Hyperglycemia

[NPO]

In the past 2 weeks I have had 3 hyperglycemic patients, all of whom were having other issues that put them on the cusp of emergency transport (one got upgraded after seizing 30 seconds into transport).

I am wondering how hyperglycemia of this level can effect a patient, and if the other issues were possibly a result of the hyperglycemia. All of these patients have had persistent hyperglycemia following insulin administration.

Patients 1 and 2 had BGL of 500+, going down to 450 and 480 after 10 units of regular insulin, before coming back up to the 500s. Patient 2 was less severe with 450 down to 380 after 9 units. All of these patients received their insulin about an hour before the second BGL check.

I have always been told HYPERglycemia is better than HYPOglycemia, but now every time hyperglycemia comes over my page I start preparing for a messed up SNF patient.

 

[Carlos Danger]

Hyperglycemia in itself is much less of an acute emergency than hypoglycemia. It can cause serious problems, both acute (DKA and/or NHC) and chronic (CNS, PNS, neuromuscular, renal, cardiac, and other types of dysfunction), but it isn't going to cause massive destruction of brain cells and/or death in a short period of time like severe hypoglycemia will.

One way to think of it: both are serious, but one requires immediate treatment in the field, where the other does not.

The type of hyperglycemia you describe is common in older patients who have pre-existing diabetes and experience some sort of physiologic stress - often an infection - which results in sympathetic activation, glucagon release, and elevated glucose levels. They don't need to have diabetes though, or even a readily identifiable source of stress. Some medications predispose people.

 

[mycrofft]

Never head of HYPERglycemia causing a seizure unless it was a co-morbidity with say alcohol detox or seizure disorder.

I'd also be real chary about messing with insulin prehospital, especially Regular insulin versus fingersticks. That can get out of hand even in-house real quick, and while hyperglycemia pts can be stabilized one enough to get to a hospital, an iatrogenic hypoglycemic emergency can kill your pt in ten minutes or so.

Prehospital insulin can be like throwing a blanket over a burning pan of grease. For a moment the flames abate and you feel very competent, then they come roaring through the blanket and not only do you have a worse emergency, you also look like Wile E. Coyote.

 

[unleashedfury]

In most cases of hyperglycemia in a seizure patient. the Hyperglycemia was a symptom of another diagnosis.

Pathophysiology states that Blood Glucose levels are elevated when the body is responding to a stressor,

I've had a patient with a BGL of 500 and I at first thought her AMS was related to the High Blood Sugar turns out she was bordering the sepsis margin

 

[NPO]

Thanks for all the input, ive never received a lot of education I HYPERglycemia and google only returns results for people wondering about controlling their DM, not prehospital treatment of 500+.

I'd also be real chary about messing with insulin prehospital, especially Regular insulin versus fingersticks. That can get out of hand even in-house real quick, and while hyperglycemia pts can be stabilized one enough to get to a hospital, an iatrogenic hypoglycemic emergency can kill your pt in ten minutes or so.

For clarification, we did not administer the insulin. Both were administered in the SNF per the pts prescription on their sliding scale.

Never head of HYPERglycemia causing a seizure unless it was a co-morbidity with say alcohol detox or seizure disorder.

The patient that seized did have a history of seizures, and had not received her last round of meds. Whether any antiepileptic drugs were supposed to be in the missed round was unclear.

 

[NPO]

I've had a patient with a BGL of 500 and I at first thought her AMS was related to the High Blood Sugar turns out she was bordering the sepsis margin

I was leaning toward sepsis on patient 1, but number 2 was giving me a seperate vibe but still fits the criteria. His etiology seemed down the respritory route.

 

[VFlutter]

Thanks for all the input, ive never received a lot of education I HYPERglycemia and google only returns results for people wondering about controlling their DM, not prehospital treatment of 500+.

Hyperglycemia is not something that should be treated in the prehospital setting except for IV fluids and respiratory support for DKA.

 

[NPO]

Hyperglycemia is not something that should be treated in the prehospital setting except for IV fluids and respiratory support for DKA.

Doesn't prevent me from wanting to understand it though.

 

[Aprz]

I don't think he's against you understanding more about diabetic ketoacidosis. From what I've seen, these patients usually end up in the intensive care unit, insulin is a high risk drug, and hyperglycemia isn't their only issue.

Insulin assist with bringing glucose and potassium into the cell. If insulin isn't bringing glucose and potassium into the cell, the patient will become hyperglycemic and hyperkalemic. Hyperkalemia risks heart arrhythmias.

I think because glucose is a large molecule, it pulls and keeps fluid towards it. If it's in intravascular space instead of intracelluer (inside cell), fluids will go to and remain in intravascular space. Less fluids for tissues and cells.

Glucose will still be going to the brain, but not to the rest of the body's cells. I think this is the reason that hyperglycemia has a slower onset than hypoglycemia.

The body (not the brain) will have to rely on alternative ways of making energy such as breaking down fat, the byproduct of fat break down is ketones, which is acidic (low pH). It's important for the pH to remain about normal for reactions to occur in the body, for proteins to remain in the proper shape (heat and pH can cause the protein shape to change), and even for oxygen exchange (look at oxygen-hemoglobin dissociation curve).

(increase H+ is increase in acidity or decrease in pH)

They may be breathing rapidly, fruity breath, to attempt to self correct their pH.

The patient will urinate frequently (polyuria) and have the urge to drink/thirsty (polydipsia). The will deplete their electrolytes via urination, and perhaps dilute it more via drinking.

End result is that you will have a patient with relatively high blood glucose level, crazy electrolytes probably mostly depleted, acidotic, and dehydrated. Being a diabetic period doesn't help.

Treatment for EMT is primarily oxygen and transport. Protect airway and positive pressure ventilation as needed. In some areas, EMTs cannot check blood sugar, but it's still OK for them to administer oral glucose to diabetic patients who are altered that can self administer because hypoglycemia is more of an immediate life threat than hyperglycemia. While hyperglycemia is the cause of a lot of the problems, it itself isn't really that big of a deal compared to electrolyte issues and acidosis.

Treatment for paramedic is the same as EMT, but the paramedic should start at least an IV, give a fluid bolus to rehydrate the patient. Monitor EKG (especially for hyperkalemia). If suspected hyperkalemia, administer calcium chloride.

Hope I am not too simple minded or straight up wrong, lol. Don't really get a chance to discuss these kind of things with co-workers, didn't discuss these kind of things at school.

 

[NPO]

No it's all good. Its all information. Some ive heard before but its good to hear again, and its connecting some dots even on stuff I've heard before.

 

[mycrofft]

One of our MD participants here taught me you can live on ketones and had the citations to prove it. I still have some personal reservations because I am aware of the absolute toxic effect of ketones and that people with significant ketone levels tend to become obtunded. Just found a study that brain cells increase uptake of glucose at lower insulin levels than peripheral cells do (i.e., I give you a small insulin dose, the muscles etc use some, but the brain jumps on it).

Also, "hyperglycemia" qua hyperglycemia is not horribly bad. It is the consequences of continued hyperglycemia, and the conditions which are causing it (which have their own sets of morbidities) that are of acute interest.

One of the most insidious is not acute: the continual abnormal growth, thickening and sclerosing of blood vessels, most notably those involving the kidneys, eyes, lower extremities, heart, etc. It leads to renal failure, sepsis, serial and bilateralizing amputations, blinds, heart disease, and others.

 

[zmedic]

I'd also point out that 10 units of insulin isn't all that much. For DKA patients get put on 0.1units/kg/hour drips. So a 80kg person will get 8 units an hour usually for 6-8 hours until their BGLs drop to 250, at which point they get glucose added to their IV fluids (so their glucose doesn't get too low while they are still needing insulin to metabolize their ketones.)

The keys to these patients is hydration. They get lots of IVF up front before you even start the insulin.

 

[Brandon O]

One of our MD participants here taught me you can live on ketones and had the citations to prove it. I still have some personal reservations because I am aware of the absolute toxic effect of ketones and that people with significant ketone levels tend to become obtunded.

You don't need dietary glucose either way, since you can synthesize it via gluconeogenesis, of course.

Other than that, ketogenic diets are somewhat popular in certain circles. The jury's still out on their value. Certainly people can and do maintain homeostasis while in such a state (albeit grumpily in most cases); the difference between this and DKA is presumably due to the degree, the amount of other available fuel (i.e. are you providing dietary fats to compensate, as a ketogenic dieter would do, or is your body wasting adipose and muscle), and your ability to clear the acid. Plus of course an untreated type I diabetic has a sky-high blood glucose level, whereas an otherwise healthy ketogenic dieter is fully able to use and regulate the stuff, he's just choosing to limit his intake.

 

[mycrofft]

Wide variety of metabolism though.

There are folks who spontaneously go into hypoglycemia, especially if they've been staving it off with sugar, and some of them will continue down to altered consciousness etc. Some will start kicking in glu-neo in time, some won't.

And there are guys who drink Sterno and isopropyl and ETOH and manage to survive what for most of us would be lethal; plenty of ketones and aldehydes there.

Gluconeogenesis is fantastic but some folks can't kick it in fast enough.