Diabetic emergencies: Patients with no history of diabetes
Erratic glucose levels can indicate a number of more serious conditions that should be considered before releasing a patient
By Joseph Tadlock, EMS1 Contributor
It can be easy to forget about differential diagnoses when presented with something as common as hypoglycemia. Diaphoresis and an altered consciousness all lead to what can be an obvious working diagnosis of hypoglycemia. A quick finger stick and suspicions can be confirmed with a glucose monitor.
Emergency room visits can expensive, and EMS crews in some cities are tasked to the breaking point. To address this, some EMS crews allow their members to treat hypoglycemia without transporting the patient. This is great in cases when hypoglycemia is a reoccurring event in a patient’s life, and can potentially save them from a costly ER bill, in addition to freeing up the EMS crew for other calls.
However, there are times when what may seem routine may actually indicate that something more severe has caused the patient’s blood glucose levels to fluctuate. Hypoglycemia and hyperglycemia are both potentially fatal, but it’s more common in elderly patients and individuals who may be living with additional diseases. While treating and releasing a patient can be beneficial, there are many things to consider when choosing to let a patient sign a refusal form.
Glucose levels in a healthy body rise and fall throughout the day, and the pancreas responds to this through the release of insulin or glucose to help regulate serum levels. Islet and beta cells release these hormones which move through a duct into the duodenum. There, they perform their function in the digestive system and regulate the glucose levels in the serum.
Additionally, other enzymes, such as amylase, are secreted to help break down carbohydrates and lipase for proteins. A normal pancreas can maintain these levels in healthy individuals, however, any disruption in this organ can lead to wildly varying levels to the point of death. In patients who have an onset of glucose levels that are out of normal ranges, this can indicate something potentially life-threatening.
In the U.S., pancreatic cancer is the fourth most-common cancer diagnosis. Epidemiological evidence suggests that pancreatic cancer and diabetes share a direct relationship. Studies show that between 25 and 50 percent of patients with a pancreatic cancer diagnosis are determined to be diabetic within 36 months of the cancer diagnosis. As such, being called to a pancreatic cancer patient’s home whose glucose levels fall outside of the normal range may be indicative of a more serious issue.
Of course, while we can’t treat cancer prehospital, and most typical ER visits won’t either, it’s noteworthy to mention to a patient that the potential cause for their glucose abnormality may be due to something more severe. A follow-up visit with their general practitioner would be beneficial and may reveal the underlying cause of their episode.
The older we get the less sensitive our noses become to smells. Alcohol on the breath of patients can be easily overlooked, especially outside in windy environments or where other strong odors might mask the smell of alcohol. Hypoglycemia could be due to acute alcohol intoxication, and therefore treating and releasing might not be in a patient’s best interest. While most medics wouldn’t miss other possible signs of alcohol intoxication, leaving a patient behind without someone to take responsibility for the patient can lead to legal troubles.
Sepsis has been implicated in hypoglycemia after a study in the 1980s. Bacteremia in a patient that results in sepsis can lead to systemic organ failure. If left untreated this will lead to abnormal function of – and eventually no function – of the pancreas. A patient may respond to a dextrose bolus, however, many may not in extreme cases where other pancreatic functions are impaired. A thorough assessment may reveal tachycardia, hypotension and an elevated temperature. This is especially important to keep in mind with patients of an advanced age, as they have much higher mortality rates with comorbidities.
The liver is an incredible, yet undervalued internal organ. It’s prone to trauma and yet can generally, though not always, repair itself. When it comes to maintaining blood sugar, the liver is an important piece of the homeostasis equilibrium. By breaking down glycogen stores, the liver helps maintain human glucose levels within the blood. The liver is also responsible for metabolizing 50 percent of insulin, while the rest is metabolized within the kidneys. Without the ability to break down insulin, glucose can increase dramatically. At the other end of the spectrum, hypoglycemia can occur in hepatitis patients receiving interferon therapy.
These are the most common situations that can occur for a new onset of hypo- or hyperglycemia in a patient with no diabetic history. It’s important to not lose focus during patient treatment. Equally important is that it’s vital to understand the events leading up to a hypoglycemic patient’s condition, and to take into consideration that there’s an underlying – and potentially more sinister – cause than a lack of breakfast. Being a patient advocate means more than treating and releasing. While that can be beneficial and help save patients money, their safety and well-being is more important that any amount of money.
About the author
Joseph Tadlock is a paramedic located in Texas. He is finishing his bachelor's degree in biology with a minor in education. He enjoys kayaking, bicycling and spending the little spare time he has with his girlfriend and their two dogs. He may be reached at firstname.lastname@example.org.