You're responding to an unconscious person. On arrival, you find the patient in the driver's seat of a parked car, slumped over the wheel. He is breathing and opening his eyes. He responds to touch, and his speech is slurred. His heart rate is elevated, and his skin is diaphoretic. You notice an emergency bracelet identifying the patient as a diabetic, and you see a partially opened candy bar on the seat next to him.
After ruling out trauma and removing the patient from the vehicle, a blood glucose test reveals a low blood glucose level (BGL) of 50 mg/dL. Protocol calls for the administration of oral glucose for the diabetic patient presenting with hypoglycemia who can protect their airway. After the administration of 15g of oral glucose, the patient becomes more coherent. He tells you he took his insulin and had to work late. He knew his sugar was low and grabbed a candy bar from the vending machine on the way to his car, but didn't eat it in time. Your partner looks at you and asks if a rapid onset is common with diabetes.
Diabetes is a disease that alters the body's ability to manage blood glucose. The American Diabetes Association reports there are an estimated 23.6 million diabetics in the U.S. The prevalence of diabetes has increased 13.5% from 2005 2007, making it the 7th leading cause of death in the U.S.
Insulin is produced by the beta cells of the Islets of Langerhans in the pancreas. Insulin functions as a key, which opens the gate, allowing the large glucose molecule into the cell. With the exception of the brain, all cells require insulin for glucose to enter. As a person's blood glucose increases, the pancreas secretes insulin. As the BGL decreases, the alpha cells of the islets of Langerhans secrete glucagon, which facilitates the release of glycogen from the liver.
The patient above had Type 1 diabetes, also referred to as insulin-dependent diabetes mellitus. With this form of diabetes, the beta cells of the pancreas have stopped producing insulin. The body may have plenty of glucose, but without insulin, the cells can't use the glucose. These patients must take insulin daily according to their BGL.
After injecting insulin, they must make sure they eat at specific intervals to avoid a rapid drop in blood glucose. Patients who miss a meal or increase their physical activity are at risk for hypoglycemia, as seen in the patient above. Hypoglycemia can occur quickly. As soon as the brain runs out of glucose, it shuts off. Patients will have an altered level of consciousness, ranging from a slowed response to unconsciousness. A normal BGL is 60 120 mg/dL. As soon as a patient's BGL drops below 60 mg/dL, signs of hypoglycemia can present. These signs include hunger, diaphoresis, tachycardia, altered mental status and coma.
What to Look For
The administration of glucose can quickly feed the brain, resulting in an instant increase in consciousness. If the patient can control and protect their airway, glucose paste can be administered orally. If the patient is unconscious or has lost the ability to protect their airway, IV dextrose or IM glucagon may be administered. Many diabetics will have an emergency glucagon kit. Family members may administer the glucagon injection prior to the arrival of EMS. If not, the EMT should follow protocol and administer the patient's glucagon as allowed.
If a diabetic eats but fails to take their insulin, their BGL will slowly increase, causing hyperglycemia. Signs and symptoms of hyperglycemia are slower to present. The patient remains conscious because the brain does not require insulin to use glucose. The other cells in the body, however, are starving for glucose. The patient has the sensation they're hungry, so they eat frequently (polyphagia). This causes the glucose level in the blood to increase. The excess glucose is filtered by the kidneys and spills into the urine, increasing the frequency of urination (polyurea). The increased urination results in dehydration, causing excessive thirst (polydipsia).
The body tissues are starving for glucose and show signs of weakness. The body eventually breaks down fats for energy. This is an ineffective method of energy production and the byproduct is an acid known as ketones. The patient slowly develops a metabolic acidosis called diabetic ketoacidosis (DKA) and becomes unconscious. In an effort to regulate the acid buildup, the patient's respiratory rate increases in rate and depth (kussmal). These patients must be transported for rehydration and BGL regulation.
Diabetes is a common medical condition. The EMT must recognize the signs and symptoms associated with hypoglycemia and hyperglycemia. Hypoglycemic patients must receive glucose as soon as possible to avoid brain damage. Hyperglycemic patients with DKA must be rehydrated and have their BGL lowered in a controlled hospital setting to avoid tissue damage from the high concentration of glucose.
The EMT should also remember diabetes is a risk factor in many other disease processes, such as myocardial infarction and stroke. This often makes the diabetic patient difficult to assess and treat. Conduct a thorough assessment and history and maintain a high level of suspicion.
Click herefor more information on diabetes from the Centers for Disease Control and Prevention.