Diabetic Emergencies

Published on 14/03/2015 by admin

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Last modified 14/03/2015

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Diabetic Emergencies

Definitions and Characteristics

Diabetes is the most common endocrine disease. Acute complications include hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar state (HHS). Long-term complications include disorders of the microvasculature, cardiovascular system, eyes, kidneys, and nerves. Type 1 diabetes is characterized by destruction of pancreatic beta cells, leading to absolute insulin deficiency. Type 2 diabetes, the most common type, is characterized by variable degrees of insulin deficiency and resistance. Although diet and oral hypoglycemic medications are initially used to control type 2 diabetes, many individuals lose beta cell function over time and require insulin for glucose control.

Ensuring that insulin does not freeze and glucose testing equipment works properly are important for diabetic individuals in the wilderness. Strategies to ensure that insulin does not freeze include carrying the medication inside a pouch that is worn around the neck next to the body and keeping insulin in the sleeping bag at night. Carrying glucose monitoring equipment next to the skin may prevent the problems associated with battery malfunction at cold temperatures.

Accurate blood glucose measurement under extreme conditions is paramount for safe travel in the wilderness. Studies of blood glucose meters at high altitude (above 4000 m [13,123 ft]) have yielded conflicting data regarding accuracy and reliability. Both overestimation and underestimation of blood glucose level have been reported for all types of glucose meters. Glucose meters using the oxygen-insensitive enzyme glucose dehydrogenase (GDH) may perform better at high altitude than those using the enzyme glucose oxidase. High glucose levels seem to be misreported to a greater extent at altitude than are low to normal glucose levels. At altitudes above 5000 m (16,404 ft), the Accu-Chek Compact Plus GDH-based blood glucose meter was found to be most accurate when compared to standard reference glucose solutions, independent of the glucose solution used. The Accu-Chek Compact Plus also received an excellent rating by Consumer Reports for its reliability. FreeStyle Lite, FreeStyle Freedom Lite, and Accu-Chek Aviva also performed well with devices and strips purchased through regular distribution channels. Because of the variability of blood glucose meters in extreme environments, it is prudent to rely on one’s clinical assessment and not just the blood glucose meter reading when evaluating a patient for hypoglycemia.

Diabetics should wear appropriate medical alert identification, such as bracelets or necklaces, in case assistance is necessary and they are not able to communicate. If a diabetic becomes confused, weak, or unconscious, he or she may be suffering from insulin-induced hypoglycemia or lapsing into a diabetic coma.

Disorders

If a diabetic takes too much insulin or another glucose-lowering agent, fails to eat sufficient carbohydrate to match the exogenous drug administered, or exercises at a greatly increased rate, a rapid drop in blood glucose level can occur. Another factor contributing to hypoglycemia in the exercising individual with insulin-dependent diabetes is increased exogenous insulin mobilization from subcutaneous tissue because of increased blood flow. It is important for insulin-dependent diabetic patients to administer their dose of subcutaneous insulin before exercise in a location away from exercising muscle. They should avoid injections into the arms and legs, instead using the abdomen or back of the neck. Insulin absorption is fastest and most consistent when it is injected into the abdomen.

Another measure to prevent exercise-associated hypoglycemia is to reduce the dose of insulin that will be in effect during exercise. The best strategy for a type 1 diabetic patient is to monitor blood glucose level before, during, and after exercise to predict changes, and adjust insulin doses accordingly. This means that before a wilderness trip, the diabetic patient should exercise daily at a level of physical activity similar to that anticipated on the wilderness trip and consume similar types of food that will be ingested on the trip, so that adjustments in insulin dosing can be better predicted.

Signs and Symptoms

1. Altered level of consciousness, such as confusion, behavioral changes, nervousness, belligerence, syncope, seizures, unconsciousness, or coma

2. Weakness, tremor, diaphoresis, pallor, abdominal pain, ataxia, slurred speech, tachycardia

3. Minimal to absent prodrome; patient may become unarousable without warning

Treatment

1. If possible, obtain a blood glucose reading before initiating therapy.

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