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Diabetic Emergencies
Questions and Answers
Case: A neighbor calls 911 for someone continuously pounding trying to enter the apartment next door. They are worried that the person knocking is high on drugs. Police arrive to a confused male in his 20s and recognize a medical emergency. EMS is called. Meanwhile, the pale, diaphoretic male passes out across the doorway. With the noise of the sirens, the patient’s girlfriend wakes up and comes to the door and finds her boyfriend’s limp body is blocking the threshold and the officer right outside the door. She shouts, “He’s diabetic!” She then proceeds to deliver a rescue glucagon injection to the patient. He wakes up slowly, is still weak, and vomits. The EMS crew arrives, notes a glucose level of 34, establishes an IV, gives a bolus of D10, and hangs 500 mL of normal saline. The patient arrives at the emergency department nauseated, with a glucose level of 60. When asked about the events leading up to the emergency, he remembers suddenly having a feeling of “being low” and knew he needed help. He could not unlock the door to their apartment in his hypoglycemic state, which is why he was pounding.
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What is diabetes and what do type 1 and type 2 diabetes have in common?
Both types of diabetes involve abnormal glucose regulation. Although the pancreas is especially involved in insulin production and release into the blood, other organs, including the liver, kidneys, and intestines, also affect glucose regulation in the body.
2
How are type 1 and type 2 diabetes different from each other?
Type 1 diabetes is caused by an autoimmune attack of the pancreatic cells that make insulin. Imagine insulin is a key that unlocks doors for glucose to get into cells. Without insulin, there are no keys to unlock the cell’s doors so glucose cannot get in. Without insulin therapy, type 1 diabetic patients can build up high glucose levels in their blood, because the glucose cannot get into cells. Cells without glucose start to break down fats, spill ketones, and develop systemic acidosis. Your type 1 diabetes patients will need multiple daily insulin injections or continuous insulin via an insulin pump to avoid going into diabetic ketoacidosis, also known as DKA.
Type 2 diabetes differs from type 1 in that the pancreatic cells make insulin, but the cells are resistant to this insulin. Using the key analogy again, the insulin keys are being made in response to elevated glucose levels, but the insulin keys can only fit a few locks. Again, the inability to autoregulate intravascular glucose results in hyperglycemia but is less likely to cause DKA as some insulin is functioning and allowing some glucose to enter cells. Additionally, when oral or injectable type 2 diabetes therapies are no longer regulating glucose levels well, type 2 diabetics can also require insulin injections. The insulin therapy increases the likelihood of insulin keys finding a matching lock, shifts glucose intracellularly, and allows the pancreas to not work so hard making insulin.
3
How prevalent is diabetes?
About 9% of the US population has type 2 diabetes, and 0.5% have type 1.
4
At what level is a patient considered hypoglycemic?
The American Diabetes Association defines hypoglycemia at or below 70 mg/dL.
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