Diabetes
Objectives
At the conclusion of this chapter you should be able to:
1. Describe the different types of diabetes.
2. Describe the signs, symptoms and treatment of hypoglycemia and hyperglycemia.
3. Describe the signs, symptoms and treatment of diabetic ketoacidosis.
Case:
You are dispatched to an "unknown medical emergency" at 1022 Burke Street. Upon
arrival you find a 43 year-old male lying unconscious in the living room. His landlord
discovered him while doing routine maintenance. During your initial assessment you
discover:
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The patient is breathing deeply at a rate of 28 per minute
Pulse 110
Skin Warm & Dry
Unresponsive to Pain
You begin your focused assessment while your partner administers oxygen, applies a
cardiac monitor and sets up an IV. During your focused assessment you find:
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Sweet, fruity odor
ECG - Sinus tachycardia
Pulse Ox - 96%
Medic Alert Necklace that simply states "Diabetic"
Glucometer reads "Too High"
You rapidly package the patient, draw a blood sample, establish an IV of NS en route to
the hospital, rapidly infuse 2 liters per protocol, then decrease rate to TKO and contact
the receiving hospital with a detailed report. You complete a detailed assessment and
continue the ongoing assessment during the 25 minute transport. The patient's condition
remained the same during the transport.
Diabetes Mellitus
Diabetes mellitus is characterized by a deficiency of insulin or the inability of the body to
respond to insulin. Diabetes mellitus is generally classified as Type I - insulin dependent,
or Type II non-insulin dependent.
Patients with type I diabetes mellitus (DM), also known as insulin-dependent DM
(IDDM) or juvenile-onset diabetes, may develop diabetic ketoacidosis (DKA). Patients
with type II DM, also known as non-insulin-dependent DM (NIDDM), may develop
nonketotic hyperglycemic-hyperosmolar coma (NKHHC). Common late microvascular
complications include retinopathy, nephropathy, and peripheral and autonomic
neuropathies. Macrovascular complications include atherosclerotic coronary and
peripheral arterial disease.
Type I Diabetes Mellitus
Type I diabetes is characterized by inadequate production of effective insulin by the
pancreas. This form of diabetes affects 1 in every 10 diabetics, and may occur any time
after birth. This form usually presents itself in the teen years or young adult years. Type I
diabetes requires lifelong treatment with insulin injections, exercise, and diet regulation.
The symptoms of Type I diabetes can present suddenly, and can include, polyuria,
polydipsia, dizziness, blurred vision, and rapid, unexplained weight loss.
Type II Diabetes Mellitus
Type II diabetes is characterized by a decrease production of insulin by the beta cells of
the pancreas, and diminished tissue sensitivity to insulin. The disease occurs most often
in people over 40 years old and in those who are overweight. Most people with Type II
diabetes require an oral hyperglycemic medication, exercise, and dietary regulation to
help control their illness. A small number of Type II diabetics require insulin injections.
Symptoms of Type II diabetes include fatigue, changes in appetite, numbness, tingling,
and pain in the extremities.
What are Normal Blood Glucose Levels?
The amount of glucose (sugar) in your blood changes throughout the day and night. Your
levels will vary depending upon when, what and how much you have eaten, and whether
or not you have exercised. The American Diabetes Association categories for normal
blood sugar levels are the following, based on how your glucose levels are tested:
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A fasting blood glucose test. This test is performed after you have fasted (no food
or liquids other than water) for eight hours. A normal fasting blood glucose level
is less than 110 mg/dl. A diagnosis of diabetes is made if your blood glucose
reading is 126 mg/dl or higher. (In 1997, the American Diabetes Association
lowered the level at which diabetes is diagnosed to 126 mg/dl from 140 mg/dl.)
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A "random" blood glucose test taken at any time. A normal blood glucose range is
in the low to mid 100s. A diagnosis of diabetes is made if your blood glucose
reading is 200 mg/dl or higher and you have symptoms of disease such as fatigue,
excessive urination, excessive thirst or unplanned weight loss.
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Another test called the oral glucose tolerance test may be performed instead. For
this test, you will be asked, after fasting overnight, to drink a sugar-water
solution. Your blood glucose levels will then be tested over several hours. In a
person without diabetes, glucose levels rise and then fall quickly after drinking
the solution. In a person with diabetes, blood glucose levels rise higher than
normal and do not fall as quickly.
Effects of Diabetes Mellitus
Most effects of diabetes mellitus can be attributed to the following effects of insulin
levels.
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Increased blood glucose level due to a decreased use of glucose by the body cells.
Abnormal fat metabolism due to increased mobilization of fats from the fat
storage areas. This results in short-term ketoacidosis and in long term causes
atherosclerosis.
Muscle wasting due to depletion of protein in the tissues.
Diabetes attributed to pancreatic disease: Chronic pancreatitis, particularly in alcoholics,
is frequently associated with diabetes. Such patients lose both insulin-secreting and
glucagon-secreting islets. Therefore, they may be mildly hyperglycemic and sensitive to
low doses of insulin. Given the lack of effective counterregulation (exogenous insulin
that is unopposed by glucagon), they frequently suffer from rapid onset of hypoglycemia.
In Asia, Africa, and the Caribbean, DM is commonly observed in young, severely
malnourished patients with severe protein deficiency and pancreatic disease; these
patients are not DKA-prone but may require insulin.
Diabetes associated with other endocrine diseases: Type II DM can be secondary to:
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Cushing's syndrome
Acromegaly
Pheochromocytoma
Glucagonoma
Primary aldosteronism
Somatostatinoma
Most of these disorders are associated with peripheral or hepatic insulin resistance. Many
patients will become diabetic once insulin secretion is also decreased. The prevalence of
type I DM is increased in patients with certain autoimmune endocrine diseases, e.g.,
Graves' disease, Hashimoto's thyroiditis, and idiopathic Addison's disease.
Loss of Glucose in the Urine
When the glucose quantity entering the kidney tubules rises above the glomerular
filtration rate, the glucose spills into the urine. The spilling of glucose into the urine
causes diuresis because the osmotic effect of glucose in the tubules prevents tubular
reabsorption of fluid. This causes dehydration of the extracellular and intracellular
spaces.
Acidosis in Diabetes
When carbohydrate metabolism shifts to fat metabolism, ketoacidosis occurs.
Ketoacidosis is the formation of ketone bodies. Ketone bodies are strong acids, and if
they continue to produce, can lead to metabolic acidosis. Metabolic acidosis is often
compensated by respiratory alkalosis that causes kussmauls respirations. The body's
mechanism to clear the acid by the kidneys is overwhelmed by the continuous production
of ketone bodies, therefore, profound acidosis eventually
occurs. The acidosis along with the severe dehydration can
lead to death.
Diabetes mellitus is a systemic disease that can have many
long-term complications.
These include:
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Blindness
Kidney Disease
Peripheral Neuropathy-causes damages to nerves of the extremities, therefore
increase incidence of foot infections.
Autonomic Neuropathy-affect bowel and bladder control, and blood pressure
Heart Disease and Stroke
Anatomy and Physiology of the Pancreas
The pancreas is important in the absorption and use of carbohydrates, fat, and protein.
The pancreas is a principal regulator of blood glucose concentration.
Insulin
The primary function of insulin is to increase glucose transport into cells, increase
glucose metabolism, increase liver glycogen levels, and decrease blood glucose
concentration toward a normal level.
Types of Insulin
The fastest acting insulins are called lispro (Humalog)and insulin aspart (Novolog). They
should be injected under the skin within 15 minutes before eating. Patients have to
remember to eat within 15 minutes after the injection. These insulins start working in
five to 15 minutes and lower the blood sugar most in 45 to 90 minutes. It finishes
working in three to four hours. With regular insulin you have to wait 30 to 45 minutes
before eating. Many people like using lispro because it's easier to coordinate eating with
this type of insulin.
Insulin Injection Locations
Fast acting - The fast acting insulin is called regular insulin. It lowers blood sugar most in
2 to 5 hours and finishes its work in 5 to 8 hours.
Intermediate acting - NPH (N) or Lente (L) insulin starts working in one to three hours,
lowers your blood sugar most in six to 12 hours and finishes working in 20 to 24 hours.
Glucagon
Glucagon is a protein released by the alpha cells when the blood glucose level falls.
Glucagon increases the blood glucose level by stimulating the liver to release glucose
stores from glycogen and other glucose storage sites. Glucagon also stimulates glucose
formation by breaking down the fats and fatty acids.
Diabetic Emergencies
There are three life-threatening emergencies that may result from diabetes. These include:
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Hypoglycemia
Hyperglycemia
Hyperosmolar hyperglycemic nonketotic coma.
Hypoglycemia
Hypoglycemia also known as Insulin Shock is a syndrome related to the blood glucose
levels below 60. Symptoms of hypoglycemia usually develop after the blood glucose
level falls below 60. Symptoms may develop sooner if the fall in blood glucose level
rapidly drops. Hypoglycemia is usually caused by too much insulin, a delayed or missed
meal, vigorous physical activity, and emotional stress.
Signs and symptoms of hypoglycemia usually occur rapidly, and the patient may
complain of extreme hunger, or other symptoms including:
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Nervousness, trembling
Irritability
Combative behavior
Weakness
Confusion
Appearance of intoxication
Full, rapid pulse
Cold, clammy skin
Drowsiness
Seizures
Coma
Hyperglycemia (Diabetic Coma)
Symptoms of hyperglycemia distress develops gradually and include:
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Increased thirst and urination, usually for 1 to several days; increasing amounts of
sugar are "spilled" into the urine.
Nausea, vomiting, and abdominal pain.
Feeling of weakness or fatigue.
Dehydration (dry mouth and skin, sunken eyes).
Breath smells fruity.
Heavy, labored breathing that is rapid and deep.
Drowsiness or loss of consciousness.
Treatment
Take the person to an emergency room as quickly as possible. Any acute change in
alertness, consciousness, or mental status in a diabetic warrants immediate medical
attention.
Diabetic Ketoacidosis
Diabetic ketoacidosis results from an absence of or resistance to insulin. The low insulin
level prevents glucose from entering the cells and causes glucose to accumulate in the
blood. The cells then become starved for glucose and begin to use other sources of energy
usually fat. When fat is metabolized, it produces fatty acids and glycerol. The glycerol
provides energy to the cells, but the fatty acids are further metabolized to form ketoacids,
which results in acidosis.
Common Causes of Diabetic Ketoacidosis:
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Not enough insulin dose
Failure to take insulin
Infection
Increased stress
Increased dietary intake
Decreased metabolic rate
Emotional stress
Alcohol
Pregnancy
As blood sugar rises, the patient undergoes massive osmotic diuresis, which when
combined with vomiting causes dehydration and shock. The electrolyte imbalance may
cause cardiac dysrhythmias, and seizures. Signs and symptoms of diabetic ketoacidosis
include:
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Warm, dry skin
Dry mucous membranes
Tachycardia, thready pulse
Postural hypotension
Weight loss
Polyuria
Polydipsia
Abdominal pain
Nausea, vomiting
Fruity odor to breath
Kussmaul breathing
Decreased LOC
Hyperosmolar Hyperglycemic Nonketotic Coma
HHNK coma is a life threatening emergency that occurs frequently in older patients who
have Type II diabetes. It also occurs in patients who have undiagnosed diabetes. This
syndrome differs from DKA in that residual insulin may be adequate to prevent
ketogenesis and ketoacidosis but not enough to permit glucose use by the peripheral
tissues or decrease gluconeiogenesis to the liver. The hyperglycemia produces a
hyperosmolar state followed by an osmotic diuresis, dehydration, and electrolyte losses.
Signs, symptoms, and precipitating factors include:
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Type II Diabetes
Old age
Cardiac/Renal Disease
Inadequate insulin secretion or action
Increased insulin requirements
Medications
Supplemental feedings
Weakness
Thirst
Polyuria
Weight loss
Dehydration
Assessment of the Diabetic Patient
Patients with a diabetic emergency often have various signs and symptoms. Many of
these mimic other common conditions. You should always suspect a diabetic related
illness. Always be alert for medical alert information, the presence of insulin syringes,
and diabetic medications. Diabetic medications are often kept in the refrigerator. In
assessing the patient's history, you should assess the:
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Onset of symptoms
Food intake
Insulin or oral hyperglycemic taken
Alcohol or other drug use
Any predisposing factors such as exercise, infection or stress.
Management of the Conscious Diabetic Patient
High concentration oxygen should be administered, and if appropriate, glucose should be
given. Obtain a blood sample for laboratory testing before administering glucose. Some
field EMS services utilize Dextrostix, Chemstrips, or glucometers for this purpose. If
your patient's glucose level is below 60, and he/she is experiencing signs and symptoms
of hypoglycemia, glucose should be given. While transporting the patient, monitor the
patient's LOC, vital signs, and ECG continuously.
Management of the Unconscious Diabetic Patient
Prehospital management of any unconscious patient should be directed at maintaining an
airway, high concentration oxygen administration, and ventilatory support. Depending on
your particular protocol, an IV should be started using lactated Ringer's or a saline
solution to replenish fluids and electrolytes. If alcohol or drug use is suspected your
medical direction may recommend administration of Narcan before administering
glucose. If you are unable to obtain a blood glucose level you should administer glucose.
This additional glucose load will not adversley effect the hyperglycemic patient but it
may save the life of a hypoglycemic patient.
Differential Diagnosis
Diagnosis of a diabetic emergency is sometimes difficult. When in doubt, all diabetic
patients should receive glucose.
System
Diabetic Ketoacidosis Hypoglycemia
Pulse
Rapid
Normal to Rapid
Blood Pressure
Low
Normal
Respirations
Exaggerated
Normal to shallow
Breath Odor
Acetone - Sweet - Fruity Normal
Headache
Absent
Present
Mental State
Restless - Unconscious
Irritable - Unconscious
Tremors
Absent
Present
Convulsion
None
In late stages
Mouth
Dry
Drooling
Thirst
Intense
Absent
Vomiting
Common
Uncommon
Abdominal Pain
Common
Absent
Vision
Dim
Double Vision
Summary
Diabetic emergencies are metabolic disorders often encountered in the prehospital care
setting. The illness may be life threatening, but a proper assessment, a thorough history,
and appropriate drug therapy can often reverse the immediate pathological process.
Volume replacement is the primary goal in treating DKA and HHNK coma. Glucose is
the primary goal of therapy for the hypoglycemic patient.