# Hypoglycemia



## Ediron (Jan 5, 2010)

why do hypoglycemic patients have to take insulin?
dont they already have enough insulin and low sugar?

are type 1 diabetics hyperglycemic?


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## MrBrown (Jan 5, 2010)

This is a gross oversimplificiation and somebody else will chime in with a better answer I am sure of it.

A diabetic who takes insulin does so because he is unable to make his own.  Insulin is usually made in the pancreas, when released it stimulates the conversion of glucose into glycogen (liver) and glucose uptake by the cells.  This ensures that the BGL stays WNL.

Other diabetic patients control thier BGL with PO meds or food alone.

Insulin is not a treatment for hypoglycemia; we use either IM Glucagon (to stimulate the liver to release glucose) or IV 10% glucose.

Any diabetic patient may become hyperglycemic although type 1 diabetics are much more likely to get diabetic ketoacidosis or DKA.

Glycogenolysis and gluconeogenesis are terms you may want to research, heck, I want to too!


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## grich242 (Jan 5, 2010)

Ediron said:


> why do hypoglycemic patients have to take insulin?
> dont they already have enough insulin and low sugar?
> 
> are type 1 diabetics hyperglycemic?



Hypo and Hyperglycemia are medical terms not  necessarily diseases. People who are "hypoglycemic" tend to have their blood sugar drop based on diet when they have too much simple sugar and their body overproduces insulin and burns it up quickly. they do not take insulin. A type 1 diabetic takes insulin because they do not produce it on their own and may become hypoglycemic ic they dont eat enough but the principal is the same. Not enough insulin and too much fuel makes them hyperglycemic and it can change rather quickly from one to the other. both of these are different from type 2 and 3 so i'd look it up and the ADA website may help lots of info simply put.


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## 18G (Jan 5, 2010)

> why do hypoglycemic patients have to take insulin?


A hypoglycemia patient will NOT be taking insulin. If they are hypoglycemic their blood glucose level is already too low and taking insulin will only make the body use what little glucose they have making the level drop even further. 

Hypoglycemia patients need sugar (ie D50, oral glucose, or sweet foods/drink).

Q. Why do some diabetics have to take insulin? 

A. Because their pancreas is not able to produce any or only an insufficient supply of insulin. Glucose is a large molecule that requires help crossing over the cell membrane and into the cell. Without insulin, glucose is not able to move into the cells at a rate capable of meeting the body's needs. Think of a lock and key. The cell is the lock and insulin is the key. Insulin unlocks the cell so glucose can enter.  

The beta cells in the pancreas are the cells that produce insulin. When these cells are destroyed, they no longer produce insulin. There are a few reasons and thoughts as to what causes this. One is some patients are genetically predisposed to an early deterioration of the beta cells and another is a viral or other type of infection kills the beta cells. An autoimmiune response is thought to be a player in some. 


Q. Are type 1 diabetics hyperglycemic?

A. If they are not compliant with their insulin regimen and diet, yes they will become hyperglycemic. When type 1 diabetes is first detected, it is usually because of a hyperglycemic event or DKA. Remember, Type 1 means no to very little insulin production. Without insulin, the blood glucose level will rise and lead to a bunch of problems with acidosis and dehydration if it is not controlled and brought back down. 

Normally, if the person is taking insulin as directed and watching their diet, no they will not be hyperglycemic. They should be euglycemic (normal level) or at least what is baseline for them.


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## VentMedic (Jan 5, 2010)

Both hypoglycemia and hyperglycemia can be associated with something other than just noncompliance. Don't judge your patients so quickly for placing blame or writing them off as noncompliant. A thorough assessment should be done to find other possible causes. This is why just treating hypoglycemia in the field and leaving the patient thinking you fixed them may not always be the best treatment plan. A fever can raise blood glucose because of higher levels of stress hormones, gluconeogenesis and insulin resistance. Illness associated with vomiting and diarrhea can lower blood glucose. 

Patients who have never been diagnosed with diabetes can have glucose issues from stress related to trauma or CVAs. It is not uncommon to see a patient who has suffered a trauma or surgery to be on an insulin drip in the ED or ICU to control their glucose.


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## Akulahawk (Jan 5, 2010)

Ediron: Hypoglycemia and Hyperglycemia are basically descriptions of the blood glucose level. That's quite literally it!!! The problem is figuring out WHY the patient's blood glucose deviated from a normal range. While "Type 1" diabetics need insulin, they must balance their carbohydrate intake, exercise output, insulin requirements, and might even have to do blends of insulin types to maintain their blood glucose levels within a normal range. If they under or overestimate anything, they can get themselves into a LOT of trouble very quickly. They also might be required to test themselves several times per day to be CERTAIN they're on the right track.

"Type 2" diabetics generally exhibit insulin resistance. Their problem can be much more difficult to manage. While insulin is present in their bloodstream, their cells might become less responsive to that insulin. The medication they take is targeted toward improving insulin resistance. 

Even in normal non-diabetic people, during times of physiologic stress, the body can release corticosteroids... which can result in markedly increased blood glucose levels. In order to control that, as Vent noted, the patient can be put on an insulin drip to control the BGL increase. After all, the body likes the BGL to be in a certain range... anything outside that, over a sustained period of time, can lead to significant and undesirable damage.

Clear as mud? They body's regulatory systems are pretty good (most of the time) at maintaining homeostasis. As good as modern medicine is at helping the body do this, the healthy body is even better at it!


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## ghostrider (Jan 5, 2010)

Just as a side note adrenalin will often drastically increase bg levals in type 1 diabetics resulting in a rebound low that can require quite a lot of glucose to correct. There are also what are known as brittal diabetics whose insulin sensitivity ratio will fluctuate hourly, daily or monthly, compounding the already delicate dance of exertion carbs and insulin. unless you have lived with or currently diabetic you cannot possibly inagine how complicated this disease is to manage.


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## Akulahawk (Jan 6, 2010)

One of my paramedic instructors' "pet" issues was diabetes. His son is a type 1 diabetic. Guess what he had to become an expert in? Yep! Fortunately, the kid wasn't a brittle diabetic. "Dad" later became a very good PA, and has been practicing in CA for about 8 years now. 

A good friend's late wife was a VERY brittle diabetic who gave up on herself. My friend had one heck of a time trying to manage her diabetes for her AND manage to get along with her... she often wasn't the nicest of people either. One day, she moved herself out (didn't want to remain a burden) and about 2 months later, checked out.

That's about as close as I _ever_ want to come to having to manage brittle diabetics long term (years...).


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## nomofica (Jan 6, 2010)

The extent of my care of diabetic patients is nil (to date), aside from the occasional administration of oral glucose to severely hypoglycemic patient.

I find it interesting how severely hypo/hyperglycemic patients can appear, and even smell, ETOH. The appearance is obvious to me, but why do they smell like they're intoxicated? I'm curious about that...


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## Aidey (Jan 6, 2010)

VentMedic said:


> Both hypoglycemia and hyperglycemia can be associated with something other than just noncompliance. Don't judge your patients so quickly for placing blame or writing them off as noncompliant. A thorough assessment should be done to find other possible causes. This is why just treating hypoglycemia in the field and leaving the patient thinking you fixed them may not always be the best treatment plan. A fever can raise blood glucose because of higher levels of stress hormones, gluconeogenesis and insulin resistance. Illness associated with vomiting and diarrhea can lower blood glucose.
> 
> Patients who have never been diagnosed with diabetes can have glucose issues from stress related to trauma or CVAs. It is not uncommon to see a patient who has suffered a trauma or surgery to be on an insulin drip in the ED or ICU to control their glucose.




On this note, steroids can cause a patient's blood sugar to run high. 



There are also women who have been diagnosed with PCOS/Metabolic syndrome who take medications to regulate their glucose, both oral and insulin. The current working theory of the syndrome revolves around insulin resistance, but these people do not technically have diabetes.


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## ghostrider (Jan 6, 2010)

nomofica said:


> The extent of my care of diabetic patients is nil (to date), aside from the occasional administration of oral glucose to severely hypoglycemic patient.
> 
> I find it interesting how severely hypo/hyperglycemic patients can appear, and even smell, ETOH. The appearance is obvious to me, but why do they smell like they're intoxicated? I'm curious about that...



my understanding through my sons endo is that the dka process creates a by-product that is similar to acetone, which smells similar to iso. alch.


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## 18G (Jan 6, 2010)

Ghostrider is right... 

People who become hyperglycemic can enter into a metabolic process known as diabetic ketoacidosis (DKA). This occurs when the body is not able to utilize glucose for energy and cell functioning due to a lack of insulin.

The body needs to create energy and since it cannot get it from glucose, it attempts to get energy by using a much less efficient method which is by breaking down fatty acids. The by-products of fatty acids are ketones which include acetone.

It is these by-products (the acetone) that can give the characteristic, fruity like odor. 

People with low blood sugar levels will not have this odor since they are not producing the ketones.


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## ghostrider (Jan 6, 2010)

yeah what he said  ^


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## nomofica (Jan 7, 2010)

Awesome, thanks for filling me in! I was always curious about it. Never really learned why, just how to treat (within my scope).


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## Shishkabob (Jan 7, 2010)

Keep in mind though, that not all hyperglycemic patients will have the acetone smell, especially in HHNK.


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## 18G (Jan 7, 2010)

Linuss brings up something I didnt and is important to remember.


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## nomofica (Jan 7, 2010)

I think I'm going to read up on all of this, as I was never taught it and appears to be quite important. Thanks guys, I knew there was a reason I posted on EMTLife other than keeping myself from dying of boredom during the downtime.


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## mycrofft (Jan 7, 2010)

*Search "bariatric surgery" or "dumping syndrome"*

doo dee doo dee doooooo


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## ghostrider (Jan 8, 2010)

nomofica said:


> I think I'm going to read up on all of this, as I was never taught it and appears to be quite important. Thanks guys, I knew there was a reason I posted on EMTLife other than keeping myself from dying of boredom during the downtime.



my son being diagnosed with type 1 is what led me into ems. 3 transports while out of state (on vacation) and a crash course in diabetis care before heading home 400 miles away was a real eye opener. we found out like most people that he had type 1 when he went into DKA. the moniter at the hospital read HIGH BG and the boy was about to slip into a coma. very compitent emts and icu staff in north Fla. my hats off to you guys.


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## Akulahawk (Jan 8, 2010)

Aidey said:


> On this note, steroids can cause a patient's blood sugar to run high.
> 
> 
> 
> There are also women who have been diagnosed with PCOS/Metabolic syndrome who take medications to regulate their glucose, both oral and insulin. The current working theory of the syndrome revolves around insulin resistance, but these people do not technically have diabetes.


While doing a bit of reading a couple years ago about metabolic syndrome, I came across that. The steroid thing... I'm not at all surprised.


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## Akulahawk (Jan 8, 2010)

Yeah, that acetone odor can smell a LOT like an alcoholic beverage. That odor and the patient not acting right (like they're drunk) can make you think all you've got on your hands is another HBD patient.

HHNK patients still have some insulin that works... enough to keep the body from producing ketones (and therefore the odor). They do NOT have enough insulin to be able to keep the blood glucose levels under control.


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## Jeffrey_169 (Jan 9, 2010)

Hypoglycemia does not always equate to diabetes. There are a variety of other causes for both hypo and hyperglycemia.


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## MrBrown (Jan 9, 2010)

Jeffrey_169 said:


> Hypoglycemia does not always equate to diabetes.



While you can technically be hypo and non diabetic, I bet you $100 you'd be hard pressed to find a non diabetic hypo of clinical significance

I mean we all feel a bit wonky after missing a meal but I don't count that as being clinically significant


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## Aidey (Jan 9, 2010)

People with Eating Disorders come to mind.


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## 18G (Jan 9, 2010)

Hypoglycemia outside of diabetes is pretty rare.


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## NJFLGHTMDC (Jan 9, 2010)

*HypoGlycemia without Diabetes*

Just don't eat for several days, and you will be come hypoglycemic. Sometimes you will find the syncope in the gym, hypoglycemic. From using up their glycogen stores, and not replacing the energy they processed.
Also it is common to use up your glycogen stores and become hypoglycemic in trauma patients. Think of the excess energy patients use in the different compensatory systems used to keep them alive. We check for hypoglycemia in all trauma patients.
Ill take my $100.


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## reaper (Jan 9, 2010)

How about your chronic alcoholic????


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## Shishkabob (Jan 10, 2010)

Now that's  fun one.  A drunk with Wernicke-Korsakoff.


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## reaper (Jan 10, 2010)

Other causes,

ASA overdose
Sulfa drugs
Quinine
Alcohol (large amounts in anyone)
Sepsis
Tumors
Hormone deficiencies
kidney problems
Liver problems

There are a lot of causes outside of Diabetes.


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## 18G (Jan 10, 2010)

There are causes of hypoglycemia outside of diabetes, agreed. But they are considered infrequent and rare. If you want sources to support this statement I can provide them for you. 

How often do you treat a hypoglycemia that isn't related to diabetes?


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## MrBrown (Jan 10, 2010)

Saw an interesting lecture by one of our Clinical Support Officers on glucagon and certian types of diabetics.  Cadavet was to call Intermediate or Intensive Care (ALS) for 10% glucose IV rather than sit around for twenty minutes and wait for the IM Glucagon to work because it is unlikely to work.

Specifically mentioned were chronic alcoholics who have seizures and fall down a lot and young, exercise induced hypos in IDDMs


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## 18G (Jan 10, 2010)

Chronic alcoholics have a very poor nutritional status and as such have very minimal to no glycogen stores. Throw on top of that the cirrhosis and/or other liver dysfunction caused by the alcohol and the body has an even harder time of maintaining glucose level. 

Since alcohol is perceived by the body as a poison, it causes the liver to NOT release any glycogen until all of the alcohol has been metabolized. This is why known diabetics need to eat and have food available in their stomachs if they are going to be consuming alcohol. Because their liver is not going to release glycogen as along as alcohol is present.


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## reaper (Jan 10, 2010)

18G said:


> There are causes of hypoglycemia outside of diabetes, agreed. But they are considered infrequent and rare. If you want sources to support this statement I can provide them for you.
> 
> How often do you treat a hypoglycemia that isn't related to diabetes?



I have seen the sources and don't hold much account to them.

You do not treat Sepsis Pt's? Trauma Pt's? Or medication induced Hypoglycemia? You must not treat very many Pt's.


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