglycemia…

50. How Quick?
• Case #1: Nursing home worker (cook) found unconscious, unresponsive on
floor inside kitchen
• Known down time approx. 30 minutes
• BG “LO”
• Did not respond to 25 GM D10, F/U BG 190 mg/dl
• Temp: 87 degrees rectal
• Case #2: Hotel Janitor noticed “Acting strangely” wandering around hotel.
Known diabetic.
• Found on concrete floor in work room
• Missing approx. 45 minutes
• BG: “LO”
• Did not respond to 25 GM D10
• F/U BG 152 mg/dl
• Rectal Temp < 80 degrees F

51. Get them
warm!!!
• Hypothermia and
hypoglycemia go
hand in hand.
• Can easily get to
SEVERE hypothermia
(<86 degrees F) even
when indoors.
• Get them Dry, Warm,
and fed.

52. 5 Look for the pump
Almost 400,000 diabetics use insulin pumps to
manage their diabetes in the US.

53. Who is on a pump?
• Almost 400,000 patients in the US alone
• Predominantly well managed Type I
diabetics
• Also
• Some Type II
• Some gestational diabetics
• Price approximately 5000 before
insurance

55. Integrated Pumps

56. Most modern pumps are “integrated” to either a glucometer or a
“CGM”

57. Management
• 1st – CONFIRM HYPOGLYCEMIA
• 2nd – DO NOT PUSH BUTTONS
• 3rd – Disconnect the PUMP from
the patient
• Do not cut the line
• Do not discard the line,
instead keep it clean and
safe.
• 4th – LEAVE CGM in place

58. Don’t lose the CGM!!! ($250 +)

59. Key points
• CGMs can be 5-10 mg/dl off
• If the patient does not calibrate daily, it can be 30 mg/dl off
• 15-minute delay/lag from actual BG

60. Alternative sites for CGM

62. DIY Insulin Pumps

63. The future: Actual Artificial Pancreas

64. 6 Treat and Release with
caution and care
Around 95 percent of hypoglycemic events
occur outside of medical settings, requiring
assistance by family members, other
caregivers or EMS personnel

65. Keep in mind…
• The goal of a “treat and release” protocol isn’t to clear up resources,
it is to find the most appropriate deposition for the patient in a safe
way.
• Criterial should be based on the patient’s best interest and Safety
• Must be followed with a good assessment
• Sepsis
• Stroke
• Cardiac
• Respiratory Issues

67. Questions?