Diabetes: The Highs, Lows, and "When Can They Go's"
James J Augustine // August 1, 2011
Diabetic emergencies come in a variety of types and causes, but the tools available to EMS professionals allow excellent evaluation and initial treatment of the patient.
For most EMS professionals, the evaluation of emergency patients with diabetes is built around a protocol for "Patients with Mental Status Changes who are Known or Suspected Diabetic." A good history from the patient or knowledgeable bystanders, an assessment of the vital signs, and a physical evaluation that looks for all potential causes of altered mental status, are the first elements of managing patients with this problem.
The information then provided by testing a very small amount of blood will provide the approximate level of glucose in the patient's vascular system, and treatment can then be targeted to restore the patient's normal level of functioning. At the hospital, further testing may need to be done to establish the cause of the blood sugar abnormality, or whether there are other significant medical problems.
The process begins with the request by a patient or others who have noted the person acting abnormally. This can be family, friends, co-workers, teachers, police officers, or just a passerby. Beginning with the history and examination, the EMS professional can make a decision that the patient has a medical presentation consistent with an abnormal blood sugar.
In a known diabetic, the patient, family, or friends may describe the patient as having symptoms that are consistent with high or low blood sugar (usually when they have seen this patient act like this in the past). The medic will then make proper use of the blood glucose evaluation tool utilized by the EMS organization.
It is probably unnecessary for EMS to test for blood sugar if the patient has had a valid blood sugar test done with an appropriate glucose measuring device in the last 15 minutes. This may occur in a health care facility (nursing home, dialysis center, urgent care center, etc) or in the patient's home or worksite.
The blood glucose measuring device must be maintained as the critical and delicate piece of medical equipment that it is. Disposable portions of the blood sugar testing system must be maintained, and should be rotated to insure that they have not passed an expiration date. Most EMS systems specify an equipment-maintenance program that includes inspection and care to keep the monitor system clean, to regularly verify the accuracy of the monitor, and to maintain the monitor in working order. The process should be accomplished per the manufacturer's instructions, and should include an inspection of the condition and expiration date of the lancets and monitor strips.
With the blood sugar measuring device in functional status, EMS professionals caring for the patient will inform the patient and/or family member(s) that the medic will be testing a small amount of blood. It is appropriate for the medic performing the test to utilize Personal Protective Equipment (PPE), and if there is a concern that the patient will be difficult to control, then the whole crew will use PPE.
Whole blood is used for sugar testing. It can be obtained by lancing the fingertip of the patient, or by using a drop of blood when an intravenous line is started.
There are a variety of levels that are used to define low and high blood sugars, but for EMS professionals, simple levels should be established. Many emergency systems define elevated blood sugar as a value over 300 in persons without a known history of diabetes, or over 400 in the diabetic patient with an altered level of consciousness or other symptoms.
The patient with altered mental status and high blood sugar typically has treatment started by administering fluids and, in the EMS patient, establishing an intravenous line and administering a bolus (250cc or 500cc are common amounts) of normal saline. The patient has routine care provided and is transported to the emergency department in a position of comfort, maintaining an airway, and avoiding complications such as vomiting and aspiration. Document the assessment and treatment of the patient, the result of the blood glucose test, and the response of the patient to treatment.
The most common problem in diabetic patients with altered levels of consciousness is low blood sugar, typically defined as less then 60 to 80. If the sugar reading is low, the patient needs to have the protocol for low blood sugar followed, typically with the administration of oral glucose, intravenous dextrose, or glucagon. The choice of agent to increase the patient's blood sugar is based on a number of factors. Oral glucose is part of many EMS protocols when the patient is awake enough to cooperate, has an intact gag reflex that will protect the patient from aspirating the substance, and is not nauseated or vomiting.
Many patients do not fulfill this set of factors, particularly being awake enough to cooperate. In this case the patient protocol will call for the administration of sugar in the form of intravenous glucose. The medic must obtain excellent venous access to give intravenous dextrose. Note that dextrose solutions accidentally leaving the vein will cause severe skin loss. The administration of a 50% or 25% solution of sugar is given carefully, making sure there is no extravasation of the fluid outside the vein.
Most EMS systems use intramuscular or intranasal glucagon, if the crew is unable to establish vascular access. Glucagon is a medicine that counteracts the effects of insulin, and causes the patient to mobilize stores of glucose that are stored in the liver and other sites. Glucagon administration produces a much more gradual increase in blood glucose and, since the patient has already proven to have inadequate sugar to maintain consciousness, it will still be necessary to give the patient some sugar when they can tolerate it.
So, after glucagon is given and the patient awakens and is not nauseated, he or she will need to have oral fluid or food to provide a sustained source of calories and prevent recurrence of low blood sugar.
Most EMS systems have removed thiamine from the protocols for routine administration in the hypoglycemic patient. Thiamine 100mg by intravenous or intramuscular route is still used before glucose is given by some systems for suspected alcoholic patients who have low blood sugar, or in the presence of obvious malnutrition or chronic debilitating disease (e.g., cancer, or AIDS).
In a diabetic patient with an insulin pump and a glucose <60, disconnect the pump from the patient or have a knowledgeable family member "suspend" the device if he/she is familiar with its operation. If a patient does not awaken after administration of sugar, and the return of a blood sugar over 100 on repeat testing, consider other source for altered level of consciousness.
Diabetic emergencies: Refusal of transport
Waking up the diabetic, whether with oral sugar, intravenous sugar or an intramuscular dose of glucagon, leads to the important transportation decisions. There is good literature demonstrating a low rate of problems in those released by EMS after treatment for insulin reactions. It is potentially problematic to write a policy that all patients who have been treated for low blood sugar must be transported. EMS providers are not empowered to "kidnap" patients and force them to go to hospitals after treatment. The legal issue is the assessment of competence after the patient is aroused, whether the patient has a clear mental status at that time, and is competent to refuse transport to a hospital. Some systems make the transport/nontransport decision with the assistance of online medical control.
Many EMS organizations have developed policies that allow patients to refuse transportation. A conservative approach to patients treated for acute hypoglycemic reactions due to insulin would include these elements:
- There is a reasonable explanation for the hypoglycemic episode
- A blood glucose test after treatment shows blood sugar levels that are normal or slightly above
- Vital signs are otherwise stable
- The patient has absolutely no other medical complaints or problems (fever, chest pain, palpitations)
- The patient is not nauseated or vomiting. The EMS professionals observe the patient eating (or drinking) something, to make sure the patient is able to tolerate oral intake of calories
- A competent person is with the patient, and that person understands the potential for later problems, and can assist the patient or re-contact EMS if needed
- The patient will not be put in a situation where others will be placed at risk, such as driving a car, flying a plane, or manual labor
There are several patient types to exclude from a "treat and no transport" policy. In these situations, the underlying issue causing low blood sugar can't be adequately treated in a short time by EMS personnel, and blood glucose is likely to drop again without ongoing treatment. These groups include:
- Patients who are acutely ill in some other way, such as having fever, chest pain, or vomiting
- Diabetics who aren't taking insulin, and have low blood sugar due to the use of oral agents to lower sugar
- Poorly nourished persons with alcohol abuse problems
- Diabetics on insulin pumps
For some complicated diabetic patients, it may be appropriate to have the patient or family contact the patient's personal physician to get their advice. Many are happy to see the patient in their office if the patient does not want to go to the hospital. Local medical direction should be followed so that consistent approaches are in place for your group of providers.
Waking diabetics can be challenging, and all EMS professionals have memorable occasions related to the struggle to get patients treated and back to his/her baseline. A few of my memorable patients:
- A man finally awakened with two doses of IV glucose. He had been ill for two days, and had a fever and chest pain. He wanted to refuse transport, due to his high medical bills, and said, "If you insist on taking me to the hospital, I will tell my family to never call you again when I have a low sugar! It required a lengthy conversation to get him to go to the hospital, and to educate the family that they must call anytime they suspect his sugar was dropping.
- It took 10 firefighters to hold down a raging bull of a male patient and administer a dose of IV glucose. He awoke as the meekest and gentlest man, asking "Why are you all so sweaty?"
- A very pregnant young woman who was administered IV glucose at her business office asked: "Did I keep my clothes on this time?" Fortunately, no one in the office remembered a prior episode where that had occurred.
- The police nudged a car off the road and into a soft yard, after its erratic driver had hit a dozen or so other cars, chased pedestrians off sidewalks and clipped a natural gas line. The man had a blood sugar of 15. After his dose of intravenous glucose, he insisted that he wanted to drive his car the rest of the way home. The police officers threatened to immediately throw him in jail if he refused to go to the hospital.
EMS professionals must be expert at dealing with patients who have high and low blood sugar, and be experts at managing the tools used for blood sugar measurement and treatment.