Emergency Live – Pre-Hospital Care, Ambulance Services, Fire Safety and Civil Protection Magazine
Diabetes is a group of metabolic disorders that involve elevated blood sugar levels over a prolonged period of time.
If left untreated, diabetes can cause many complications.
Acute complications may include diabetic ketoacidosis, hyperglycaemic hyperosmolar state or death.
Serious long-term complications include cardiovascular disease, stroke, chronic kidney disease, foot ulcers, nerve damage, eye damage and cognitive impairment.
Although diabetes is characterised by high blood sugar, low blood sugar (or hypoglycaemia) is a major concern for patients with diabetes.
Hypoglycaemia occurs when the plasma glucose concentration falls below 70 mg/dL; most patients do not experience symptoms until plasma glucose levels fall below 55 mg/dL.
A low plasma glucose concentration that requires assistance from another individual qualifies as severe hypoglycaemia.
In 2019, an estimated 463 million people have diabetes worldwide (8.8 per cent of the adult population), with type 2 diabetes accounting for about 90 per cent of cases.
Diabetes rates are similar in women and men.
Trends suggest that rates will continue to increase over time.
Unfortunately, diabetes at least doubles the risk of early death.
In 2019, diabetes caused about 4.2 million deaths and was the seventh leading cause of death worldwide.
Hypoglycaemia is a major concern for patients with diabetes and the main reason for a diabetes-related emergency room call.
Hypoglycaemia is a condition in which the level of sugar (glucose) in the blood is lower than normal.
Glucose is the body’s main source of energy.
Hypoglycaemia occurs when a person’s plasma glucose concentration falls below 70 mg/dL.
However, most patients do not experience symptoms until plasma glucose levels fall below 55 mg/dL.
A low plasma glucose concentration that requires assistance from another person qualifies as severe hypoglycaemia and, depending on the context, all first aid interventions fall into this category.
Hypoglycaemia is often related to the treatment of diabetes.
But other drugs and a number of conditions, many of them rare, can cause low blood sugar in people who do not have diabetes.
When blood sugar levels are low, hypoglycaemia must be treated immediately.
For many people, a fasting blood sugar of 70 milligrams per decilitre (mg/dL) or less, or 3.9 millimoles per litre (mmol/L), should be an alarm for hypoglycaemia.
Treatment consists of rapidly bringing blood glucose back to normal with high-sugar foods or drinks or with medication.
Long-term treatment requires identifying and treating the cause of hypoglycaemia.
An episode of hypoglycaemia, or low blood sugar, can be unpleasant and dangerous.
You may feel confused and have difficulty concentrating.
Other symptoms of hypoglycaemia are dizziness, rapid heartbeat, blurred vision, tremors, weakness and headaches.
This is why it is essential to assess the risk of hypoglycaemia during diabetes treatment.
Once the risk factors are known, the physician can help develop a strategy to prevent hypoglycaemia before it becomes severe.
Increasing age. The risk of severe hypoglycaemia approximately doubles for every decade of life after age 60.
This may be due to the fact that older people are more sensitive to medication.
Skipping meals. If you suffer from diabetes, skipping a meal can alter the glycaemic balance and cause glucose levels to fall too low.
Taking some diabetes drugs without food can greatly increase the likelihood of having a hypoglycaemic episode.
Skipping meals can also make people eat more foods rich in refined carbohydrates, which are not suitable for people with diabetes.
Irregular eating patterns. Eating randomly or inconsistently throughout the day can alter the balance between blood sugar levels and diabetes medication.
Research also shows that people with regular eating habits have a lower risk of hypoglycaemia than those with irregular eating habits.
Intense exercise. When you exercise, you consume blood glucose faster and increase your sensitivity to insulin.
To avoid hypoglycaemia during exercise, it is a good idea to test blood glucose before, during and after exercise and adjust your diet or medication accordingly.
It may be necessary to snack or take a glucose tablet before or after exercise to maintain proper blood sugar levels.
Weight loss. Weight management is essential for treating diabetes.
But if you lose weight too quickly, you may become more sensitive to insulin, which could mean that you need less insulin.
Before starting a weight-loss programme, consult your doctor.
You may need to adjust the dosage of some diabetes drugs to avoid hypoglycaemic episodes.
Taking beta-blockers. Beta-blockers can make it difficult to recognise the symptoms of hypoglycaemia.
For instance, one sign of hypoglycaemia is an accelerated heart rate.
But beta-blockers can slow down the heart rate so that this symptom is not recognised.
If you take a beta-blocker, you should check your blood sugar levels more often and eat consistently.
Using the same injection site. Insulin injected repeatedly at the same site can cause lipohypertrophy, i.e. the accumulation of fat and scar tissue under the surface of the skin.
Lipohypertrophy can affect the way the body absorbs insulin, with an increased risk of hypoglycaemia and hyperglycaemia.
For this reason, it is essential to rotate the injection sites.
Antidepressants. The use of antidepressants has been associated with hypoglycaemia.
Tricyclic antidepressants have been more associated with the risk of severe hypoglycaemia than selective serotonin reuptake inhibitors.
Symptoms of depression, such as loss of appetite, may also contribute to an increased risk of hypoglycaemia.
Drinking alcohol. Alcohol blocks glucose production in the liver.
With alcohol and diabetes medication in your system, your blood sugar can drop rapidly.
If you drink alcohol, remember to have a meal or snack before going to bed.
Also, be very careful when monitoring your blood glucose levels the next day.
Cognitive dysfunction. People with diabetes who also have cognitive dysfunction, such as dementia or Alzheimer’s disease, may be at increased risk of hypoglycaemia.
People with cognitive dysfunction may have irregular eating habits or frequently skip meals.
They may also accidentally take the wrong dose of their medication, which can lead to hypoglycaemia.
Underlying kidney damage. The kidneys play a key role in metabolising insulin, reabsorbing glucose and removing drugs from the body.
For this reason, people with diabetes and kidney damage may be at increased risk of hypoglycaemia.
Underactive thyroid. The thyroid gland releases hormones that help the body regulate and utilise energy.
Hypothyroidism occurs when the thyroid gland does not produce enough thyroid hormones, causing a slowdown in metabolism.
As a result, diabetes medication lingers in the body, which can lead to hypoglycaemia.
Gastroparesis. Gastroparesis is a condition in which the stomach empties too slowly.
This condition can be the result of an interruption of nerve signals in the stomach.
Although many factors can cause gastroparesis, including viruses or acid reflux, it can also be caused by diabetes.
With gastroparesis, the body does not absorb glucose at a normal rate.
If insulin is taken with a meal, blood sugar levels may not respond as expected.
Having diabetes for a long time. The risk of hypoglycaemia also increases in people with a longer history of diabetes.
This may be due to taking insulin therapy for a longer period of time.
Pregnancy. Pregnancy involves a major change in hormones.
Women with diabetes may experience a drop in blood glucose levels during the first 20 weeks of pregnancy.
Taking a standard dose of insulin may be too much.
If you are pregnant, talk to your doctor about reducing your insulin dose to avoid hypoglycaemia.
Seek help immediately if
Call the Emergency Number if a person with diabetes or a history of hypoglycaemia presents symptoms of severe hypoglycaemia or loses consciousness.
If insulin or another drug is used to lower blood sugar and signs and symptoms of hypoglycaemia occur, blood sugar levels should be tested with a glucometer.
If the result shows a low blood sugar level (below 70 mg/dL), treat accordingly.
If you are not using drugs known to cause hypoglycaemia, your doctor will want to know the following:
In case of symptoms of hypoglycaemia, proceed as follows:
Hypoglycaemia is considered severe if you need someone’s help to recover. For example, if you are unable to eat, you may need an injection of glucagon or intravenous glucose.
In general, people with diabetes treated with insulin should have a glucagon kit for emergencies. Family members and friends should know where to find the kit and how to use it in an emergency.
If you are helping someone who is unconscious, do not try to give them food or drink. If a glucagon kit is not available or you do not know how to use it, call an emergency doctor immediately.
To prevent recurrent hypoglycaemias, it is necessary for the doctor to identify the underlying condition and treat it. Depending on the underlying cause, treatment may include
In the event of an emergency due to diabetic symptoms, a rescuer or paramedic will probably be the first healthcare professional to assess and treat your condition.
Rescuers have a set of well-defined protocols and procedures for most emergencies they encounter, including diabetes symptoms.
For all suspected symptoms of diabetes, the first step is a rapid and systematic assessment of the patient.
For this assessment, most rescuers use the ABCDE approach.
ABCDE stands for Airway, Breathing, Circulation, Disability, and Exposure.
The ABCDE approach is applicable in all clinical emergencies for immediate assessment and treatment.
It can be used on the street with or without equipment.
It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals or intensive care units.
THE RADIO OF RESCUERS AROUND THE WORLD? IT’S RADIOEMS: VISIT ITS BOOTH AT EMERGENCY EXPO
The National Association of State EMT Officials (NASEMSO) National Model EMS Clinical Guidelines provide treatment guidelines for hyperglycaemia on page 75 and for hypoglycaemia on page 78.
NASEMSO maintains these guidelines to facilitate clinical guidelines, protocols, and operating procedures for state and local EMS systems.
These guidelines are evidence-based or consensus-based and have been formatted for use by EMS professionals.
The guidelines include the following inclusion criteria for hyperglycaemia:
Exclusion criteria: Patient in cardiac arrest
The guidelines include the following inclusion criteria for hypoglycaemia:
Exclusion criteria: Patient in cardiac arrest
This protocol may be used to treat patients who have been previously diagnosed with diabetes and who currently present with altered mental status:
If blood glucose is below 60 mg/dl and if:
EMT IN THE USA – If blood glucose is below 60, be prepared to start a D5W drip and administer 200 cc of D5W or give intravenous glucagon 1 mg for adults, 0.5 mg for children under 1 year of age or give 50% dextrose intravenously. Recheck blood glucose in 10-15 minutes.
If blood glucose is 60 or above, start intravenous administration of NS. If systolic blood pressure is less than 90, administer 200 cc of NS, recheck blood pressure, then titrate the IV rate according to the patient’s condition (see discussion of “IV fluid rates” in the Intravenous Lines protocol).
PRESCRIBE MEDICAL CONTROL. Obtain the order to administer glucagon.
Adult/child – Glucagon 1 mg. I.M.
Children under 1 year – Glucagon 0.5 mg I.M. in the anterolateral thigh.
Repeat blood glucose test in 15-20 minutes. REPORT TO MEDICAL CONTROL. Glucagon can be repeated in 20 minutes with doctor’s permission.
Transport. Consider ALS intercept for hypoglycaemic patients who do not respond to initial treatment.
Treatment protocol and release (ONLY with medical control authorisation)
Do not consider transport with medical control authorisation for patients who have received the above treatment and meet ALL of the following criteria:
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