Diabetes in EMS: A Common Emergency
Diabetic emergencies are among the most common medical calls in EMS. Approximately 37 million Americans have diabetes, and many will experience a blood sugar crisis at some point. The two primary emergencies are hypoglycemia (dangerously low blood sugar) and hyperglycemia (dangerously high blood sugar, manifesting as diabetic ketoacidosis or hyperosmolar hyperglycemic state). Differentiating between these conditions is critical because treatment is different, and misidentification can be harmful.
Blood glucose measurement should be part of the assessment for any patient with altered mental status, regardless of their known medical history. Hypoglycemia can mimic stroke, intoxication, seizure, and psychiatric emergencies. A simple fingerstick glucose check takes seconds and can immediately identify a treatable cause of altered consciousness.
Hypoglycemia
Hypoglycemia is generally defined as a blood glucose level below 70 mg/dL, though symptoms can occur at higher levels in patients with chronically elevated blood sugars. The brain is entirely dependent on glucose for energy, so low blood sugar produces primarily neurological symptoms: confusion, slurred speech, weakness, diaphoresis, tremor, anxiety, and seizures. Severe hypoglycemia causes unconsciousness and can be fatal if untreated.
Common causes include insulin overdose (either accidental or intentional), missed meals in patients taking diabetes medications, excessive exercise, and alcohol consumption (which impairs the liver's ability to release glucose). Sulfonylurea medications (glipizide, glyburide) are particularly prone to causing prolonged hypoglycemia.
Treatment depends on the patient's level of consciousness. For conscious patients who can swallow safely, administer oral glucose (glucose gel, juice, regular soda, or glucose tablets). The standard dose of oral glucose gel is one tube (15 to 24 grams). For unconscious patients or those who cannot safely swallow, administer dextrose IV (D10W or D50W per protocol) or glucagon intramuscularly (1 mg for adults). Recheck blood glucose after 5 minutes and repeat treatment if still below 70 mg/dL.
Diabetic Ketoacidosis (DKA)
DKA occurs primarily in Type 1 diabetics (though it can occur in Type 2) when insulin is absent and the body cannot use glucose for energy. The body breaks down fat for fuel, producing ketone bodies as a byproduct. Ketones are acidic, and their accumulation causes metabolic acidosis. DKA develops over hours to days and presents with polyuria (excessive urination), polydipsia (excessive thirst), nausea, vomiting, abdominal pain, weakness, and Kussmaul respirations (deep, rapid breathing as the body attempts to blow off CO2 to compensate for acidosis). A characteristic fruity or acetone odor on the breath results from ketone exhalation. Blood glucose is typically above 300 mg/dL.
Hyperosmolar Hyperglycemic State (HHS)
HHS occurs primarily in Type 2 diabetics and is characterized by extreme hyperglycemia (often above 600 mg/dL), severe dehydration, and altered mental status, but without significant ketoacidosis. HHS develops more slowly than DKA (over days to weeks) and carries a higher mortality rate (up to 20%). Prehospital management for both DKA and HHS includes IV fluid resuscitation (normal saline bolus followed by ongoing infusion), cardiac monitoring (hyperkalemia from DKA or hypokalemia from treatment can cause arrhythmias), and rapid transport. Do not administer insulin in the field; insulin therapy requires careful monitoring of potassium levels that can only be done in the hospital.