Diabetes mellitus is the most common endocrine disorder. Insulin production is limited or absent, and blood sugar is elevated as a result. The body’s ability to metabolize simple carbohydrates is also impaired. Complications of diabetes mellitus include neurological damage, vascular damage, blindness, limb amputation, kidney failure, heart disease and stroke. It’s important prehospital providers quickly treat health issues caused by diabetes in order to prevent permanent damage or death.
According to the American Diabetes Association, diabetes causes more deaths each year than breast cancer and AIDS combined–it’s the seventh leading cause of death in the United States. In 2010, 1.9 million new cases of diabetes were diagnosed in people 20 years of age and above. In 2011, the prevalence of diabetes in the U.S. was 8.3% of the population and an additional 7.0 million people were thought to have undiagnosed diabetes.
The Centers for Disease Control notes that diabetes is underreported as a cause of death, and studies have found that 35—40% of decendents with diabetes had the condition listed on their death certificates, but only 10—15% had it listed as the underlying cause of death. Overall, the risk of death from diabetes is about twice that of people of similar age without diabetes.
Anatomy & Physiology
The pancreas is a digestive gland that sits near the liver in the right upper abdominal quadrant. It secretes digestive enzymes into the duodenum through the pancreatic duct. Cell groups called the Islets of Langerhans secrete hormones–mainly glucagon and insulin.
When the pancreas secretes insulin, it circulates in the bloodstream and enables sugar to enter the cells, thus lowering the amount of sugar in the bloodstream. As blood sugar drops, so does the secretion of insulin.
Glucagon (a starch form of glucose) is secreted when blood sugar levels are reduced; it stimulates the liver to change glycogen into sugar and secrete it into the bloodstream. The glucose can come from food or the liver, the latter of which makes and stores glucose by metabolizing stored glycogen into glucose when insulin levels are low. Glucagon can also be administered as a medication in the prehospital setting to have the opposite effect of insulin.
Insulin is the hormone that removes glucose from the blood for storage as glycogen, fats and protein. When blood sugar levels are elevated, the Islets of Langerhans secrete insulin. The cells then take in more glucose for use in energy production. Insulin is the only hormone that decreases blood glucose levels, and it’s essential for glucose to enter the cells.
Patients may control their diabetes with oral hypoglycemics taken in the form of pills, or by self-administration of insulin injections. Some patients will have insulin pumps–small medical devices about the size of a pager–that deliver prescribed amounts of insulin subcutaneously at certain times. EMS personnel should familiarize themselves with insulin pumps and their characteristics.
There’s no cure for diabetes. The disorder is generally formally diagnosed when a marker called glycated hemoglobin (Hemoglobin A1C) becomes elevated above normal levels of 4—7. Levels of 5.7—6.4 indicate a condition called prediabetes and treatment with oral hypoglycemic agents often begins with a reading of 6 or higher.
Prediabetes arises when blood glucose or Hemoglobin A1C levels are higher than normal, but not high enough for the diagnosis of diabetes. Patients with prediabetes have increased risk of developing diabetes. Weight loss and increase in physical activity can prevent or delay the diagnosis of Type 2 diabetes, and in some cases, blood glucose levels may drop into the normal range.
Types of Diabetes
Type 1 diabetes, formerly called “juvenile onset” diabetes, has genetic predisposition, although it’s believed environmental factors are also part of the cause. In Type 1 diabetics, the immune system destroys the insulin-producing cells in the pancreas. Most of these patients produce no insulin and require insulin injections to control blood sugar.
Type 2 diabetes, formerly called “adult onset” diabetes, is far more common. It may be related to metabolic syndrome when excessive abdominal fat, hypertension and hyperlipidemia occur. Many Type 2 diabetics have a condition called insulin resistance, where the body produces sufficient insulin but is unable to use it effectively. Both genetic susceptibility and environmental factors play a role in causing Type 2 diabetes, although being overweight is strongly linked to
Gestational diabetes is found for the first time when a woman is pregnant. Seven out of every 100 pregnant women in the U.S. get gestational diabetes.
During pregnancy, the placenta produces hormones that may increase insulin resistance. The pancreas normally responds by producing extra insulin to overcome the resistance; when it can’t, gestational diabetes can result.
Uncontrolled gestational diabetes can lead to hypertension. It may also result in a large baby (macrosomia) and a difficult delivery, or even fetal death. Women who have had gestational diabetes have a 35—60% chance of developing diabetes in the next 10—20 years.
Symptoms & Risk Factors
Symptoms of diabetes include altered mental status, fatigue, nausea, polydipsia (thirst), polyuria (frequent urination) and polyphagia (hunger). Unexplained weight loss, blurred vision, frequent infections and confusion can also be symptoms of diabetes. Diabetes may present for the first time in previously diagnosed adults or children who have an altered mental status.
Risk factors for diabetes include being an overweight adult over the age of 40 and a lack of physical activity.
For Type 1 diabetes, family history of the disease plays a role. It’s more common in Caucasians than other races, and environmental factors, such as exposure to a viral illness, may also play a role. A number of dietary factors have also been linked to an increased risk, such as early exposure to cow’s milk or cereals before 4 months of age.
For Type 2 diabetes, body weight is a significant factor because the more fatty tissue a person has, the more likely they are to develop insulin resistance. A body mass index >25 is a risk factor. Inactivity further increases risk, as activity keeps weight down, uses up glucose for energy and makes cells more sensitive to insulin. Family history and race increases risk as well: Blacks, Hispanics, Native Americans and Asians are at higher risk. Hypertension, high triglyceride levels, low HDL cholesterol levels and polycystic ovary syndrome in women are also risk factors.
Across all races and ages, depression is associated with a 60% increased risk of developing Type 2 diabetes.
Risk factors for gestational diabetes include being older than 25; having a first-degree relative with diabetes; hypertension; low HDL levels; high triglyceride levels; being of African American, Native American, Asian, Latino or Pacific Islander race; being overweight or previous episodes of gestational diabetes.
The risk of complications from diabetes increases the longer a person has diabetes, and rises dramatically when blood sugar isn’t controlled, particularly over a period of time.
Neuropathy. The presence of excess glucose in the bloodstream can damage capillaries, particularly in the legs. The result may be neuropathy, which may be experienced by the patient as tingling, numbness, burning or pain. Untreated diabetic neuropathy can result in loss of sensation. Damage to nerves related to digestion can result in nausea, vomiting, constipation or diarrhea, and for men, neuropathy can result in erectile dysfunction. Damage to the nerves in the feet is common and can result in inability to recover from cuts or blisters, as well as frequent infections. About 60—70% of patients with diabetes have mild to severe neuropathies.
Amputation. More than 60% of non-traumatic lower-limb amputations occur in diabetic patients. In 2006, about 65,700 amputations of this type were performed.
Nephropathy. Diabetes can damage the delicate glomeruli that filter waste from blood in the kidneys. Severe damage can lead to kidney failure, resulting in the need for dialysis or kidney transplant. Diabetes is the leading cause of kidney failure; in 2008 a total of 202,290 people were living on dialysis or with a kidney transplant as a result of diabetes.
Retinopathy. If the blood vessels in the retina are damaged, blindness can result. Diabetes is the leading cause of new cases of blindness among adults ages 20—74.
Skin/mouth conditions. Elevated blood glucose levels are linked with bacterial and fungal infections.
Heart disease and stroke. Adults with diabetes have heart disease and stroke rates two to four times higher than adults without diabetes.
Periodontal disease. Young adults with diabetes have about twice the risk of periodontal disease as those without diabetes. Adults age 45 or older with poorly controlled diabetes (A1C >9%) were almost three times more likely to have severe periodontitis than those without diabetes. The likelihood is almost five times higher in diabetics who smoke.
Pregnancy complications. Poorly controlled diabetes in the first trimester is associated with major birth defects in 5—10% of pregnancies, and spontaneous abortions in 15—20% of pregnancies. Women with gestational diabetes can experience macrosomia (excess growth) of the fetus that can result in difficult deliveries or the need for cesarean delivery. Early deliveries of babies from mothers with gestational diabetes are also linked with respiratory distress syndrome and jaundice.
Compromised immune system. Diabetics are susceptible to many illnesses and often have worse prognoses. For example, they’re more likely to die from pneumonia or influenza than non-diabetics.
Decreased mobility. Diabetics over the age of 60 are two to three times more likely to report an inability to walk a quarter mile, climb stairs or do housework.
Depression. Patients with diabetes are twice as likely to suffer depression, which can complicate the management of the disease.
Preeclampsia. Mothers with gestational diabetes may also develop preeclampsia–a syndrome involving high blood pressure, excess protein in the urine and edema. It can progress rapidly into eclampsia, which presents with seizures.
Diabetic patients should be counseled to wear a bracelet identifying their condition so EMS providers can quickly assess a diabetic emergency. Rapid identification of the emergency is needed to expedite treatment that’s necessary to prevent brain damage in hypoglycemic patients.
Checking blood glucose level is a quick, standard way to determine if your patient has diabetes-related problems. Photo A.J. Heightman
Diabetic emergencies account for 3—4% of EMS calls. EMS is likely to encounter two types of diabetic emergencies: hypoglycemia and diabetic ketoacidosis, with hypoglycemia being the most common. Both are potentially life-threatening, and EMS can play a large role in reducing morbidity and mortality. Protocols for handling diabetic emergencies should designate a plan for care.
Assessment begins with the 9-1-1 call. Dispatchers should ask questions about whether the patient is diabetic, if they’re insulin dependent, and what their level of consciousness is to provide a path to appropriate pre-arrival instructions. These instructions should be part of EMS dispatch protocols and should be developed and regularly reviewed by the EMS service’s medical director.
Patients may have an altered mental status, so scene safety is important since patients can behave in an unpredictable or aggressive manner. Patients may complain of a constellation of symptoms, including nausea, dizziness or light-headedness, or even abdominal pain. History taking is crucial, although patients with altered mental status may be unable to give a reliable history. The medications a patient is on may provide vital clues to their condition, as will questions about when and what they have eaten, onset of symptoms, vital signs and blood glucose measurement. Glucometer readings have been found to be both safe and accurate in the prehospital setting, providing that the glucose strips have been properly stored.
EMS protocols should outline appropriate treatment guidelines. They should include administration of glucose and glucagon when IV access cannot be obtained. Protocols for treatment and release of hypoglycemic patients should be clear and concise. Any “no-loads” of diabetic patients should be reviewed by the medical director.
The central nervous system relies entirely on glucose as its energy source. If glucose levels fall, the brain is affected and a change in mental status occurs. Hypoglycemia is defined as a serum glucose level below 70 mg/dL. Normal blood glucose is between 70—110 mg/dL. Hypoglycemia is the most common endocrine emergency. In the insulin-dependent diabetic population, hypoglycemia can result if too much insulin is taken, or if the patient eats too little. Sometimes both occur. Studies estimate 30% of diabetics experience serious hypoglycemic episodes annually.
Signs of hypoglycemia include altered mental status, confusion, diaphoresis, shaking, tachycardia and a feeling of extreme hunger. Epinephrine is secreted as the body enters into “fight or flight” mode as a result of the brain receiving inadequate glucose.
If glucose continues to be unavailable, a change in the patient’s mental status results. Patients become confused, experience headache, and then progress into semiconsciousness and unconsciousness, progressing rapidly to brain damage. Seizures may also occur. Hypoglycemia can present as alcohol intoxication, and patients could become combative and aggressive, with slurred speech and lack
Hypoglycemia can also occur in the non-diabetic patient. It’s important to consider hypoglycemia as the cause of unconsciousness in all patients, as it can present in alcoholics, cancer patients, liver disease, kidney disease and other conditions.
Hypoglycemia is a medical emergency that must be treated immediately. An initial blood glucose reading may confirm suspicion of hypoglycemia.
If the patient is alert and has a gag reflex–a good rule of thumb is if the patient can hold a glass of juice or a candy bar on their own–glucose can be administered orally. It’s important never to administer any oral glucose, soda or candy to a patient who is obtunded, as this can cause aspiration of the glucose and create a serious medical emergency.
If the patient is unconscious or has an altered mental status, IV administration of glucose (D50) through a large bore catheter is the treatment of choice. Although airway management is always important, hold off on the use of airway adjuncts until it can be determined that administration of glucose hasn’t rapidly resulted in a return to a normal level of consciousness. Onset of action is rapid; usually two to five minutes. It’s important to administer glucose slowly through an intact IV line as severe tissue damage can result from extravasation. The usual dosage of D50 is 25 grams; another dose of 25 grams can follow. The administration of 50 mL of 50% dextrose raises blood glucose by an average of 166 mg/dL but the response varies widely.
Glucagon is an alternative or adjunct to the administration of glucose in some EMS services when an IV line cannot be established. Recovery time is significantly longer because it’s administered intramuscularly. Patients will respond in anywhere from 8—21 minutes. Glucagon can also be used subcutaneously.
Patients may refuse transport to the hospital after their blood sugar level normalizes and they regain a normal level of consciousness; follow your service protocols to determine whether the patient has decisional capacity and whether you can discontinue the IV line and allow refusal of transport. The patient allowed to refuse transport should have a history of insulin-dependent diabetes, a pretreatment blood glucose of less than 80 mg/dL, a return of a normal mental state within 10 minutes of glucose administration, the ability to eat and normal vital signs after treatment. They shouldn’t have a condition, such as persistent vomiting, that could precipitate another episode of hypoglycemia.
With a patient who refuses transport, it’s always best to ensure a responsible adult stays with them to help if another hypoglycemic episode occurs. One study noted that diabetic calls accounted for 9% of non-transports. Studies examining the safety of allowing patients to refuse care have shown that the patients who refuse are no more likely than those transported to experience recurring hypoglycemia or to require later care. Patients should always be advised to follow up with their physician; these instructions should be given in writing. It’s always best to contact medical control in a patient who has undergone a hypoglycemic episode and is now refusing treatment.
Hyperglycemia & Diabetic Ketoacidosis
Hyperglycemia is defined as blood glucose levels greater than 200 mg/dL. Although elevated blood glucose is not a medical emergency in and of itself, elevated BGl in the setting of ketoacidosis is. The mortality rate ranges from 9—14%. Hyperglycemia is a serious complication of diabetes that’s generally seen in patients who are insulin dependent. Diabetic patients should keep their glucose levels below 160 mg/dL. Hyperglycemia can result from eating too much food or simple sugar, insufficient insulin dosages, infection, illness, surgery and emotional stress.
Without intervention, hyperglycemia can progress into diabetic ketoacidosis (DKA). This is a life-threatening condition in which the body produces acids, called ketones, as a result of breaking down fat for energy. The body may also break down protein. DKA can be precipitated by metabolic stressors such as infection, injury and illness. Any of these may disrupt the patient’s normal insulin routine.
Symptoms can develop within 24 hours. Classic symptoms of hyperglycemia include the three Ps: polydipsia, polyuria and polyphagia. Symptoms may also include nausea, vomiting, abdominal pain, fatigue and confusion. Ketones have a smell much like Juicy Fruit gum and can often be detected by EMS personnel on the patient’s breath. The unconscious patient in DKA may demonstrate “Kussmaul’s respirations” (deep, rapid respirations) as the body attempts to blow off excess carbon dioxide to compensate for the metabolic acidosis.
Patients in DKA undergo osmotic diuresis. They pass large amounts of urine because of the high solute concentration of the blood and the body’s attempts to get rid of excess sugar. Patients can test their urine with over-the-counter urine test kits to see if they’re producing ketones. Untreated DKA can be fatal.
The most important prehospital treatment is a good assessment, recognition of the problem and transport to the hospital without delay. Patients in DKA are often severely dehydrated and prehospital fluid resuscitation may be appropriate. DKA is treated in the hospital with the administration of fluids and electrolytes such as sodium, potassium and chloride, as well as insulin. Since insulin isn’t administered by prehospital EMS personnel, rapid transport to a facility is critical. Be alert for vomiting, monitor cardiac rhythm, start an IV line and infuse normal saline at the rate indicated by protocol.
Hyperglycemic Hyperosmolar Syndrome
Patients with hyperglycemia may also exhibit a non-ketotic hyperosmolar state. This is a serious diabetic emergency that carries a mortality rate between 10—50%. Hyperosmolarity is a condition in which the blood has a high sodium and glucose concentration, causing water to move out of the cells into the bloodstream. It creates a cycle of increasing blood glucose levels and dehydration. When this occurs without ketones, it’s called hyperosmolar nonketotic syndrome, and can lead to unconsciousness. It’s unlikely EMS personnel will be able to differentiate DKA from non-ketotic hyperosmolar state in the prehospital setting. Patients present with extreme dehydration, tachycardia and hypotension, as well as extremely high blood glucose levels. The goal of prehospital treatment is to correct the dehydration. As with DKA, this is a life-threatening condition that cannot be corrected in the prehospital setting; patients should be moved rapidly to the ED.
Diabetes in Pediatrics
The prevalence of diabetes in the pediatric population is one in 400—600 children and adolescents. Prehospital providers must be alert to the possibility of an initial presentation of diabetes in pediatric patients who have dehydration, weight loss, polydipsia and polyuria. Any pediatric patient who is seizing, has altered mental status, or has volume depletion secondary to illness such as gastroenteritis, should have blood glucose measured.
Administration of glucose in hypoglycemic pediatric patients is as essential as it is for adults. Dextrose given to infants and children should be diluted from 50% to 25%. Hyperglycemia in pediatric patients is treated with fluid resuscitation and rapid transport to a hospital facility.
Intentional insulin overdoses have been reported. Frequent episodes of hypoglycemia in a patient should arouse suspicion of overdose, either intentional or unintentional. Treatment should be the same for these patients; however, the ED should be alerted if a patient has recurrent episodes of hypoglycemia.
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