Diabetic
Emergencies
Not too Sweet – Not too Sour
What is Diabetes?
 Diabetes Mellitus – a disorder of Insulin
Diabetes Mellitus
 Type I – insulin dependent

Usually starts at an early age

Caused by autoimmune
destruction of Beta cells

No insulin production at all

No Insulin = Death

1922 – first successful use of
insulin to treat kids with
DKA – always fatal up until
that point.

Currently – insulin pumps
and various types of insulin
are state of the art in
treatment for Type I DM.
Diabetes Mellitus
Type II – insulin resistant
 Obesity, sedentary lifestyle
 Beta blockers, glucocorticoids,
thiazides
 90% of all diabetes in US
 Insulin is unable to do its work
 Dietary changes, medications or
insulin may be needed
 Usually does not cause DKA
Diabetes Mellitus
 Gestational Diabetes
 Occurs during
pregnancy
 Resolves with delivery
most of the time.
 Due to hormone levels
and obesity
Diabetes
Insulin
 What is Insulin?
 A hormone made by Beta cells in the Pancreas
 Insulin works on multiple cells to regulate blood
Glucose levels
 Muscle – prevents protein breakdown
 Adipose tissue – increases fat production
 Liver – increased glycogen synthesis
 Increased glucose and amino acid uptake
 Inhibits Glucagon production
Effects
 Vasculopathy - Vascular damage
Effects
 Nephropathy - Kidney Damage
Effects
 Neuropathy – nerve damage
Effects
 Retinopathy – eye damage
Effects
 Diabetic
Ketoacidosis
Effects
 Hypoglycemia – caused by treatment
Medications used in
Treating Diabetes
 Antihyperglycemics – stimulate insulin production
 Sulfunylureas – Diabinese, Glucotrol, Diabeta, Amaryl
 Meglitinides – Prandin, Starlix
 Antihyperglycemics – do not stimulate insulin
 Biguanide – Metformin – Lactic acidosis
 Thiazolidinediones – Avandia, Actos
 Alpha-glucosidase inhibitor – Precose, Glyset
 DPP-4 Inhibit – Januvia, Onglyza
Hypoglycemia
 The brain MUST have glucose to function
 Brain is not affected by insulin.
 Normal blood sugar levels range from 70-100
 Low blood sugar can be caused by

Taking insulin when you cannot eat or forget to eat

Intentionally overdosing on insulin

Taking the wrong type

Exercising more than normal and not adjusting diet

Certain diabetes medications, but not all

Infections/illness which prevent eating
Hypoglycemia
 Clinical symptoms
 Lethargy
 Unconsciousness
 Stroke-like symptoms (especially in those with prior
strokes)
 Seizures
 Trouble speaking
 Confusion
 Cardiac Arrest
Hypoglycemia
 Testing
 Fingerstick blood sugar
 Make sure machine gets calibrated regularly
 Make sure you have the right test strips that are not
expired
 Clean finger off with alcohol
 Prick side of finger with lancet
 Squeeze finger (milk it) to get enough to cover testing area
 Read machine when test is complete
DEMO TIME…
Hypoglycemia
 Treatment – Glucose!
 IV Dextrose – AEMTs/Paramedics
 Adults – 50% 1 ampule (50ml = 25gm)
 Children – 25% 2ml/kg
 Neonates – 12.5% - 1ml/kg
 Oral Glucose – EMR/EMTs
 Must have gag reflex and be alert to avoid
aspiration/choking
 Glucagon – for adults
 1-2 mg IM if cannot get an IV
Dextrose
 Class – carbohydrate
 Mechanism – provides metabolic substrate
 Contraindications
 Absolute – None
 Relative – hyperglycemia
 Dosage – 50ml of D50, repeat x1 if needed
 Peds – 2ml/kg of D25
 Neonates – 1ml/kg of D12.5
Glucagon

Class – hormone

Mechanism – stimulates glycogen breakdown in the liver and
muscle, increasing glucose levels

Contraindications

Absolute - sensitivity

Relavtive – starvation, fasting, adrenal insufficiency

Uses – hypoglycemia, beta-blocker overdose, calcium channel
overdose, anaphylaxis (for folks on beta-blockers)

Dosage – hypoglycemia – 1mg IV/IM Q20 min; beta-antagonist
OD – 3-5mg IV; anaphylaxis 1-2mg IV


Kids - <20kg – 0.5mg IV/IM; >20mg – 1mg IV/IM
Side effects – Nausea, vomiting, diaphoresis, hypotension, rash
Meter is broken…
 Get as much history as possible.
 Smell for ketones (only half of us can)
 Are there empty insulin bottles on scene? Recent
exercise or illness?
 Err on the side of treating for hypoglycemia
DKA
 No insulin activity = high blood sugar levels

Can’t make glycogen, fatty acids and cannot move glucose
into cells  Cells starve  Fatty Acid breakdown  Ketosis

High blood sugar  sugar in urine  peeing a lot 
dehydration  acidosis

Diabetic Ketoacidosis!
 Fruity odor to breath
 Increased respiratory rate
 Abdominal pain
 Nausea/Vomiting
 Tachycardia / hypotension
Hyperglycemia
 Low Insulin activity = high blood sugars
 Still able to get some glucose in cells = no starvation =
no ketosis
 Acidosis also less likely
 No fruity odor
 Generalized weakness
 Less nausea/vomiting
 Death very rare
Hyperglycemia
 Treatment
 ABC’s
 IV fluids!
 Adults – 500ml – 1 liter WO
 Children – 20ml/kg fluid boluses
 May repeat if needed for hypotension or tachycardia
What about Insulin
Pumps
 If hypoglycemia – have patient turn off pump after
you wake them up with D50
 If hyperglycemia – don’t touch it
 May not be working
 Patient may be able to do a bolus on their own based on
their sliding scale
 If infected, leave in place, but do not use.
Alcoholic Ketoacidosis
 Chronic Alcoholics are malnourished
 Few glycogen stores
 After a binge, their glucose levels can drop, stimulating
fatty acid breakdown
 Treatment is glucose with Thiamine
 Don’t withhold glucose if level is abnormal!
You wanna refuse?
 While people have a right to make their own decisions, it
must be an INFORMED decision
 They must:

Be alert, oriented to person, place, time, and situation

Know of the risk for relapse

Have recovered within 10 minutes. FSBS >80
 They should

Have test strips available or have someone there to call back
if they get hypoglycemic again.

Have adequate follow-up.
Questions
 A diabetic’s family calls 911 for sudden onset of left
sided weakness that started 10 minutes prior to arrival.
After ABCs, what is your next step?
Questions
 A Diabetic teen-ager decides to say “f&^% you” to his
diet, and eats an ice cream sundae. A day later, he
calls 911 for vomiting and abdominal pain. His
Glucose on fingerstick reads “Hi” What should you
give?
Questions
 You come across a “local regular” beside the bar. He
smells of alcohol, and is lethargic. He looks like he
hasn’t been eating regularly for quite some time. You
consider _____ as a possible diagnosis, and _________