Emergency interventions with diabetic patients: the US rescuers' protocol

By Cristiano Antonino On Jan 12, 2023

Diabetic symptoms (hypoglycaemia) are among the 10 most common emergencies that emergency professionals respond to, accounting for 2.5% of all emergency calls

Diabetes is a group of metabolic disorders that involve elevated blood sugar levels over a prolonged period of time.

Symptoms in diabetic patients may include frequent urination, increased thirst and appetite

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.

Emergencies with diabetic patients: what is hypoglycaemia?

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.

Risk factors for 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.

Conditions that may increase the risk of hypoglycaemia include:

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.

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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.

When to call the Emergency Number for hypoglycaemia and diabetic patients

Seek help immediately if

you have symptoms of hypoglycaemia and you do not have diabetes.
You have diabetes and hypoglycaemia does not respond to treatment, e.g. drinking fruit juices or normal soft drinks, eating sweets or taking glucose tablets.

Call the Emergency Number if a person with diabetes or a history of hypoglycaemia presents symptoms of severe hypoglycaemia or loses consciousness.

Rescue and diabetic patients: how to treat the symptoms of diabetes (hypoglycaemia)

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:

What were the signs and symptoms? If you do not experience signs and symptoms of hypoglycaemia during your first visit with your doctor, the latter may make you fast overnight or longer. This will allow you to check the symptoms of hypoglycaemia so that the doctor can make a diagnosis.
It is also possible that you may have to undergo an extended fast in hospital. If your symptoms occur after a meal, your doctor will want to analyse your glucose levels after eating. What is the blood sugar level in the presence of symptoms? The doctor will take a blood sample for laboratory analysis. Do the symptoms disappear when the blood sugar level rises? In addition, the doctor will probably perform a physical examination and test your medical history.

Immediate treatment of hypoglycaemia

In case of symptoms of hypoglycaemia, proceed as follows:

Eat or drink 15-20 grams of fast-acting carbohydrates. These are sugary foods without protein or fat that are easily converted into sugar by the body. Try glucose tablets or gels, fruit juices, regular, non-diet drinks, honey and sugary sweets.
Re-check blood sugar levels 15 minutes after treatment. If blood sugar levels are still below 70 mg/dL (3.9 mmol/L), eat or drink another 15-20 grams of fast-acting carbohydrates and recheck blood sugar levels in 15 minutes. Repeat these steps until your blood sugar is above 70 mg/dL (3.9 mmol/L).
Have a snack or meal. Once blood sugar is normal, eating a snack or meal can help stabilise it and replenish the body’s glycogen stores.

Immediate treatment of severe hypoglycaemia

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.

Treatment of a recurring condition

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

Medication. If the cause of hypoglycaemia is a drug, the doctor will probably suggest changing or discontinuing the drug or changing its dosage.
Treatment of the tumour. A pancreatic tumour is treated by surgical removal of the tumour. In some cases, partial removal of the pancreas is necessary.

How do rescuers and paramedics treat the symptoms of diabetic patients?

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.

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Diabetic patients, treatment guidelines and resources for medical first responders in the US

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:

Adult or paediatric patient with altered level of consciousness [see altered mental status guideline].
Adult or paediatric patient with stroke symptoms (e.g. hemiparesis, dysarthria) [see Guideline on suspected stroke/transient ischaemic attack].
Adult or paediatric patient with seizures [see seizure guideline].
Adult or paediatric patient with symptoms of hyperglycaemia (e.g. polyuria, polydipsia, weakness, dizziness, abdominal pain, tachypnoea)
Adult or paediatric patient with a history of diabetes and other medical symptoms.

Exclusion criteria: Patient in cardiac arrest

The guidelines include the following inclusion criteria for hypoglycaemia:

Adult or paediatric patient with blood glucose below 60 mg/dL and symptoms of hypoglycaemia.
Adult or paediatric patient with altered level of consciousness [see guideline on altered mental status].
Adult or paediatric patient with stroke symptoms (e.g. hemiparesis, dysarthria) [see suspected stroke/transient ischaemic attack guideline].
Adult or paediatric patient with seizures [see seizure guideline].
Adult or paediatric patient with a history of diabetes and other medical symptoms
Paediatric patient with suspected alcohol ingestion
Adult patient who appears to be intoxicated

Exclusion criteria: Patient in cardiac arrest

Responders’ protocol for diabetic emergencies

This protocol may be used to treat patients who have been previously diagnosed with diabetes and who currently present with altered mental status:

Perform the initial assessment of the patient. Look for medical warning symptoms.
Carry out a targeted history and physical test.
Determine last meal, last dose of medication (including insulin type(s), number of units, time of administration and oral hypoglycaemic drugs).
Administer oxygen.
Measure blood glucose with a glucose meter.

If blood glucose is below 60 mg/dl and if:

The patient is sufficiently awake to protect their airways. Administer oral sugar/glucose.
The patient is semi-conscious but still has a gag reflex. Place a small amount of oral glucose between the patient’s cheek and gum.
The patient has an altered level of consciousness. Follow the protocol for altered level of consciousness.

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:

Blood glucose above 70 mg/dl
The patient is able to eat a meal
The patient is in the company of responsible adults who will stay with him/her for at least 12 hours or ensure that someone else does.
The patient agrees to contact their GP within 24 hours.
The patient is able to measure his/her own blood glucose and adjust his/her medication (e.g. insulin) accordingly.
There are no other acute medical problems (e.g. suspected stroke, heart attack, trauma, drugs, alcohol, use of oral hypoglycaemic drugs or serious infections).

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