Level With Me, Sugar!

     You and your EMT partner are dispatched on an altered mental status call. The dispatcher informs you that police are on the scene of a male experiencing violent behavior.

     Upon arrival, you find a morbidly obese man in his mid-30s, who is running through his house throwing anything he can find, putting holes in walls and breaking windows. One of the police officers tells you, "We think he's on something!" The patient's wife informs you that the patient is an unstable diabetic.

     Diabetic emergencies are commonly encountered in the prehospital setting, and signs and symptoms may manifest themselves in different ways. Recognizing those signs and symptoms, what causes them, what tools BLS providers have at their disposal and when to involve ALS are all crucial and may have a significant effect on the outcome of even the most "routine" diabetic emergency.

What Is Diabetes?
     Diabetes mellitus is a disorder of the endocrine system, which is brought about by a decrease in the production of insulin—a hormone that is produced in the pancreas—and/or the inability of body cells to use insulin in the proper way, which is to combine with glucose (sugars that the body converts from the food a person consumes) and enter the cells to give the body the energy it needs to function. An average human's blood glucose level is between 80 and 100 milligrams per deciliter (mg/dl). Seven percent of the population in the United States is diabetic.¹

     If the body cells use glucose too quickly, it requires an increase in insulin production, which the diabetic body may not be able to compensate for. The decreased glucose level in the bloodstream is known as hypoglycemia. This can be caused by an increase in insulin intake by the patient; overexertion, which makes the body metabolize glucose faster than normal; and/or a reduction in food intake. Reduced glucose in the bloodstream leads to altered levels of consciousness, and, if left untreated, can lead to a loss of consciousness, damage to vital organs and even death, as cells are literally starved of glucose. Hypoglycemia is usually the most commonly encountered diabetic emergency; however, if glucose is administered quickly, the patient commonly recovers relatively soon. Signs and symptoms of hypoglycemia are usually of sudden onset and may include altered mentation, perfuse sweating and abnormal behavior.

     Conversely, without insulin, the body cells cannot use glucose, and it remains in increasing levels in the bloodstream. This is known as hyperglycemia. Typically, things like stress, changes in dietary intake, infections and noncompliance with insulin intake may lead to hyperglycemia. Unlike hypoglycemia, signs and symptoms associated with hyperglycemia often have a more gradual onset, and the patient will have increased hunger, thirst and increased urinary output. These patients may have the classic "fruity breath" sign as well.

     Commonly, diabetics fall into two categories: Type I and Type II. Type I, also known as insulin-dependent diabetes, is based on limited or no ability of the body to produce glucose. This has also been known as "juvenile diabetes," as it commonly begins in children. Type I diabetics must receive some dose of supplemental insulin on a daily basis.

     Type II is more commonly known as adult-onset diabetes. The body is able to produce insulin but at decreased levels, and/or the body cannot properly metabolize insulin. This is most commonly seen in obese individuals, but is also seen in the elderly and in obese children. Many Type II diabetics can manage their diabetes very effectively through special diet, oral medications or both. However, these are often the most unstable diabetics, due to noncompliance with medications or dietary restrictions, or both.

Treating Diabetic Emergencies
     Many of the signs and symptoms associated with diabetic emergencies mirror those related to other medical emergencies, so it is important to be as specific as possible, ruling out as much as you "rule in" about the patient's condition and what treatments may be required.

     It is very important for EMTs to make their own safety and that of their crew a top priority, especially in cases of diabetic patients with an altered mental status who are exhibiting violent behaviors, as in the earlier example. It is also important to know the local, regional and state treatment protocols for diabetic emergencies. Many of the treatment options described in this article may or may not be applicable to your EMS system.

     After ensuring scene safety, do a focused assessment using the ABCs, provide oxygen as needed, and provide assistance in maintaining the patient's airway, if it is unstable. Be sure to make note of the patient's current mental status, continuing to assess and document it at regular intervals, as it may change quickly, either positively or negatively. Also be sure to note skin temperature and feel (clammy or dry).

     Perform a thorough examination of the patient and his surroundings, especially if you are called to his residence. You may find a glucometer that diabetics use to measure their blood glucose levels; lancets that patients use to prick their skin to draw blood to be tested and/or test strips for the glucometer. Typically, this is done on one side of a finger, but glucometer manufacturers have recently released "alternate site" or "painless" glucometers that obtain blood from areas of the body (upper arms, thighs, base of the thumb, stomach and forearms) with fewer nerve endings than the fingers and result in less pain.² The diabetic patient may also have a medical identification bracelet, and may have insulin or other similar medication stored in the refrigerator. Be sure to gather as thorough a medical history as you can from the patient and any others on scene, especially family. They may be able to give you vital information, such as last meal, last administration of insulin or other medications and the dosages, and if the patient has had any other recent illnesses, additional stress or unusual exercise or physical exertion.

     Keep in mind that what is considered a "normal" blood glucose level in an adult may not be normal for your patient. Many diabetics know what their normal blood glucose level range is. Be sure to document this information.

     One of the first steps in treating the diabetic patient is ensuring that ALS or a higher level of care is en route to your location, or you and the patient are en route to a hospital. While BLS providers may do a lot for diabetic patients, higher levels of EMS or hospital care may be more effective, especially if the patient is found unconscious or loses consciousness during treatment and transport.

     If your system allows, do a blood glucose check as soon as possible, either by assisting the patient to check his own blood glucose level with his glucometer, or by using one from your EMS vehicle. A glucometer carried on an EMS vehicle should be calibrated per manufacturer guidelines, but the patient's glucometer may not be calibrated and may give a false reading. You should refrain from using a patient's glucometer, especially if you are unfamiliar with how it works, as there are many different types. Remember to "treat the patient, not the device." Don't let the blood glucose reading be your only focus when treating the patient.

     Prior to using a glucometer, you should be wearing gloves and have all necessary equipment ready, including the lancet with which the blood will be obtained. Turn the glucometer on and insert a test strip to prepare for the blood sample.

     Cleanse one of the patient's fingers with an alcohol prep and allow it to air dry, then pierce the side of the finger with the lancet. When a drop of blood shows, place the test strip on the blood to activate the glucometer. Wipe the site with a gauze pad and cover it with a Band-Aid, if needed.

     When finished, document the blood glucose level and the time it was read. If the reading is abnormally high or low, continue to monitor the patient's airway, mental status and vital signs, and transport to definitive care immediately.

     If your system allows, and the patient is alert and oriented with a patent airway, administer oral glucose. Do not, under any circumstances, administer oral glucose to any patient with an altered mental status or inability to swallow.

     Oral glucose, commonly known by trade names like Glutose or Insta-Glucose³, is typically a mixture of dextrose and water and comes in a gel form in a tube similar to cake icing.⁴ It is also manufactured as tablets, but they are not as quickly absorbed into the bloodstream as the gel. There are no acute hazards or side effects to oral glucose, aside from those stated above.⁵

     To administer oral glucose, break the seal on the tube and let the patient squeeze it into his mouth and swallow, or assist him in doing so. Be sure to document the medication given, the time it was given, the dose as noted on the tube, the route of administration and any effects, positive or negative. Check the patient's vital signs frequently and transport to definitive care without delaying to administer oral glucose.

     The author gratefully acknowledges the assistance of Jodi Kuhn and Gregory Neiman from the Virginia Office of EMS.

References

1. www.diabetes.org/about-diabetes.jsp.

2. www.americandiabetes.com/AlternateSite.htm.

3. www.paddocklabs.com/glutose.html.

4. valeantcanada.com/html/insta-glucose.html.

5. www.paddocklabs.com/forms/msds/Glutose%20Lemon%20and%20Grape%20MSDS.pdf.

Timothy J. Perkins, BS, EMT-P, is the EMS systems planner for the Virginia Department of Health's Office of EMS. E-mail him at tjperkins5@yahoo.com.