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Chapter 19
Diabetic Emergencies
and Altered Mental Status
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
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U.S. DOT Objectives are covered and/or supported by the PowerPoint™ Slide
Program and Notes for Emergency Care, 11th Ed. Please see the Chapter 19
correlation below.
*KNOWLEDGE AND ATTITUDE
• 4-4.1 Identify the patient taking diabetic medications with altered mental status
and the implications of a diabetes history. Slides 9, 14-15, 18-33
• 4-4.2 State the steps in the emergency medical care of the patient taking
diabetic medicine with an altered mental status and a history of diabetes. Slides
21-42
• 4-4.3 Establish the relationship between airway management and the patient
with altered mental status. Slides 14, 20-21, 28-29, 42, 45, 53, 59, 65
• 4-4.4 State the generic and trade names, medication forms, dose,
administration, action, and contraindications for oral glucose. Slides 37-42
• 4-4.5 Evaluate the need for medical direction in the emergency medical care of
the diabetic patient. Slide 28
• 4-4.6 Explain the rationale for administering oral glucose. Slides 34-42
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
U.S. DOT Objectives Directory
*SKILLS
• 4-4.7 Demonstrate the steps in the emergency medical care for the patient
taking diabetic medicine with an altered mental status and a history of diabetes.
• 4-4.8 Demonstrate the steps in the administration of oral glucose.
• 4-4.9 Demonstrate the assessment and documentation of patient response to
oral glucose.
• 4-4.10 Demonstrate how to complete a prehospital care report for patients with
diabetic emergencies.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Diabetes Mellitus
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Diabetes Mellitus
The condition brought about by
decreased insulin production, or the
inability of the body cells to use
insulin properly (which prevents the
body’s cells from taking the simple
sugar called glucose from the
bloodstream)
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Insulin Allows Sugar to Pass from
the Bloodstream to the Body’s Cells
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Diabetes and Insulin
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Click here to view an animation on diabetes and insulin.
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Normal Glucose Regulation
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Diabetes Is Treated with Injections
of Insulin or Oral Medication
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Diabetic
Emergencies
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Two Types of Diabetic
Emergencies
Hypoglycemia
Hyperglycemia
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Hypoglycemia
Hypoglycemia (low blood sugar)
is a life-threatening emergency
for people with diabetes.
It is the most common
emergency for the diabetic
patient.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Hypoglycemia
After taking too much insulin
Vomiting
After unusual amount of exercise
Reduced sugar intake caused by
not eating
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Signs and Symptoms
of Hypoglycemia
Rapid onset
Intoxicated appearance, staggering,
slurred speech, unconsciousness
Cold, clammy skin
Rapid heart rate
Seizures (severe cases)
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Signs and Symptoms
of Hypoglycemia
Unusual or bizarre behavior
Anxiety
Refusal to cooperate or
combativeness
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Hyperglycemia
Hyperglycemia (high blood sugar)
is a slow-onset condition from
decreased insulin levels in people
with diabetes.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Hyperglycemia
Forgotten or insufficient insulin dose
Infection
Stress
Increased dietary intake
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Signs and Symptoms
of Hyperglycemia
Slow onset
Nausea/vomiting
Acetone odor on breath
Increased urination/hunger/thirst
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Distinguishing the Difference
Hypoglycemia
Hyperglycemia
Rapid onset
Slow onset
Skin is cold, pale,
moist, or
“clammy.”
Skin is warm, red,
or dry.
No breath odors
Acetone odor on
breath
Increased
urination/hunger/
thirst
Abdominal cramps
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing Diabetic Emergencies
Perform initial assessment.
Perform focused history and
physical exam.
Get SAMPLE history.
– Note any medical alert tags.
Take baseline vital signs.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
Perform initial
assessment.
– Maintain airway.
– Administer
oxygen.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
Perform focused history and
physical exam.
– When and how did it start?
– How long did it last?
– Complaints of other symptoms?
– Any trauma involved?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
Perform focused history and
physical exam.
– Any medical alert tags?
– Has the patient seized?
– Fever?
– Interruptions in episode?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Diabetic Patients Often Test
Their Blood Glucose at Home
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
Get a SAMPLE history.
If the patient has a history of
diabetes:
– When did patient last eat?
– Any medications? Last taken?
– Any other illnesses?
– Can the patient swallow?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
Take baseline vital signs.
– In some areas, protocols direct the
EMT to treat the patient before
getting vital signs.
FOLLOW YOUR
LOCAL PROTOCOL!
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
Give oral glucose if all of these
conditions are met:
– History of diabetes
– Altered mental status
– Patient can swallow
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
Reassess patient.
If patient becomes unconscious,
stop glucose administration
immediately and secure the airway!
If no improvement, consult medical
direction.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessing and Treating Diabetic
Emergencies
If patient is not awake enough to
swallow:
– Secure airway.
– Administer oxygen.
– Position appropriately.
– Request ALS and transport.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Blood Glucose
Meters
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Using Blood Glucose Meter
and Test Strip
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Blood Glucose Readings
80–120 mg/dl
Normal
60–80 mg/dl
Moderate hypoglycemia
Below 50 mg/dl
Severe hypoglycemia
Above 120 mg/dl
Hyperglycemia
Question results that are inconsistent
with patient’s condition.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Inaccurate Reading
Meter not calibrated
Low batteries in meter
Improperly stored or expired
test strip
Insufficient blood on test strip
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Administration
of Oral Glucose
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Squeeze Glucose onto Tongue
Depressor
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Insert Tongue Depressor between
the Patient’s Cheek and Gum
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Oral Glucose
Indications:
– Altered mental status
– Ability to swallow
Contraindications:
– Unconsciousness
– Diabetic who has not taken insulin
for days
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– Inability to swallow
(cont.)
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Oral Glucose
Dosage: one tube
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Oral Glucose
Administration:
– Assure altered mental status with history
of diabetes.
– Assure patient is conscious.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Oral Glucose
Administration:
– Administer glucose on tongue
depressor between cheek and gum,
or let patient self-administer.
– Perform ongoing assessment.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Oral Glucose
Actions:
– Increases blood sugar
Side effects:
– None when given properly
– May be aspirated if given
to patient without gag
reflex
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Oral Glucose
Reassessment strategies:
– If patient seizes or loses
consciousness, remove tongue
depressor and secure airway.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Altered
Mental Status
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Altered Mental Status
Hypoglycemia
Poisoning (including alcohol and
drugs)
Infection
Head trauma
Hypoxia
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Emergency Care of Altered
Mental Status
Secure airway.
Ventilate and suction as needed.
Transport.
Evaluate potential causes.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Emergency Care of Altered
Mental Status
Treat patient as trauma patient if
injury cannot be ruled out.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Seizures
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Seizures
Sudden change in sensation,
behavior, or movement caused
by irregular electrical activity of
the brain
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Seizures
Toxin (including drugs and alcohol)
Brain tumor
Congenital brain defects
Trauma
Infection/fever (#1 cause in pediatric
patients 6 months to 3 years old)
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Seizures
Epilepsy
Stroke
Hypoglycemia
Eclampsia (complication of pregnancy)
Hypoxia
Unknown
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Information to Obtain
What was the patient doing before
the seizure?
What movements were exhibited?
Loss of bladder or bowel control?
What did the patient do after the
seizure?
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Length of episode?
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Emergency Care During Seizures
Place patient on floor.
Position patient on side.
Loosen restrictive clothing.
Remove harmful objects.
Protect patient from injury; do not hold patient still or place anything in mouth.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Emergency Care of Seizures
After seizure subsides:
– Protect airway with positioning and
suction.
– If cyanotic, ventilate with oxygen.
– Treat injuries.
– Transport.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Simple Partial Seizures
In a simple partial seizure (also
called focal motor, focal sensory,
or Jacksonian), there is tingling,
stiffening, or jerking in just one
part of the body.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Complex Partial Seizures
This type of seizure (also called
psychomotor or temporal lobe) is
characterized by abnormal behavior
that varies widely from person to
person.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Generalized Seizures
In a tonic-clonic (also called grand
mal) seizure, there is often no aura or
other warning. This type of seizure is
characterized by unconsciousness
and major motor activity.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Absence Seizures
An absence seizure (also called petit
mal) is brief. There is no dramatic
motor activity and the person usually
does not slump or fall. Instead there is
a temporary loss of concentration or
awareness.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Status Epilepticus
A life-threatening condition in which
the patient has two or more
convulsive seizures without regaining
consciousness or lasting more than 5
minutes
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Emergency Care of Status
Epilepticus
Secure the airway.
Ventilate with 100% oxygen.
Request ALS.
Transport immediately.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Stroke
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Stroke
Death or injury of brain tissue that is
deprived of oxygen
Caused by a blockage (ischemic) or
bleeding (hemorrhagic) of a blood
vessel in the brain
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Signs and Symptoms of Stroke
Intoxicated appearance, slurred
speech, unconsciousness
Severe headache, vision changes
One-sided weakness on body
Confusion
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Signs and Symptoms of Stroke
Loss of bladder/bowel control
Unequal pupils
High blood pressure
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Transient Ischemic Attack (ITA)
“Mini-stroke”
Signs and symptoms of a stroke
Often resolved before EMS arrival
Symptoms resolve without treatment
in less than 24 hours
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Significant risk of having a “full”
stroke
Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Treatment of Stroke
Prompt transport is critical.
Identify potential stroke patients and notify the
hospital.
Maintain airway; administer oxygen.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Cincinnati Prehospital Stroke
Scale
Have patient
attempt to smile.
© Michal Heron Photography
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Cincinnati Prehospital Stroke
Scale
Have patient attempt to hold arms
straight in front of her for 10 seconds.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Cincinnati Prehospital Stroke
Scale
Evaluate
patient’s
speech.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Dizziness and Syncope
Syncope is a brief loss of
consciousness.
It can occur at any age; more common
in elderly.
It may be an indicator of a serious
medical problem.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Dizziness
and Syncope
Hypovolemia
– Trauma
– Dehydration
Metabolic
– Hypoglycemia
– Stroke
– Seizure
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Dizziness
and Syncope
Environmental/toxicological
– Alcohol/drugs
– Carbon monoxide
– Panic/anxiety
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of Dizziness
and Syncope
Cardiovascular
– Fast or slow heart rates
– Electrical system disturbance
– Vagus nerve stimulation
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Assessment of Dizziness
and Syncope
Obtain a SAMPLE history.
Ask about onset time, activities.
Length of episode?
Any previous episodes?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Treatment of Dizziness
and Syncope
Any medications for this condition?
Any nausea/vomiting/bowel
changes?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Treatment of Dizziness
and Syncope
Administer high-concentration oxygen.
Loosen restrictive clothing.
Lay patient flat and elevate legs (if no suspected spinal injury).
Treat any associated injuries.
Request ALS and transport.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Review Questions
1. List the signs and symptoms of a
diabetic emergency.
2. Explain how you can determine a
medical history of diabetes.
3. Explain what treatment may be given
by an EMT for a diabetic emergency
and the criteria for giving it.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Review Questions
4. Tell whether treatment for a diabetic
emergency should be given before or
after baseline vital signs are taken.
5. Explain the care that should be given
to a patient who has had a seizure.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Review Questions
6. Explain the care that should be given
to a conscious and to an
unconscious patient with
suspected stroke.
7. Explain the care that should be given
to a patient who has experienced
dizziness or syncope.
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Street Scenes
Does this patient need a thorough
assessment?
What is the first concern when
starting to assess this patient?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Street Scenes
What types of underlying medical
problems might make a patient
appear to be drunk?
Does your assessment plan change
at this point?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Street Scenes
How will you get a SAMPLE history if
the patient is alone?
What is the priority level of this
patient? Is there a need for ALS
assistance?
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ
Sample Documentation
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Limmer et al., Emergency Care, 11th Edition
© 2009 by Pearson Education, Inc., Upper Saddle River, NJ