Chapter 23 José G. Cabañas, Jorge L. Falcon-Chevere, and Jane H. Brice Diabetes is a commonly encountered disease in the out-of-hospital environment. Characterized by defective insulin production and use, diabetes is the most common endocrine disorder, and hypoglycemia is the most common endocrine emergency [1]. Several types of diabetes are recognized. Type 1 diabetes occurs when the pancreatic beta cells are destroyed, which removes the body’s only insulin-producing mechanism. Typically occurring in children and adolescents, type 1 diabetes accounts for 5–10% of all cases of diabetes. These individuals require exogenous insulin administration to survive. Type 2 diabetes is more common, responsible for 90–95% of all diabetes diagnoses. Rather than a defect of insulin production, type 2 diabetes is characterized by insulin resistance at the cellular level and gradual failure of pancreatic production of insulin. Type 2 diabetes is a disease predominantly in older adults and is associated with physical inactivity, obesity, and a history of gestational diabetes, a form of glucose intolerance found among pregnant women. Typically resolving after delivery of the infant, the individual who was diagnosed with gestational diabetes carries a 35–60% chance of developing diabetes over the next 5–10 years [2]. Diabetes remains a major cause of coronary heart disease and stroke, and it is the seventh leading cause of death in the United States. Diabetes is a chronic disease that, at present, has no cure. In 2011, it was estimated that 25.8 million persons in the United States suffered from diabetes. This represents 8.3% of the total US population. Of these 25.8 million, 18.8 million are persons with a known diagnosis of diabetes, and the remaining 7 million have unrecognized and untreated diabetes. It is also estimated that 51 million people aged 40–74 years have impaired glucose tolerance, impaired fasting glucose, or both [2]. Diabetes occurs more frequently in certain populations, including African Americans, Hispanics, and Native Americans. One-and-a-half million new cases of diabetes are diagnosed each year, and diabetes-related visits to US emergency departments (EDs) totaled 20.2 million between 1997 and 2007 [2,3]. Additionally, there were approximately 5 million ED visits for hypoglycemia between 1992 and 2005, with 25% of these visits resulting in admission to hospital. In the same interval, there were approximately 750,000 ED visits for diabetic ketoacidosis (DKA), with 87% admitted predominantly to intensive care settings [4,5]. The cost of diabetes in the United States is staggering. An estimated $174 billion is spent annually for direct and indirect medical costs. This is in addition to lost work opportunities and disability, summing to an estimated $58 billion per year [2]. Diabetic emergencies account for 3–4% of EMS call volume. The majority of EMS responses for diabetic emergencies are for hypoglycemia [1]. The consequences of both hypoglycemia and hyperglycemia are dire. Therefore, it is imperative that appropriate care is started in the field to decrease morbidity and mortality. EMS physicians and medical directors must have adequate clinical operating guidelines to appropriately manage these patients in the prehospital setting. This chapter addresses the most common diabetic conditions prehospital providers will encounter. The initial evaluation of a diabetic emergency starts with the emergency medical dispatcher when 9-1-1 is called. Crucial information may be obtained through the telephone while the response unit is dispatched. Treatment may begin with prearrival instructions. Medical oversight is crucial to ensure quality within the dispatcher’s interrogation protocols and that prearrival instructions are appropriately given (see Volume 2, Chapter 10). Once responders arrive, scene safety is a priority, given that patients experiencing diabetic emergencies have altered mental status and may act in unpredictable ways. Although most diabetic patients may call for an ambulance for a specific diabetic condition, such as hypoglycemia, many patients will have non-specific complaints such as nausea, vomiting, dizziness, or abdominal pain, requiring the responders to gather information to determine the cause of the illness. The initial patient evaluation is the same as any other case in the prehospital setting (Box 23.1). In the instance of diabetic emergencies, history taking is important because it provides pertinent information that may alter treatment, particularly in patients with altered mental status. Key history elements in the assessment of a patient with altered mental status should include the following: The possibility of intentional overdose in the hypoglycemic, depressed patient, and of inadvertent overdose in the elderly or confused patient should be considered. Attention should be paid to the type of insulin or medication the patient is taking. The use of long-acting insulin formulations may require close monitoring of the patient by a responsible adult at home or continuous monitoring and additional treatment at the hospital. Patients on certain oral hypoglycemic agents should be transported to the hospital because they have a higher risk of recurrent hypoglycemia and, by extension, increased morbidity. Hyperglycemia should prompt prehospital personnel to think about infectious sources such as urinary tract infection or pneumonia, especially in an elderly or debilitated patient. Acute medical illnesses, such as myocardial infarction, stroke, or pancreatitis, can also cause hyperglycemia in the diabetic patient. Recent cocaine use or poor compliance with medication can also be causes of hyperglycemia, all of which should be considered by prehospital personnel. Current EMS practice embraces the prehospital measurement of plasma glucose using glucometers. In past decades, dextrose was empirically given to all patients with altered mental status without first measuring plasma glucose. Investigators found that few patients benefited from such empiric treatment, and a few patients were harmed, as in the case of stroke [6,7]. Glucometer use by prehospital personnel has been found to be safe and accurate [8,9]. It is important to note that the glucose strips must be stored in temperature-controlled sections of the ambulance so they provide reliable readings [10]. The prehospital measurement of plasma glucose is now considered a standard practice in EMS. Diabetic management emphasizes tight glycemic control to prevent long-term complications, such as heart disease and blindness. This strategy, however, may lead to adverse consequences, such as the development of hypoglycemia. Hypoglycemia, usually defined as a serum glucose concentration less than 70 mg/dL (3.8 mmol/L), is the most common endocrine emergency [7]. Estimates are that persons with diabetes suffer mild (self-treated) hypoglycemic events 1–2 times per week and that 30% of persons with diabetes suffer severe hypoglycemic events annually [11–14]. Symptomatic hypoglycemia requires intervention to prevent organ compromise. Several treatment options exist for the prehospital environment, including oral glucose, IV dextrose, or intramuscular (IM) glucagon. Oral glucose may be used in alert patients with intact swallowing mechanisms. For patients with decreased level of consciousness or concern for aspiration, IV administration of 50% dextrose has been the standard for many years. One study found that the administration of 50 mL of 50% dextrose raised blood glucose by an average of 166 mg/dL, but the response varied widely among patients, from an increase of 37 mg/dL to 370 mg/dL [15]. In the unconscious patient, IV glucose administration provides a rapid onset of action (2–5 minutes). There are, however, several reports in the literature of tissue injury secondary to extravasation, which can cause significant complications, including skin and soft tissue injury, compartment syndrome, and loss of limb [16,17]. In a controlled clinical trial, Moore and Woollard found no difference in time to regain consciousness in hypoglycemic patients when comparing the administration of 10% dextrose versus 50% dextrose. In their cohort of 51 patients, 25 patients received a 10% dextrose solution and 26 received a 50% dextrose solution. Both groups had a median recovery time of 8 minutes. Patients in the 10% dextrose group received a median of 15 g less glucose than the 50% dextrose group to achieve the same response. Additionally, patients in the 10% dextrose group were less likely to have high glucose levels after treatment. Patients occasionally had difficulty bringing their glucose levels back into a normal range after treatment with 50% dextrose [18].
Diabetic emergencies
Introduction
Prehospital assessment
General approach
Other considerations
Measurement of glucose
Prehospital treatment
Hypoglycemia
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