diabetes. Additionally, 51 million people aged 40 to 74 years had impaired glucose tolerance, impaired fasting glucose, or both [3]. Diabetes occurs more frequently in Native American, Hispanic, and African American populations.
One‐and‐a‐half million new cases of diabetes are diagnosed annually, and diabetes‐related visits to U.S. emergency departments (EDs) totaled 16 million in 2016 [3, 4]. Approximately 235,000 ED visits were for hypoglycemia; 22.3% of which resulted in hospital admission. In the same interval, there were approximately 203,000 ED visits for diabetic ketoacidosis (DKA) [3].
The cost of diabetes in the United States is staggering. In 2017, an estimated $327 billion dollars were spent annually for direct and indirect medical costs [3]. After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than expenditures in the absence of diabetes [5].
As the prevalence of diabetes increases, clinicians are more likely to encounter patients experiencing hypoglycemic and hyperglycemic emergencies. Diabetes‐related EMS responses are greater among young adults, males, and non‐Hispanic black people with diabetes. However, more than one third of patients are not transported to the ED for further care [6].
While most EMS responses for diabetic emergencies are for hypoglycemia, both hypoglycemia and hyperglycemia can result in fatal outcomes [1]. Thus, the ability of EMS clinicians to recognize and promptly initiate appropriate treatment for diabetic emergencies is crucial.
Prehospital assessment
General
The initial evaluation of a diabetic emergency starts with the public safety answering point telecommunicator when 9‐1‐1 is notified. Important information may be obtained while the response unit is dispatched. Treatment may begin with prearrival instructions. The telecommunicator can often identify a diabetic‐triggered event, despite challenges of obtaining medical information during a 9‐1‐1 call [7]. However, medical oversight is vital to ensure quality within the interrogation protocols and that prearrival instructions are appropriately given (see Chapter 88).
Once EMS personnel arrive, scene safety is a priority, given that patients experiencing diabetic emergencies may have altered mental status and act in unpredictable ways. While some calls for diabetic emergencies may specify the exact condition, such as hypoglycemia, many patients will have nonspecific complaints such as nausea, vomiting, dizziness, or abdominal pain, requiring EMS clinicians to gather information to determine the cause of the illness.
Table 20.1 Key elements in the prehospital assessment of diabetic emergencies
| Evaluation of ABCs and level of consciousnessABCs (airway, breathing, circulation)AVPU scale (alert, verbal, painful, unresponsive)Vital signsGlucose checkHistoryPast medical history, diabetes mellitus?Recent illness or injuryPregnancyPrecipitating factorsPhysical examinationGeneral impressionFocused examination |
As with any other patient presentation, EMS clinicians should obtain a thorough history, review all medications, and conduct a comprehensive physical examination. (Table 20.1) A patient experiencing a diabetic emergency should be placed on a cardiac monitor, if available, due to the possibility of electrolyte disturbances. The history is particularly important, as gathered information may focus treatment plans, especially in patients with altered mental status. Key elements in the assessment of a patient with altered mental status should include 1) a medical history, especially history of diabetes; 2) medications; 3) onset of symptoms; 4) complete set of vital signs; and 5) measurement of glucose. A diabetic patient may receive insulin through a subcutaneous insulin pump, which allows insulin to be absorbed gradually. A physical exam is important, as this device may be hidden from view during the initial assessment. Insulin pumps administer rapid‐acting insulin that is provided around the clock at a specific rate. Increased exercise, illness, or decreased food intake may promote hypoglycemic episodes. These devices may be removed in hypoglycemic patients, and local EMS protocols should provide guidance in this regard.
Other considerations
The EMS clinician should assess not only the specific diabetic emergency, but also consider the reason behind the glycemic dysregulation. The possibility of intentional overdose in the hypoglycemic depressed patient, or of inadvertent overdose in the elderly or confused patient, should be considered. Attention should be paid to the patient’s type of insulin or medication. Long‐acting insulin use may require close monitoring of the patient by a responsible adult at home or continuous monitoring and additional treatment at the hospital. Patients taking certain oral hypoglycemic agents such as sulfonylureas 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 elderly or debilitated patients. Other acute illnesses, such as myocardial infarction, stroke, or pancreatitis, and recent cocaine use can also cause hyperglycemia in the diabetic patient. Of course, poor compliance with medication regimens may be a factor, as well.
Measurement of glucose
Prehospital measurement of plasma glucose using a glucometer is a key element of assessment. 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 some were harmed, as in the case of stroke [8, 9]. Glucometer use by prehospital personnel is safe and accurate [10, 11]. Glucose test strips must be stored in temperature‐controlled sections of the ambulance to maintain shelf life and ensure they provide reliable results [12]. Prehospital measurement of plasma glucose is now considered standard practice in EMS.
Prehospital treatment
Hypoglycemia
Diabetic management emphasizes tight glycemic control to prevent long‐term complications, such as heart disease, kidney disease, and blindness. Tight glycemic control is a fine line to walk, and occasional episodes of hypoglycemia may be expected. Severe hypoglycemia can be a surrogate measure for declining health. An epidemiologic analysis found that severe hypoglycemia is associated with a higher absolute risk of cardiovascular events and mortality [13]. Hypoglycemia, usually defined as a serum glucose concentration less than 70 mg/dL (3.8 mmol/L), is the most common endocrine emergency [9]. While hypoglycemia can occur in a variety of settings, it is most commonly a complication of the treatment of diabetes [14]. Estimates are that people with diabetes suffer mild (self‐treated) hypoglycemic events one to two times per week and that 30% of people with diabetes suffer severe hypoglycemic events annually [15–18].
Symptomatic hypoglycemia requires intervention to prevent organ compromise. Prehospital treatment options include oral glucose, IV dextrose, or 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, administration of 50% dextrose IV has been the standard for many years. One study found an average blood glucose elevation of 166 mg/dL following administration of 50% dextrose (50 mL), but the response varied widely among patients (range: 37 mg/dL to 370 mg/dL) [19]. Dextrose administered IV results in a rapid onset of action (2‐5 minutes). There are, however, several reports in the literature of soft tissue injury secondary to extravasation, which can cause significant complications, including compartment syndrome and loss of limb [20, 21].
Dextrose as a 10% solution (D10W) is becoming more commonly used due to its lower risk of skin or soft tissue injury should extravasation occur, diminished risk of hyperglycemia due to overcorrection of hypoglycemia, and lower cost relative to D50W [22]. Recent observational cohort studies of