MASTER TEACHING NOTES
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Detailed Lesson Plan
Chapter 20
Acute Diabetic Emergencies
120–130 minutes
Case Study Discussion
Teaching Tips
Discussion Questions
Class Activities
Media Links
Knowledge Application
Critical Thinking Discussion
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
I.
5
5
Master Teaching Notes
Introduction
Case Study Discussion
A. During this lesson, students will learn about assessment and emergency
care for a patient suffering from an acute diabetic emergency.
B. Case Study
1. Present The Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed.
II. Understanding Diabetes Mellitus—Glucose (Sugar)
A. Major source of fuel for the cells
B. Significantly affects brain cells
C. Tendency to attract water when glucose molecule moves
D. Excess spills off into the urine

What types of problems might cause a
sudden change in Mr. Bennet’s
behavior?
 If Mr. Bennet is unable to give you a
medical history, how can you find out
additional information about him?
Discussion Question
What happens to the glucose that is not
immediately needed by our cells for
energy?
Class Activity
To illustrate the breakdown of starches into
simple sugars, pass out saltine crackers.
Ask students to begin to chew the crackers
but not to swallow right away. Enzymes in
saliva begin to break down the starches,
and the cracker takes on a sweet taste after
it is held in the mouth for a short period of
time.
III. Understanding Diabetes Mellitus—Hormones that Control Blood
5
Glucose Levels
A. Insulin
1. Increases the movement of glucose out of the blood and into cells
2. Causes the liver to take up the glucose out of the blood and convert it
into glycogen
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
Weblink
Go to www.bradybooks.com
and click on the mykit link for Prehospital
Emergency Care, 9th edition to access a
web resource on insulin resistance.
PAGE 1
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
3. Decreases the blood glucose level and facilitates the movement of the
glucose into the cells and the liver
4. Not needed in order for glucose to cross into the brain
B. Glucagon
1. Converts glycogen stored in the liver back into glucose and releases it
into the blood (opposite of insulin)
2. Converts other, noncarbohydrate substances into glucose
3. Increases and maintains the blood glucose level, converting glycogen
and other substances into glucose
C. Other hormones (epinephrine)
1. Released by the adrenal glands when the blood glucose level is
decreasing to a dangerously low level
2. Stops the secretion of insulin and promotes the release of stored
glucose from the liver as well as the conversion of other substances in to
glucose
IV. Understanding Diabetes Mellitus—Normal Metabolism and Glucose
5
Regulation
A. Blood glucose level increases within hour after first meal.
B. Insulin, released from the pancreas, increases movement of glucose into
cells.
C. As body cells, the liver, and the brain take up the glucose, the blood glucose
level lowers.
D. Pancreas secretes glucagon as the blood glucose level drops.
E. Liver converts glycogen back to glucose and releases into blood stream.
F. Glucose in blood stream maintains normal range until next meal.
V. Understanding Diabetes Mellitus—Checking the Blood Glucose
5
Level
A. Glucose meters can determine blood glucose, or sugar, level (BGL).
1. Normal blood glucose level is 80–120 mg/dL.
2. Normal level following a meal is 120–140 mg/dL.
3. Determine when the patient last had something to drink or eat.
4. Average BGL in a diabetic patient is 200 mg/dL.
5. Hypogylcemia is a BGL of 60 mg/dL or less with signs or symptoms OR
50 mg/dL with or without signs and symptoms.
6. Hyperglycemia is a persistent BGL greater than 120 mg/dL.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
Knowledge Application
Ask students to explain what happens to
glucose and hormone levels in response to
eating and fasting.
Teaching Tip
Use the analogy of a thermostat’s role in
regulating heat to explain the pancreas’ role
in regulating blood glucose levels.
Discussion Question
How is the blood glucose level normally
regulated?
Video Clip
Go to www.bradybooks.com
and click on the mykit link for Prehospital
Emergency Care, 9th edition to access a
video on how to use a blood glucose meter.
Discussion Questions

At what point is a patient considered
hypoglycemic?
 At what point is a patient considered
PAGE 2
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
B. Use glucose meters in conjunction with information collected in history and
signs in physical examination.
C. Determine whether medical direction or local protocol allow you to test the
patient’s BGL.
D. Test the BGL prior to administration of any oral glucose or sugar-containing
solution.
E. Ensure that you have a glucose meter, glucose meter test strips, a lancet, a
lancet device (optional), and alcohol swabs.
F. Follow the steps listed in Table 20-1.
10
VI. Understanding Diabetes Mellitus—Diabetes Mellitus (DM)
A. Disturbance in metabolism of carbohydrates, fats, and proteins
1. Lack of insulin being secreted by pancreas
2. Inability of the cell receptors to recognize the insulin and allow glucose
to enter at a normal rate
3. Brain has more glucose than it needs since it does not require insulin
while the body cells are starving for glucose.
B. Common signs and symptoms
1. Elevated blood glucose level (hyperglycemia)
2. Polydipsia: frequent thirst
3. Polyuria: frequent urination
4. Polyphagia: frequent hunger
5. Prone to a wide variety of diseases and disorders involving blood
vessels
C. Types
1. Type I diabetes
a. Also called insulin-dependent diabetes mellitus (IDDM)
b. Pancreas does not secrete insulin.
c. Peak age is 10–14 years.
d. Patient may suffer from diabetic ketoacidosis (DKA) or
hypoglycemia.
2. Type II diabetes
a. Also called non-insulin dependent mellitus
b. Typically overweight and middle-aged or older patients
c. May suffer from hyperglycemic hypersmolar nonketotic syndrome
(HHNS)
d. More common than Type I diabetes
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
hyperglycemic?
Video Clip
Go to www.bradybooks.com
and click on the mykit link for Prehospital
Emergency Care, 9th edition to access a
video on diabetes.
Critical Thinking Discussion
What causes the three “Ps” of untreated
diabetes mellitus?
Discussion Question
What are the similarities and differences
between Type I and Type II diabetes?
PAGE 3
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
15
Content Outline
Master Teaching Notes
VII. Acute Diabetic Emergencies—Hypoglycemia
A. Patient suffers from low blood glucose level.
B. More common in Type I IDDM patients
C. Most dangerous acute complication of diabetes mellitus; can result in brain
cell death
D. Pathophysiology of hypoglycemia
1. Noted as blood sugar less than 60 mg/dL with signs and symptoms of
hypoglycemia or less than 50 mg/dL with or without signs and symptoms
2. Patient takes insulin but with excessive results for one of the following
reasons.
a. Patient takes insulin and does not eat a meal.
b. Patient takes insulin, eats a meal, but drastically increases activity
beyond normal.
c. Patient takes too much insulin (either takes too much at one time or
forgets and takes another dose).
E. Assessment findings in hypoglycemia (also referred to as “insulin shock”)
1. Signs and symptoms caused by epinephrine release
a. Diaphoresis
b. Tremors
c. Weakness
d. Hunger
e. Tachycardia
f. Dizziness
g. Pale, cool, clammy skin
h. Warm sensation
2. Signs and symptoms caused by brain cell dysfunction
a. Confusion
b. Drowsiness
c. Disorientation
d. Unresponsiveness (coma)
e. Seizures
f. Stroke-like symptoms
3. Misinterpretation of signs and symptoms can be deadly (Look for a
medical bracelet.)
F. Hypoglycemia unawareness: Signs and symptoms may change over time,
causing the person to become unaware of the drop in glucose level and
suddenly experiencing hypoglycemia.
G. Emergency medical care for hypoglycemia
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
Weblink
Go to www.bradybooks.com
and click on the mykit link for Prehospital
Emergency Care, 9th edition to access a
web resource with a NIH interactive X-plain
tutorial about hypoglycemia.
Discussion Question
What are the likely events leading to an
episode of hypoglycemia?
Class Activity
Draw a grid on the white board with
Hypoglycemia and Hyperglycemia as
column headings. Label rows Signs,
Symptoms, History, and Management.
Have students fill in the grid. Review the
grid, emphasizing key points and filling in
any gaps.
Critical Thinking Discussion
Why do patients with hypoglycemia often
present with bizarre or aggressive
behavior?
PAGE 4
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
1. It is important that the patient is given sugar to increase the blood
glucose level as quickly as possible to prevent the brain cells from dying.
2. Unresponsive patient, patient unable to swallow, or patient unable to
obey your commands
a.
Establish open airway.
b.
Provide oxygen via a nonrebreather mask at 15 lpm if breathing is
adequate.
c.
Provide positive pressure ventilation if breathing is inadequate.
d.
Contact advanced life support.
e.
Assess the blood glucose level.
3. Responsive patient, patient able to swallow, or patient able to obey your
commands
a.
Ensure airway is patent.
b.
Assess the blood glucose level if your protocol permits.
c.
Administer one tube of oral glucose.
4. Continuously reassess patient’s condition
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VIII. Acute Diabetic Emergencies—Oral Glucose
A. Heavy sugar gel that raises the amount of glucose circulating in the blood
and increases the amount of glucose available to the brain
B. Criteria for administration
1. Altered mental status
2. History of diabetes controlled by medication or blood glucose reading
less than 60 mg/dL
3. Ability to swallow
C. If patient does not meet all three criteria, provide emergency care as if for a
patient with altered mental status and an unknown history.
Discussion Question
What are the management priorities for
patients with hypoglycemia?
Animation
Go to www.bradybooks.com
and click on the mykit link for Prehospital
Emergency Care, 9th edition to access an
animation about the use of oral glucose.
Teaching Tip
Pass around tubes of oral glucose for
students to see and handle.
IX. Acute Diabetic Emergencies—Hyperglycemia
A. Condition where diabetic patient is suffering from a lack of insulin and a high
blood glucose level
B. Patients may suffer diabetic ketoacidosis (DKA) or hyperglycemic
hyperosmolar nonketotic syndrome (HHNS) from being hyperglycemic.
X. Acute Diabetic Emergencies—Hyperglycemic Condition: Diabetic
20
Ketoacidosis (DKA)
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
PAGE 5
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
A. Pathophysiology of DKA
1. Most common in Type I diabetic
2. Brain has an excess amount of glucose, and the other cells in the body
are starving for glucose because of an inadequate amount of insulin.
3. Effects include dehydration, acidosis, and cardiac disturbances.
4. Causes
a. Infection that has upset the insulin and glucose balance
b. Inadequate dose of insulin
c. Medications such as Thiazide, Dilantin, or steroids.
d. Types of stress such as surgery, trauma, pregnancy, or heart attack
e. Change in diet
B. Assessment findings in DKA
1. Polyuria
2. Polyphagia
3. Polydipsia
4. Nausea and vomiting
5. Poor skin turgor
6. Tachycardia
7. Rapid deep respirations (Kussmaul’s respirations)
8. Fruity or acetone odor on the breath (from ketone buildup)
9. Positive orthostatic tilt test
10. Blood glucose level greater than 350 mg/dL
11. Muscle cramps
12. Abdominal pain
13. Warm, dry, flushed skin
14. Altered mental status
15. Coma
C. Emergency medical care for DKA
1. Establish and maintain a patent airway.
2. Provide oxygen via a nonrebreather at 15 lpm if the breathing is
adequate.
3. If the breathing is inadequate, provide positive pressure ventilation with
oxygen connected to the ventilation device.
4. If protocol permits, determine the blood glucose level.
5. If you are unsure about the condition, administer oral glucose if the
patient is able to swallow since hypoglycemia could cause brain cell
death.
6. Contact medical direction for further orders.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
Discussion Question
What are the management priorities for
patients with hyperglycemia?
PAGE 6
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
XI. Acute Diabetic Emergencies—Hyperglycemic Condition:
15
Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
A. Pathophysiology of HHNS
1. Most common in Type II diabetic
2. Condition that causes the blood glucose level to increase dramatically
(600–1,200 mg/dL)
3. Glucose draws large amounts of water into the urine
4. Less fat burned for energy than in DKA (meaning lesser production of
ketones)
5. May be first indication that patient has diabetic condition
6. Possible causes
a. Diabetic condition
b. Trauma
c. Burns
d. Dialysis
e. Drugs
f. Heart attack
g. Stroke
h. Infection
i. Head injuries
B. Assessment findings in HHNS
1. Tachycardia
2. Fever
3. Positive orthostatic tilt test
4. Dehydration
5. Polydipsia
6. Dizziness
7. Poor skin turgor
8. Altered mental status
9. Confusion
10. Weakness
11. Dry oral mucosa
12. Dry, warm skin
13. Polyuria
14. Nausea and vomiting
C. Emergency medical care for HHNS
1. Emergency care is the same as for DKA.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
Discussion Question
How are DKA and HHNS distinguished
from one another?
Critical Thinking Discussion
Why is the blood glucose level typically
higher in HHNS than in DKA?
Weblink
Go to www.bradybooks.com
and click on the mykit link for Prehospital
Emergency Care, 9th edition to access a
web resource on Hyperglycemic
Hyperosmolar Nonketotic Syndrome.
Knowledge Application
Given several different scenarios, students
should be able to identify patients with
hypoglycemia and hyperglycemia.
PAGE 7
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
2. When in doubt or protocol does not permit you to distinguish between
hypoglycemia, DKA, or HHNS, treat the patient as if he is hypoglycemic
to prevent brain death or even the patient’s death.
XII. Assessment-Based Approach: Altered Mental Status in a Diabetic
5
Emergency—Scene Size-Up and Primary Assessment
A. Assess the patient in the same manner as an altered mental status patient
with no known history of diabetes mellitus
B. Err on the side of caution by administering oral glucose if you are unable to
assess the patient with a glucose meter
C. Scene size-up and primary assessment
1. Look for clues gathered during the scene size-up and primary
assessment that may lead you to suspect that the patient may be
diabetic (e.g., prescription medications).
2. Look for medical alert tags or other medical identification.
XIII. Assessment-Based Approach: Altered Mental Status in a Diabetic
10
Emergency—History and Secondary Assessment
A. Secondary assessment
1. Ask SAMPLE history questions
2. Medications often taken by diabetics
a. Insulin (Humlin®, Novolin®, Iletin®, Semilente®)
b. Actos®
c. Diabanese®, Glucamide®
d. Orinase®
e. Micronase®, Diabeta®
f. Tolinase®
g. Glucotrol®
h. Humalog®
i. Glucophage®
j. Glynase®
k. Exenatide (Byetta®)
l. Exubra®
3. Important questions
a. Did the patient take his medication the day of the episode?
b. Did the patient eat (or skip any) regular meals on that day?
c. Did the patient vomit after eating a meal on that day?
d. Did the patient do any unusual exercise or physical activity on that
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
Discussion Questions

What are some medications that would
indicate to you that your patient is a
diabetic?
 What are some key characteristics to
help differentiate between hypoglycemia
and hyperglycemia?
Knowledge Application
Given several descriptions of patients with
altered mental status, students should be
able to obtain a relevant history to
PAGE 8
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
day?
e. Was the onset of altered mental status gradual or fast?
f. How long has the patient had the signs and symptoms?
g. Are there any other signs or symptoms associated with the altered
mental status?
h. Is there any evidence of injury that might be the cause of the altered
mental status?
i. Was there any period in which the patient regained a normal mental
status and then deteriorated again?
j. Did the patient suffer a seizure?
k. Does the patient appear to have a fever or other signs of infection?
B. Signs and symptoms
1. Rapid onset of an altered mental status after missing or vomiting a meal,
unusual exercise, or physical work
2. Intoxicated appearance
3. Tachycardia
4. Cool, moist skin
5. Hunger
6. Seizure activity
7. Uncharacteristic or bizarre behavior, combativeness
8. Anxiousness or restlessness
9. Bruising at insulin injection sites on the abdomen
10. Stroke symptoms (in elderly patient)
11. Blood glucose reading of < 60 mg/dL
XIV. Assessment-Based Approach: Altered Mental Status in a Diabetic
5
Emergency—Emergency Medical Care
A.
B.
C.
D.
Establish and maintain an open airway.
Determine if the patient is alert enough to swallow.
Administer oral glucose.
Transport.
determine if the patient is more likely
suffering from hypoglycemia or
hyperglycemia.
Class Activity
Have pairs of students role play assessing
and instructing each other as if they were
assessing a patient to see if they can
swallow and follow commands in order to
receive oral glucose.
Critical Thinking Discussion
Why is it important to err on the side of
giving glucose if in doubt about a patient’s
blood glucose level?
XV. Assessment-Based Approach: Altered Mental Status in a Diabetic
5
Emergency—Reassessment
A. Reassess the patient to determine if the oral glucose has had any effect.
B. If local protocol permits, retest the blood glucose level.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
PAGE 9
Chapter 20 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
C. If the patient’s BGL is increasing and mental status is improving, the patient
is likely suffering from a low blood glucose level.
D. If otherwise, the patient may be suffering from another condition in addition
to the low blood glucose level.
E. Communicate and record any changes in the patient’s condition.
XVI. Assessment-Based Approach: Altered Mental Status in a Diabetic
5
Emergency—Summary: Assessment and Care
A. Review assessment findings that may be associated with diabetic
emergencies and emergency care for diabetic emergencies.
B. See Figures 20-10a and b and 20-11 and Table 20-2.
5
XVII. Follow-Up
A. Answer student questions.
B. Case Study Follow-Up
1. Review the case study from the beginning of the chapter.
2. Remind students of some of the answers that were given to the
discussion questions.
3. Ask students if they would respond the same way after discussing the
chapter material. Follow up with questions to determine why students
would or would not change their answers.
C. Follow-Up Assignments
1. Review Chapter 20 Summary.
2. Complete Chapter 20 In Review questions.
3. Complete Chapter 20 Critical Thinking.
D. Assessments
1. Handouts
2. Chapter 20 quiz
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 20
Case Study Follow-Up Discussion
Why is it important to check the
refrigerator for medications?
 Why was Mr. Bennet placed on his left
side after receiving oral glucose?

Class Activity
Alternatively, assign each question to a
group of students and give them several
minutes to generate answers to present to
the rest of the class for discussion.
Teaching Tips

Answers to In Review and Critical
Thinking questions are in the appendix
to the Instructor’s Wraparound Edition.
Advise students to review the questions
again as they study the chapter.
 The Instructor’s Resource Package
contains handouts that assess student
learning and reinforce important
information in each chapter. This can be
found under mykit at
www.bradybooks.com.
PAGE 10