"When you are called to the scene of a diabetic emergency, your task will not be to diagnose or treat diabetes but rather to recognize and treat a condition that diabetes, or the poor management of, has caused." (Limmer and O, 2007)
I was recently paged out for a "diabetic problem." Upon arriving to the scene, we found our 64 year old, female patient supine on the couch, snoring and her husband about to administer glucagon. He handed the vial with needle and syringe prepped to me, stated her blood sugar was 45 and that the glucagon would bring her "out of this." He then stepped into the other room. (Why he left the room? I have no idea.)
As EMT-B, it is out of our scope of practice to administer glucagon. Unsure what to do, we set the vial aside. I proceeded with my assessment and a sternal rub. The patient opened her eyes, looked at me and then closed them again. We placed oxygen via a NRB at 15 LPM. We obtained a set a vital signs and rechecked her blood sugar, which was now at 30 mg/dL. BP was slightly elevated and HR was in the 60-70 range. Patient was cool, clammy, diaphoretic, slightly pale.
The husband re-entered the room at this point. We informed him that we couldn't give the glucagon, but if he wanted to he could. So he did. Brigham EMS arrived on scene at this time.
We waited for the glucagon to work it's magic. Several minutes passed, the patient starting waking up. We assisted her to a sitting position. When she was a little more coherent, the husband gave her milk, bread and ginger ale. She complained of being nauseous and didn't want to eat anything. (Later I learned, glucagon makes you nauseous.)
Patient denied need for transport and husband stated he would continue to monitor his wife.
I came home (about 0430) and decided that before I could go back to sleep I needed to learn more about glucagon. Here's a little bit of what I learned.
glucagon (gloo-ka-gon)*
Classification:
Therapeutic: hormones
Pharmacologic: pancreatics
Indications:
Acute management of severe hypoglycemia when administration of glucose is not feasible.
Action:
Stimulates hepatic production of glucose from glycogen stores (glycogenolysis). Relaxes the musculature of the GI tract (stomach, duodenum, small bowel, and colon), temporarily inhibiting movement. Has positive inotropic and chronotropic effects.
Therapeutic Effects: Increase in blood glucose. Relaxation of GI musculature, facilitating radiographic examination.
Route: IM
Onset: within 10 min
Peak: 30 min
Duration: 12-27 min
Route: IV
Onset: within 1 min
Peak: 5 min
Duration: 9-17 min
Adverse Rxn/Side effects:
CV: hypotension.
GI: nausea, vomiting.
Misc: hypersensitivity reactions including anaphylaxis.
Route/Dosage:
Hypoglycemia
IV, IM, Subcut (adults & children > 20 kg)
1 mg; may be repeated in 15 min if necessary
Assessment:
Assess for signs of hypoglycemia (sweating, hunger, weakness, headache, dizziness, tremor, irritability, tachycardia, anxiety) prior to and periodically during therapy.
Assess neurological status throughout therapy. Institute safety precautions to protect patient from injury caused by seizure, falling or aspiration.
Feed patient supplemental carbohydrates orally to replenish liver glycogen and prevent secondary hypoglycemia as soon as possible after awakening, especially pediatric patients.
Assess for nausea and vomiting after administration of dose. Protect patients with depressed level of consciousness from aspiration by positioning on side; ensure that a suction unit it available.
*Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2012). Davis's drug guide for nurses. (12 ed., pp. 634-36). Philadelphia: F A Davis Co.
Quick Overview of Diabetes Mellitus**
Glucose, a form of sugar, is the body's basic source of energy. They sugars that a person eats are converted into glucose, which is then absorbed into the blood stream. However, this blood sugar cannot simply pass from the bloodstream into the body's cells. To enter the cells, insulin, a hormone produced by the pancreas must be present. Without insulin, the cells can be surrounded by glucose but still starve for sugar.
When sugar intake and insulin production are balanced, the body can effectively use sugar as an energy source. If, for some reason, insulin production decreases, glucose cannot be used by the cells. This glucose remains in circulation increasing in concentration as more sugars are digested by the person. The level of blood sugar climbs, eventually to be spilled over into the urine. High sugar leads to increased urine output, which in turn makes the patient abnormally thirsty.
Hypoglycemia
The most common medical emergency for the diabetic patient is a condition called hypoglycemia, or low blood sugar. Hypoglycemia is caused when the diabetic does any one of the following:
- takes too much insulin, thereby putting too much sugar into the cells and leaving too little sugar in the blood
- reduces sugar intake by not eating
- over-exercises or over-exerts self, thus using sugars faster than normal
- vomits a meal, emptying the stomach of sugar as well as other food
When blood sugar is thus reduced, an altered mental status, possible unconsciousness, even permanent brain damage can occur quickly if the sugar is not replenished. Rapid onset, abnormal behavior, and very sweaty skin are all typical of a sudden drop in blood sugar level. Quick administration of glucose, when it can be done without threatening the airway (that is, if the patient is conscious and can swallow), is critical to this patient's outcome. Glucose must be given promptly, before the patient becomes unconscious.
Hyperglycemia
High blood sugar. Usually caused by a decrease in insulin, which leaves sugar in the bloodstream rather than allowing it to enter the cells. The insulin deficiency may be due to the body's inability to produce insulin or may exist because insulin injections were forgotten or not given in sufficient quantity. Infection, stress, or increasing dietary intake can also be a factor in hyperglycemia.
Unlike, hypoglycemia, hyperglycemia generally has a slower onset with the patient experiencing increased urination, thirst and hunger. the patient may also be nauseated and have an acetone-like odor on their breath.
Patient Assessment
- Perform an initial assessment. Identify altered mental status.
- Perform focused history and physical exam. Gather the history from the patient or bystanders.
- gather history of the present episode. Ask about how the episode occurred, time of inset, duration, associated symptoms, any mechanism of injury or other evidence of trauma, whether there have been any interruption to the episode, seizures, fever.
- during SAMPLE history, determine if the patient has a history of diabetes.
- perform blood glucose monitoring
- Determine if the patient is alert enough to swallow
- Take baseline vital signs. (In some cases, oral glucose should be administered before vitals are taken)
- If the patient has a history of diabetes, has an altered mental status, and is alert enough to swallow, prepare to administer oral glucose by squeezing it onto a tongue depressor.
- Insert the tongue depressor and oral glucose into the patient's mouth between the cheek and gum. Or, if appropriate, allow the patient to do so. Leave in place until the oral glucose has been absorbed or until the patient can no longer protect her airway. The tongue depressor should then be removed from the patient's mouth.
- Re-assess the patient.
**Limmer, D., & O, M. F. (2007). Emergency care. (10th ed., pp. 422-29). Upper Saddle River, NJ: Pearson Prentice Hall.
All in all, it was an educational call for me.
