Diabetic Emergencies

An article in the New England Journal of Medicine, dated December 28, 1995, states that patients with Insulin Dependant Diabetes Mellitus (IDDM) where unaware of impending hypoglycemia because they maintained normal glucose uptake in the brain, which preserves cerebral metabolism, during the impending hypoglycemic event. There are many logical (non-medical, unproven) conclusions that can be drawn from these findings, two such conclusions are: The brain utilizes stores of glucose from within; and/or, the brain is able to 'draw' glucose from the blood when blood-glucose levels are below those at which other 'body cells' are unable. Whatever the case the brain "demands" the final amounts of systemic glucose during a hypoglycemic event.

And what about a hypoinsulinemic event?

There is a common belief among some researchers that some tissues do not require insulin for efficient uptake of glucose: important examples are brain and the liver. This not only serves as an indication of the high degree of dependency of the brain on glucose, but also serves as good news for the DKA patient, because it means that the 'health' of the brain is not affected by the lack of insulin. It may, however, be threatened by inadequate perfusion secondary to the circulation of "pancake syrup" (a less-emergent situation.)

Diabetes Mellitus

For the patient of hypoglycemia, however, the lack of available blood glucose represents an IMMEDIATE threat to the "health" of the brain, and subsequently an IMMEDIATE life threat as glucose storage is depleted. This patient needs sugar (glucose, dextrose, fructose, etc.) And they need it NOW! A patient with developing hypoglycemia will present with respirations that are normal (or slightly faster than normal,) and most likely shallow. The rest of the presentation will most likely mimic DKA.

For that reason, we would like to highlight the differences between some of the signs and symptoms of Insulin Shock and Diabetic Coma. A patient in Insulin Shock will experience a RAPID onset of symptoms (within minutes) and will probably be breathing at a near-normal rate, while the patient in Diabetic Coma will most likely report that the development of symptoms has taken several hours (or even days) and will be breathing rapidly and deeply (impending Kussmaul Respirations.) The "rapid onset" of symptoms associated with Insulin Shock should remind you that the condition demands a "rapid treatment". Patients in Insulin Shock have very little time before permanent brain damage may occur. Left unchecked, both conditions can (and will) lead to unresponsiveness. It is very possible that you will encounter an unresponsive patient, with a history of diabetes, and be unable to determine if it is Insulin Shock or Diabetic Coma, without the aid of a glucometer. Assume the worst (Insulin Shock) and make IMMEDIATE arrangements for transport to the nearest facility, or transport to intercept the responding ALS Paramedics. This unconscious patient needs immediate IV Dextrose. If this were a conscious, but confused, diabetic patient and again you were unable to determine the cause (hypo or hyperglycemic) again, assume the worst, and administer some oral glucose, and closely monitor the patient for changes. Recovery from Insulin Shock is almost as quick as the onset of symptoms.

Your text will explain the proper method for administering oral glucose to a patient, and probably goes into detail on the different types of diabetes (type I and type II,) but we wanted to add something different to the 'mix' by giving you some of the "inside scoop" on what was happening to your patient in Diabetic Emergency. We feel it gives you a better basis from which to make treatment decisions.