Level With Me, Sugar!

     You and your EMT partner are dispatched on an altered mental status call. The dispatcher informs you that police are on the scene of a male experiencing violent behavior.

     Upon arrival, you find a morbidly obese man in his mid-30s, who is running through his house throwing anything he can find, putting holes in walls and breaking windows. One of the police officers tells you, "We think he's on something!" The patient's wife informs you that the patient is an unstable diabetic.

     Diabetic emergencies are commonly encountered in the prehospital setting, and signs and symptoms may manifest themselves in different ways. Recognizing those signs and symptoms, what causes them, what tools BLS providers have at their disposal and when to involve ALS are all crucial and may have a significant effect on the outcome of even the most "routine" diabetic emergency.

What Is Diabetes?
     Diabetes mellitus is a disorder of the endocrine system, which is brought about by a decrease in the production of insulin—a hormone that is produced in the pancreas—and/or the inability of body cells to use insulin in the proper way, which is to combine with glucose (sugars that the body converts from the food a person consumes) and enter the cells to give the body the energy it needs to function. An average human's blood glucose level is between 80 and 100 milligrams per deciliter (mg/dl). Seven percent of the population in the United States is diabetic.¹

     If the body cells use glucose too quickly, it requires an increase in insulin production, which the diabetic body may not be able to compensate for. The decreased glucose level in the bloodstream is known as hypoglycemia. This can be caused by an increase in insulin intake by the patient; overexertion, which makes the body metabolize glucose faster than normal; and/or a reduction in food intake. Reduced glucose in the bloodstream leads to altered levels of consciousness, and, if left untreated, can lead to a loss of consciousness, damage to vital organs and even death, as cells are literally starved of glucose. Hypoglycemia is usually the most commonly encountered diabetic emergency; however, if glucose is administered quickly, the patient commonly recovers relatively soon. Signs and symptoms of hypoglycemia are usually of sudden onset and may include altered mentation, perfuse sweating and abnormal behavior.

     Conversely, without insulin, the body cells cannot use glucose, and it remains in increasing levels in the bloodstream. This is known as hyperglycemia. Typically, things like stress, changes in dietary intake, infections and noncompliance with insulin intake may lead to hyperglycemia. Unlike hypoglycemia, signs and symptoms associated with hyperglycemia often have a more gradual onset, and the patient will have increased hunger, thirst and increased urinary output. These patients may have the classic "fruity breath" sign as well.

     Commonly, diabetics fall into two categories: Type I and Type II. Type I, also known as insulin-dependent diabetes, is based on limited or no ability of the body to produce glucose. This has also been known as "juvenile diabetes," as it commonly begins in children. Type I diabetics must receive some dose of supplemental insulin on a daily basis.

     Type II is more commonly known as adult-onset diabetes. The body is able to produce insulin but at decreased levels, and/or the body cannot properly metabolize insulin. This is most commonly seen in obese individuals, but is also seen in the elderly and in obese children. Many Type II diabetics can manage their diabetes very effectively through special diet, oral medications or both. However, these are often the most unstable diabetics, due to noncompliance with medications or dietary restrictions, or both.

Treating Diabetic Emergencies
     Many of the signs and symptoms associated with diabetic emergencies mirror those related to other medical emergencies, so it is important to be as specific as possible, ruling out as much as you "rule in" about the patient's condition and what treatments may be required.