Diabetic treatment

[MacAttack]

A quick question for a few of our medical people.

How would you asses and treat a diabetic in the field? Or in other words what would you do about someone you don't know going through a diabetic problem?


I only ask this because of someone I work with and his problem. Obviously he has diabetes and has had a few "zone out" situations at work. He told us what to do for him but what should or could we do for others we run across in or daily travels.

[98pointsix]

Truths, and assumptions.
1 You cannot determine hypo/hyperglycemia without a glucometer, the syptoms are to close to call
2 If your bloodsugar is too high its because your insulin levels ar too low. More sugar will not make this situation worse.
3 If your bloodsugar is too low more sugar will fix the problem.
4 Outside of the bloodvessels and digestive system sugar DESTROYS things
5 Less than concious people WILL aspirate things put into thier mouths. In the case of sugar see above.
6 Diabetic crisis looks, smells, and acts just like a drunk prick.
7 There arre several ways to administer sugar in the field look them up Im not going into it. (People get all butthurt if you bring it up)
That help at all?

[MacAttack]

Somewhat.

I knew there was a difference but was hoping that a non meter way was available to positively tell the difference.


With my co-worker his sugar would be low and we would just give him sugar and he would be fine in a few minutes.

With my other friend his sugar was always high and he would need insulin.


In both cases they each looked lethargic and a bit disoriented. Like a drunk sort of. Unless things went on to long untreated then it was off to the hospital.



Thanks. I just wanted to make sure.

[Sixty-Eight Whiskey]

I knew there was a difference but was hoping that a non meter way was available to positively tell the difference.

There is, if you're experienced enough. But even then I'd not recommend not backing up your diagnosis with a testing.

As for treatment, we've got something in our cars called "Jubin" which is basically a gel of pure sugar. So even if the person is unconscious you can still put it in his mouth without danger of aspiration. Of course this is just first aid until you can administer a Glucose IV but it's really handy if you don't have one at you for example.

[JIM]

Simply said:

Diabetic people don't make enough insulin so their bloodsugar rises. They take insulin which lowers the blood sugar. A undiscovered diabetic that doesn't take meds will always have a high bloodsugar, not a low one.

So when there's a diabetic emergency and the victim hasn't eaten enough, exercised to much or injected too much insulin the bloodsugar is low. In other cases the bloodsugar is too high.

[Ad'lan]

My experience dealing with a diabetic.

[QuietRiot]

98pointsix wrapped it up pretty neatly. Although the signs and symptoms differ slightly, a blood glucose meter reading is the only difinitive way to tell the difference. Never administer field treatments without a blood test.

If the patient has proven low blood sugar (meter reading below 60) is concious and can maintain their own airway, you can give oral sugar preparations. This can be tubes of "insta glucose" from walmart or something as simple as a coke or some orange juice with an extra tablespoonful of sugar mixed in. The key points for this treatment are:

Never EVER EVER put anything in the mouth of an unconcious patient. If they are not alert enough to talk to you, they will likely just choke on whatever you try to give them. Now you have an obstructed airway on top of the diabetic emergency.

Oral glucose is fast acting, but it wears off just as quick. Their blood glucose will spike temporarily, but they need some starches to replenish their long-term stores or they will crash again 10 minutes after you leave. When I am working on the ambulance my diabetic cocktail is oral or IV glucose, a soda and a good old peanut butter and jelly sammich.

Patients with high blood sugar are usually taking some form of insulin. I suppose that you could assist them with their meds if you have been trained to do so, but the prehospital treatment around here is mostly start IV fluids to dilute the blood. Have you ever made a powdered drink and ended up with the sugary sludge in the bottom of the glass? That is what is trying to squeeze through their veins. I dont know what the laws are where you live, but in my area first responders are not allowed to perform any invasive procedures like IVs, so check your local protocols. Just to underline a point 98pointsix made, IV glucose will destroy, necrose, kill dead any tissue that contacts it, so if you are not in the vein or the fluid is leaking out, you can do big damage.

You have to understand before you can treat, so here is a detailed article explaining hypoglycemia (low blood sugar diabetes) http://www.ems1.com/ems-products/educat ... oglycemia/

And one on hyperglycemia (high blood sugar diabetes) http://www.ems1.com/ems-products/consul ... -Syndrome/

[sdjt60emt]

Most of you have wrapped this up well but from personal experience as both an EMT and a diabetic, the outward signs of hypo/hyperglycemia may look the same but symptoms are a different story. If they are combative, it could be either but do not make it worse by forcing them to do anything. Calmly suggest they should think about it. If someone points out that I look low my body will become conscious of it and the symptoms will arise. Every time I have gotten low it is a new story and a different combination of symptoms (i.e., blurred vision, irritability, lack of feeling in legs, etc.). If they have high blood sugar they sometimes emit a fruity/acetone smell while someone who is low can stumble and seem drunk. Remember, hypoglycemia becomes apparent quicker than hyperglycemia.

[rakkFO]

[quote="Sixty-Eight WhiskeyThere is, if you're experienced enough. But even then I'd not recommend not backing up your diagnosis with a testing.

As for treatment, we've got something in our cars called "Jubin" which is basically a gel of pure sugar. So even if the person is unconscious you can still put it in his mouth without danger of aspiration. Of course this is just first aid until you can administer a Glucose IV but it's really handy if you don't have one at you for example.[/quote]

Sixty-Eight Whiskey can you tell me more about this "Jubin" it sound like oral glucose ( which you are not recemended to give to an unconcious) but you say you CAN give this to an uncinsious? I am not saying you are wrong diffrent parts of country / ems systems do things diffrent and it instrests me.
we can go off thread if you want to PM me
Thanks for your service! Happy Veterans Day.

[jimdawg]

Kind of bringing up an semi old topic, but as a type 1 diabetic, I have been through and learned a lot about low blood sugars. As far as the comment from sixtey-eight whiskey and rakkfo, You can pick up glucose gels at your local pharmacy and even walmart and kmart carry it too. If you you don't have that luxury, the tubes of gel cake icing work too. Squirt a good shot into the individual's mouth between the lower lip and gums and massage it in. This is the best way to administer glucose to an unconscious diabetic, unless they are carrying a glucagon kit, which is a syringe of solution and a vial of powder. Shoot the solution into the vial, shake it up real good, draw it back out and inject the person. Make sure you inject it into a fatty area like the thighs, stomach, of back of the arms, depending on the build of the person.

[MacAttack]

Sorry but unless I get training I'm not injecting anyone with anything unless its good old man goo into a happy and willing recipient.

[JustInCase]

Kind of bringing up an semi old topic, but as a type 1 diabetic, I have been through and learned a lot about low blood sugars. As far as the comment from sixtey-eight whiskey and rakkfo, You can pick up glucose gels at your local pharmacy and even walmart and kmart carry it too. If you you don't have that luxury, the tubes of gel cake icing work too. Squirt a good shot into the individual's mouth between the lower lip and gums and massage it in. This is the best way to administer glucose to an unconscious diabetic, unless they are carrying a glucagon kit, which is a syringe of solution and a vial of powder. Shoot the solution into the vial, shake it up real good, draw it back out and inject the person. Make sure you inject it into a fatty area like the thighs, stomach, of back of the arms, depending on the build of the person.

How do you know that they are having a low blood sugar episode if they are unconscious? Is there a difference between a high sugar problem and a low sugar problem? Before you give them some kind of treatment wouldn't you want to test the blood first?

[AbelAbbot]

The major goal in treating diabetes is to minimize any elevation of blood sugar without causing abnormally low levels of blood sugar. Diabetes is treated first with weight reduction, a diabetic diet, and exercise. Thanks a lot for sharing.

[jjesusfreak01]

How do you know that they are having a low blood sugar episode if they are unconscious? Is there a difference between a high sugar problem and a low sugar problem? Before you give them some kind of treatment wouldn't you want to test the blood first?

I'm intending this post to be fairly definitive info for diabetic emergencies, so if anyone is interested, read on. I'm a NC EMT-B finishing up training as an EMT-I, so i'm both educated in these treatments and have done them on many occasions. Now, to answer the question...

You probably won't be able to tell the difference between a high/low sugar condition if they are unconscious. A DKA patient (high blood sugar, haven't had their insulin, digesting proteins and forming ketones) may have fruity/acetone/alcohol smelling breath from the production of ketones. A hypoglycemic seizure/coma patient will conceivably have their normal bad breath. Their is a third category of patient who has an extended period of high blood sugar with limited insulin production called HHS, but you may be less likely to see it and it is less dangerous than the other two conditions.

If you have a person who is a known diabetic and has been for a while, they are very unlikely to be in DKA. For a person to go into diabetic ketoacidosis, they have to stop taking their insulin altogether. Sometimes when diabetics get sick they lose the ability to regulate their blood sugar well, ie, they can't control it with standard doses of insulin, in which cases they may need to seek definitive medical care (read: hospital) to prevent HHS.

BLS care (for use in remote environments where emergency care isn't readily available):
Low blood sugar (or hypoglycemia) is by far the most likely blood sugar problem for you to encounter in the field. If you are with the patient start to finish, they may tell you ahead of time they are about to go out (they experience an "aura") and they may seize. These seizures usually last only a few minutes and are not seriously damaging to the patient if they last for only a few minutes. Use standard care for a seizure patient, that is, protect them from injuring themselves on nearby objects. The definitive care for this condition is sugar, whether it be oral, IV, or a PB&J sandwich. If you encounter a patient with suspected hypoglycemia, check their blood glucose if you can. If you are unable to check their sugar, but still have good reason to believe that is the cause, you can attempt to administer oral glucose or a similar substance. Despite what you have been warned, in an emergency situation you can give oral sugar to an semi-conscious patient. The best way to do it is to have them in a sitting position and to place the sugar under their tongue and at the gumline outside their teeth. This prevents them from aspirating the sugar even if they don't have great control of their airway. Keep in mind that some diabetics may rebound back to consciousness after seizing without any assistance, so take care to ensure that the situation warrants using oral glucose.

ALS care (for those with appropriate training in austere/wilderness environments): Glucagon is given IM to a patient when venous access isn't available. It releases glycogen stores from the liver, which are converted to glucose. These patients will still quickly need complex carbohydrates to prevent recurrent hypoglycemia. The glucagon may not even work completely and you may still need to reattempt IV access. If IV access is readily available, consider D50. IV Dextrose (D50) will almost instantaneously raise a person's blood glucose (you are literally injecting sugar into their bloodstream), but will also be short acting. IV dextrose should bring a person out of a diabetic coma even if glucagon does not. It must be followed by making the patient eat complex carbs to prevent recurrent hypoglycemia. The most important thing to remember if giving D50 is that you MUST ensure you are in a vein before pushing it (you'll kill all the tissue around if you inject it into muscle or skin). This can be done by drawing back on the syringe filled with the D50 and seeing blood return.

Again, don't attempt any of these treatments (aside from proper care of a seizing patient) if you have trained medical providers available within 30 minutes via the EMS system. Otherwise healthy diabetic patients rarely keel over, even from serious hypoglycemic episodes.

[shrapnel]

Sorry but unless I get training I'm not injecting anyone with anything unless its good old man goo into a happy and willing recipient.

What makes old man goo good or not? And do you have to pulverize the old man yourself, or can you get packets of pre-gooed old man?

[LowKey]

And do you have to pulverize the old man yourself, or can you get packets of pre-gooed old man?

Sure you can.
Check the waste baskets of motel rooms, gutters on lovers lane's, and underneath the bleachers at your local high school. You may have some luck looking around freshman college housing as well.


Happy hunting!

[MacAttack]

Sorry but unless I get training I'm not injecting anyone with anything unless its good old man goo into a happy and willing recipient.

What makes old man goo good or not? And do you have to pulverize the old man yourself, or can you get packets of pre-gooed old man?

I hope you don't have to pulverize your old man just to get his goo out. That would boarder on spousal abuse. Or you two are just REALLY kinky.




Maybe I could have added a comma to make my original post clearer though.

[JustInCase]

How do you know that they are having a low blood sugar episode if they are unconscious? Is there a difference between a high sugar problem and a low sugar problem? Before you give them some kind of treatment wouldn't you want to test the blood first?

I'm intending this post to be fairly definitive info for diabetic emergencies, so if anyone is interested, read on. I'm a NC EMT-B finishing up training as an EMT-I, so i'm both educated in these treatments and have done them on many occasions. Now, to answer the question...

You probably won't be able to tell the difference between a high/low sugar condition if they are unconscious. A DKA patient (high blood sugar, haven't had their insulin, digesting proteins and forming ketones) may have fruity/acetone/alcohol smelling breath from the production of ketones. A hypoglycemic seizure/coma patient will conceivably have their normal bad breath. Their is a third category of patient who has an extended period of high blood sugar with limited insulin production called HHS, but you may be less likely to see it and it is less dangerous than the other two conditions.

If you have a person who is a known diabetic and has been for a while, they are very unlikely to be in DKA. For a person to go into diabetic ketoacidosis, they have to stop taking their insulin altogether. Sometimes when diabetics get sick they lose the ability to regulate their blood sugar well, ie, they can't control it with standard doses of insulin, in which cases they may need to seek definitive medical care (read: hospital) to prevent HHS.

BLS care (for use in remote environments where emergency care isn't readily available):
Low blood sugar (or hypoglycemia) is by far the most likely blood sugar problem for you to encounter in the field. If you are with the patient start to finish, they may tell you ahead of time they are about to go out (they experience an "aura") and they may seize. These seizures usually last only a few minutes and are not seriously damaging to the patient if they last for only a few minutes. Use standard care for a seizure patient, that is, protect them from injuring themselves on nearby objects. The definitive care for this condition is sugar, whether it be oral, IV, or a PB&J sandwich. If you encounter a patient with suspected hypoglycemia, check their blood glucose if you can. If you are unable to check their sugar, but still have good reason to believe that is the cause, you can attempt to administer oral glucose or a similar substance. Despite what you have been warned, in an emergency situation you can give oral sugar to an semi-conscious patient. The best way to do it is to have them in a sitting position and to place the sugar under their tongue and at the gumline outside their teeth. This prevents them from aspirating the sugar even if they don't have great control of their airway. Keep in mind that some diabetics may rebound back to consciousness after seizing without any assistance, so take care to ensure that the situation warrants using oral glucose.

ALS care (for those with appropriate training in austere/wilderness environments): Glucagon is given IM to a patient when venous access isn't available. It releases glycogen stores from the liver, which are converted to glucose. These patients will still quickly need complex carbohydrates to prevent recurrent hypoglycemia. The glucagon may not even work completely and you may still need to reattempt IV access. If IV access is readily available, consider D50. IV Dextrose (D50) will almost instantaneously raise a person's blood glucose (you are literally injecting sugar into their bloodstream), but will also be short acting. IV dextrose should bring a person out of a diabetic coma even if glucagon does not. It must be followed by making the patient eat complex carbs to prevent recurrent hypoglycemia. The most important thing to remember if giving D50 is that you MUST ensure you are in a vein before pushing it (you'll kill all the tissue around if you inject it into muscle or skin). This can be done by drawing back on the syringe filled with the D50 and seeing blood return.

Again, don't attempt any of these treatments (aside from proper care of a seizing patient) if you have trained medical providers available within 30 minutes via the EMS system. Otherwise healthy diabetic patients rarely keel over, even from serious hypoglycemic episodes.

Thank you!

[jimdawg]

I always carry a glucose meter with me and extra testing supplies no matter where I go. Any prepared diabetic would do the same. It takes less than 30 seconds to prick someones finger and find out if they are low or high. At that point, you can take the necessary steps to help them. I also carry a glucagon kit with me wherever I go just in case I crash to the point where I cannot bring my glucose level up on my own. I normally feel it before it gets really bad, the issue in a survival situation is getting sugar in the body to bring it up safely. For that, I always carry an insulin pen with me if its too high and at least 2 large bottles of glucose tabs if its low. I also have a large bottle of pure honey and 4 tubes of cake gel icing in my BOB if I run out of the tabs. The cake gel icing is a great backup method of bringing up someones sugar level and they can be had for next to nothing at the grocery store. The honey has somewhere around 17g of carbs per tsp or tbsp (can't remember which, but makes a great alternate source of carbs if I'm out in the middle of nowhere. You must also remember that for the body to digest anything, you need water. Obviously you don't want to dump water down someones throat if they are unconscious but once the victim is stabilized (if possible) then get fluids in them. I carry a swiss gear quick BOB with me everywhere I go that has all my supplies and 2 bottles of water "just in case." It may be a pain in the ass but it's better than not having anything at all. Anther great reason to have a glucose meter with you at all times is that a panic/anxiety attack will give you the same feeling as a low blood sugar. ALWAYS test before taking action. I get really bad panic attacks if sugar goes above 250 (working with a new specialist to get it better controlled) and the last thing you want to do is take more sugar based on the assumption that you are having a low. I've seen people go into seizures and pass out at 400. My FAK has 2 glucose meters and extra batteries and testing supplies just in case. They can be had for a low as $10 for the walmart Reli on brand and is definitely worth having one in case you run into a diabetic in a survival situation. Testing supplies for it are dirt cheap too.

Another note, proteins such as peanut butter will help to stabilize glucose levels too. They have carbs to raise the blood sugar but the protein will help to keep them from crashing a second time.

[m1lkm4n]

Diabetes runs in my family, and while I am not diabetic, I have a lot of experience dealing with them. I was hoping to be able to add something constructive, but it looks like it has already been handled quite thoroughly.

...a soda and a good old peanut butter and jelly sammich...

Of course after reading that, now I'm just plain hungry...

[uzoezie22]

Indeed there is a difference but try to back it up with a testing.
Thanks

[croaker260]

I know that much of this thread is old, but I feel compelled to speak up.

1- Many "diabetic emergencies" that happen are self corrected by the patient. Even if you are a health care provider, often the patient knows as much or more about their own physiologic condition and they should be recruited into any first aid or more advanced care.

2- Those "diabetic emergencies" that are beyond the ability for the patient to self correct usually involve some degree of altered mental status. I could go into differentiating the difference between HHNC, DKA, and hypoglycemia, but in the end...IT DOESNT MATTER .

I want to repeat this because it is important.

IT DOESNT MATTER.
(Why you may ask?)

Because at that point it is first and foremost an ALTERED MENTAL STATUS emergency FIRST, and then a diabetic emergency SECOND.

What does this mean to you?

You first aid consists of:

1- Protect the patient from further harm. If he is stumbling around, help him sit down. If he is sitting down, make sure he doenst fall off of something, etc.

2- Protect his airway. A general rule is if the patient cant hold a cup to drink/eat something himself, you sure shouldnt give him anything. If he is "down and out" a simple jaw thrust is a valuable skill. So is the "recovery position".

3- DONT ASSUME ITS A DIABETIC EMERGENCY. Diabetics can have strokes, heart attacks, siezures, overdoses, alcohol withdrawl, be drunk, and everything else just like you or me.

Its not a diabetic emergency until its PROVEN to be a diabetic emergency. Until then its an ALTERED MENTAL STATUS. Treat and respond accordingly.

(nothing says friendship like filling up your airway with glucose gel when you are having a stroke)

One final thought. it may surprise you to know that I have seen more medics injured on diabetic calls than most other call types. Not shootings, not domestic violence, not traffic accidents. Why? Because we conduct ourselves differently (*weather we admit it or not) on these calls where we already assume there is a danger. We would be wrong of course. I have seen normally good normal people swing at paramedics, pulll guns, pull knives, and in one case...body slam an ambulance (yes, the whole ambulance) hard enough to set off the Gforce alarms...all because they were confused and combative.

So, take care of your friend, but be cautious, and treat the emergnecy first, then the underlying problem of the emergency once you are SURE that is what it is.

[croaker260]

Their is a third category of patient who has an extended period of high blood sugar with limited insulin production called HHS, but you may be less likely to see it and it is less dangerous than the other two conditions.

.

Just for what its worth, this statement is not completely true. If you are interested in themildy more complicated truth, PM me and I will do mybest to explain it over a forum like this. And for what its worth, the mortality of HHNC vs DKA is significantly higher.

[duodecima]

One final thought. it may surprise you to know that I have seen more medics injured on diabetic calls than most other call types. Not shootings, not domestic violence, not traffic accidents. Why? Because we conduct ourselves differently (*weather we admit it or not) on these calls where we already assume there is a danger. We would be wrong of course. I have seen normally good normal people swing at paramedics, pulll guns, pull knives, and in one case...body slam an ambulance (yes, the whole ambulance) hard enough to set off the Gforce alarms...all because they were confused and combative.

So, take care of your friend, but be cautious, and treat the emergnecy first, then the underlying problem of the emergency once you are SURE that is what it is.

True dat. I was taking care of a guy in severe DKA, who was going to be flown to a tertiary center because he was getting WORSE after about 90 min of treatment. We knew him well, he was generally an abusive jerk. We knew he was starting to turn the corner and respond to treatment when, shortly before transport, he went from almost unresponsive to swinging at the nurses.