Diabetic Emergencies in the Field
Diabetic emergencies are among the most common medical calls EMTs respond to. The NREMT expects you to differentiate between hypoglycemia and hyperglycemia, understand the pathophysiology behind each, and choose appropriate field interventions.
Hypoglycemia (Low Blood Sugar)
Hypoglycemia occurs when blood glucose drops below 70 mg/dL. It is the more immediately dangerous of the two diabetic emergencies because brain cells depend on glucose for fuel and can be damaged within minutes of severe hypoglycemia.
Common causes: Missed meals, excessive insulin or oral diabetes medication, unusual physical exertion, alcohol consumption
Signs and symptoms: Altered mental status, confusion, combativeness, diaphoresis, tremors, seizures, rapid onset. The patient may appear intoxicated.
EMT treatment:
- Check blood glucose if protocol permits
- If the patient is conscious and can swallow: administer oral glucose (one tube between cheek and gum)
- If the patient is unconscious: do not give oral glucose (aspiration risk). Maintain airway, provide oxygen, and transport rapidly. Some EMT protocols allow intranasal glucagon
- Reassess blood glucose after treatment
Hyperglycemia (High Blood Sugar)
Hyperglycemia develops when blood glucose rises significantly above normal, typically above 300 mg/dL. Two dangerous conditions can result:
Diabetic Ketoacidosis (DKA)
Most common in Type 1 diabetes. Without insulin, cells cannot use glucose and switch to fat metabolism, producing ketones (acidic byproducts). DKA develops over hours to days.
Signs: Kussmaul breathing (deep, rapid respirations), fruity breath odor (acetone), nausea/vomiting, abdominal pain, warm/dry/flushed skin, polyuria (frequent urination), polydipsia (excessive thirst), altered mental status
Hyperosmolar Hyperglycemic State (HHS)
Most common in Type 2 diabetes, typically in elderly patients. Blood glucose may exceed 600 mg/dL. Develops over days to weeks. More severe dehydration than DKA but without significant ketone production.
Signs: Profound dehydration, altered mental status progressing to coma, warm/dry skin, tachycardia, hypotension
Differentiating in the Field
The most important field differentiation is between hypoglycemia and hyperglycemia. Key differences:
- Onset: Hypoglycemia is rapid (minutes). Hyperglycemia is gradual (hours to days)
- Skin: Hypoglycemia presents with cool, pale, diaphoretic skin. Hyperglycemia presents with warm, dry, flushed skin
- Breathing: Normal in hypoglycemia. Kussmaul (deep, rapid) in DKA
- Breath odor: Normal in hypoglycemia. Fruity in DKA
When in Doubt
If you cannot determine whether the patient is hypoglycemic or hyperglycemic, treat for hypoglycemia first (if the patient can swallow). Giving glucose to a hypoglycemic patient can be lifesaving. Giving glucose to a hyperglycemic patient will worsen their condition slightly but will not cause immediate harm. This is a key NREMT testing point.