and a randomized controlled trial comparing D10W and D50W, have demonstrated that D10W administration is safe and effective for adults [14,23–25]. In the randomized trial, there was no difference in time to regain consciousness among hypoglycemic patients when comparing the administration of 10% dextrose versus 50% dextrose. In the 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 [24].
For patients in whom IV access cannot be achieved in a timely manner, the administration of IM glucagon provides a means of rescue. However, in alcoholic or malnourished patients with depleted glycogen storage, it is less likely to be beneficial. Recovery time may be significantly longer with glucagon than with dextrose, with response times of 8‐21 minutes depending on the severity of hypoglycemia. Although glucagon is generally considered as an IM drug, it has also been used successfully subcutaneously and intranasally [26–30]. Intranasal glucagon has been shown to have comparable efficacy to IM or subcutaneous glucagon and is devoid of most of the technical difficulties associated with administration of an injectable medication [31]. Both IM and intranasal glucagon elevate glucose levels, but the response is faster in those treated via the IM route [29]. Sibley et al. described the case of a diabetic hypoglycemic patient who was successfully treated with intranasal glucagon in the prehospital setting without further side effects or complications [30]. A prospective, open‐label study found that a single 3 mg dose of intranasal glucagon administered by caregivers was effective in treating moderate symptomatic hypoglycemic events in children and adolescents with type 1 diabetes [32]. A human factors study simulating treatment of severe hypoglycemia showed nasal delivery of glucagon to be much faster, with a higher success rate than injection, for trained caregivers of insulin‐using persons (16 seconds vs. 1.9 minutes for time to administer, 94% vs. 50% for successful delivery) and for untrained acquaintances (26 seconds vs. 2.4 minutes, 93% vs. 20% for successful delivery) for intranasal and IM administrations, respectively [33, 34]. At present, intranasal glucagon costs more than IM glucagon, but the ability to treat patients quicker and with less training may reduce the need for advanced life support response and hospital visits, lessening the overall burden in the health system.
Intraosseous access is another potential route to provide dextrose for critically ill hypoglycemic patients without IV access. However, this should be reserved for severe clinical circumstances given that intraosseous insertion poses a risk for infection or poor wound healing in diabetic patients.
Hyperglycemia
Hyperglycemia is defined as a blood glucose level greater than 200 mg/dL (11.1 mmol/L). An elevated glucose level alone does not represent a medical emergency. However, very high glucose levels and hyperglycemia in the setting of DKA are urgent medical problems that should be recognized and treated accordingly.
When DKA is treated properly, it rarely produces residual effects. Before the discovery of insulin in 1922, the mortality rate was 100%. Over the last three decades, DKA mortality rates have markedly decreased in developed countries, from 7.96% to 0.67% [35]. EMS clinicians encounter this condition predominantly in type 1 diabetics, but it may also rarely occur in type 2 diabetics dependent on daily insulin therapy to maintain glycemic control. DKA may be precipitated by metabolic stressors such as infectious processes, myocardial infarction, pregnancy, and trauma, especially if they interrupt the insulin regimen. Patients may present with nonspecific signs and symptoms that include fatigue, tachypnea, altered sensorium, abdominal pain, nausea, vomiting, polydipsia, and polyuria. They may also present with severe dehydration, hypotension, or “Kussmaul’s respirations” (deep, rapid respiration) as the body attempts to expire excess carbon dioxide to compensate for the metabolic acidosis [36].
Although little research has been dedicated to EMS treatment of DKA, most emergency medicine treatment modalities can apply out‐of‐hospital. Recognition and expeditious initiation of treatment are critical. IV fluid resuscitation should be started to correct volume depletion. These patients should be closely monitored. There is no role for insulin therapy in the prehospital setting. An important caveat relates to pediatric patients, for whom there is a risk of life‐threatening cerebral edema with rapid volume repletion. For children, insulin (at the hospital) plays a more critical early role, and initial resuscitation should only be intended to reverse appearance of shock or hypotension. Additional correction of a fluid deficit should occur over 24‐48 hours.
Patients with hyperglycemia may present with hyperosmolar hyperglycemic syndrome (HHS). HHS is a serious diabetic emergency with a mortality rate as high as 20%, about ten times higher than that of DKA [37]. While EMS clinicians may not be able to differentiate DKA from HHS, they may suspect it from the patient’s history. HHS is more common in patients with type 2 diabetes and is triggered by the same stressors that elicit DKA. Patients with HHS present with marked volume depletion, necessitating the initiation of intravenous fluid resuscitation without delay. Field treatment should be targeted to hemodynamic stabilization first. Fluid boluses should be given with continuous monitoring and frequent reassessment of vital signs.
Pediatric Considerations
The SEARCH for Diabetes in Youth Study indicated that, during 2014‐2015, there were 24,049 newly diagnosed cases of diabetes among children and adolescents younger than 20 years; 18,291 had type 1 diabetes. Between 2002 and 2015, the overall incidence of type 1 and type 2 diabetes has significantly increased [3]. Prehospital clinicians should be alert for hyperglycemia in children with volume depletion, weight loss, polydipsia, and polyuria, as this may be the patient’s first presentation of diabetes. In addition, hypoglycemia should be suspected and glucose should be measured in any pediatric patient who has altered mental status, has volume depletion secondary to illness such as gastroenteritis, or for whom there is concern for medication overdose. In one study of children requiring resuscitation in an ED, 18% were found to be hypoglycemic, requiring administration of dextrose [24]. For the seizing pediatric patient, EMS clinicians should focus on early benzodiazepine administration. Hypoglycemia is a rare cause of pediatric seizures. Blood glucose should be measured if the patient continues to seize despite treatment or has a persistent altered mental status [38].
The prehospital management of pediatric hypoglycemia mirrors that of treatment in the adult. The recognition of hypoglycemia followed by administration of dextrose is paramount. Dextrose for children and infants should be diluted to at least 25% because dextrose is irritating to vascular structures. Because 10% dextrose is effective in children and adults, EMS systems may be able to carry a single concentration [18]. Table 20.2 provides guidance for treating hypoglycemia in pediatric patients using a D10W solution. Hyperglycemia is treated with fluid resuscitation as appropriate, given the patient’s vital signs, with attention to the issue of potential cerebral edema discussed above.
Pregnancy
EMS clinicians may occasionally encounter glucose derangements in pregnant patients. Insulin resistance is increased during pregnancy. The incidence of gestational diabetes was 8.9% during 2007‐2014 [5]. Current medical practice is to intensively manage glucose in the pregnant patient to avoid complications such as macrosomia or intrauterine fetal death. Because of this very tight glucose control, pregnant patients occasionally experience hypoglycemia. Alternatively, given the emphasis on tight glycemic control, hyperglycemia is rare, with the exception of the noncompliant or undiagnosed patient. Treatment of hypoglycemia and hyperglycemia in the pregnant patient is no different than that in the nonpregnant patient [39, 40].
Medication overdose
Intentional insulin overdose has been reported with some frequency in the literature. Persistent or refractory hypoglycemia should prompt the EMS clinician to consider the possibility of overdose,