Diabetic Emergencies¶

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview¶

Diabetic emergencies include hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose, including diabetic ketoacidosis and hyperosmolar hyperglycemic state). Hypoglycemia is the acute life threat — brain cells are highly sensitive to glucose deprivation and dysfunction begins rapidly when BGL falls below ~60 mg/dL. Hyperglycemia develops more slowly but can cause serious dehydration and metabolic derangement.

The EMT-B's primary role: measure blood glucose with glucometry, administer oral glucose for hypoglycemia in patients who can protect their airway, and transport. IV dextrose for unconscious hypoglycemic patients is ALS scope.

Key Points¶

Hypoglycemia (BGL <60 mg/dL): - Presentation: altered mental status, confusion, agitation, bizarre behavior, diaphoresis (pale/cool/moist skin), trembling, rapid onset - Can mimic intoxication, stroke, or behavioral emergency — always check BGL - Requires: altered mental status + known diabetic history + ability to swallow → oral glucose - Cannot give oral glucose to unconscious patients — aspiration risk

Hyperglycemia (BGL >250 mg/dL): - Presentation: gradual onset, hot/flushed dry skin, fruity/acetone breath (ketoacidosis), Kussmaul respirations (deep/rapid), polyuria, polydipsia, polyphagia, weakness - Not an immediate life threat in most prehospital settings — primary intervention is IV fluid resuscitation and transport - DKA (type 1) vs. HHS (type 2) — both require hospital management

IDDM vs. NIDDM: Most acute diabetic emergencies occur in insulin-dependent (type 1) patients, but can occur in non-insulin-dependent (type 2) patients as well.

Assessment Relevance¶

History (history-taking): - SAMPLE: Known diabetic? Type 1 or 2? Insulin type (short-acting vs. long-acting — affects risk of recurrence), oral medications (sulfonylureas have longer hypoglycemic effect), last meal, recent illness, unusual exertion - OPQRST: Onset — sudden (hypoglycemia) vs. gradual (hyperglycemia)? Associated symptoms - Last insulin dose — when, how much, type - Has the patient eaten since their last dose?

Physical exam (secondary-assessment): - LOC (AVPU): AMS is key finding in hypoglycemia - Skin: pale/cool/moist (hypoglycemia) vs. hot/dry/flushed (hyperglycemia) - Respirations: Kussmaul pattern (deep, rapid, labored) in DKA - Breath: fruity/acetone odor in DKA - Glucometry: mandatory in all altered LOC patients — must be part of primary assessment workflow

Procedures¶

For hypoglycemia (BGL <60 mg/dL) with altered mental status: 1. Confirm patient meets oral glucose criteria: AMS + known diabetic + ability to swallow and protect airway 2. Administer oral glucose gel: 15–25g buccal/oral — see oral-glucose 3. Reassess BGL at 15 minutes 4. If no improvement or patient is unconscious → ALS intercept/transport immediately 5. Transport: even if improved, patients on sulfonylureas or long-acting insulin require transport

For hyperglycemia (BGL >250 mg/dL with symptoms): 1. Protect airway; administer high-flow O2 and assist ventilations if needed 2. Transport to appropriate facility 3. IV isotonic fluid bolus 500–1,000 mL (ALS/EMT-I/P scope for IV initiation) 4. Position patient of comfort

General: - Glucometry is EMT-B scope — perform on all altered LOC patients - If IV/IO unavailable and patient unconscious: ALS intercept is essential

NM Protocol Notes¶

From NM EMS Treatment Guidelines (2022):

Hypoglycemia (BGL <60 mg/dL): - If conscious and able to swallow: ORAL GLUCOSE 12–25g. Pediatric dose: 0.5–1 g/kg - If unconscious (ALS/EMT-I/P only): - Initiate IV/IO at TKO - 50% DEXTROSE (D50) 12.5–25g IV/IO into free-flowing line - Pediatric: 25% DEXTROSE 1 g/kg IV/IO (dilute D50 1:1 with sterile water; give 2–4 mL/kg) - Neonates (BGL <45 mg/dL): 10% DEXTROSE at 0.5–1.0 g/kg - Repeat BGL in 5 minutes; repeat treatment as needed to keep BGL >60 - If unable to obtain IV/IO: GLUCAGON 0.5–1 mg IM (requires follow-up glucose supplementation; won't work in liver disease) - Mandatory online Medical Control (MCEP) contact required for refusal in: non-diabetics, patients on oral hypoglycemics (sulfonylureas), or patients on intermediate/long-acting insulin

Criteria for release without transport (all must be met): 1. Adequate response (normal VS, normal mentation, normal BGL) to one dose of dextrose 2. No acute co-morbid conditions (chest pain, SOB, seizures, intoxication, also received naloxone, liver/kidney disease, febrile illness) 3. Patient only on short-acting insulin or pre-mixed insulin analog 4. Patient does NOT use oral medications to control BGL 5. Patient not actively vomiting 6. Patient can promptly obtain and will eat a carbohydrate meal 7. Patient or guardian refuses transport or EMS/patient agree transport not indicated 8. Released to competent adult for 2–3 hour observation

Hyperglycemia (BGL >250 mg/dL with symptoms — dehydration, vomiting, or AMS, or "HIGH" on glucometer): - Protect airway; administer high-flow O2 and assist ventilations if needed - IV isotonic fluid 500–1,000 mL bolus for adult patients if associated dehydration or signs of poor perfusion with no volume overload signs; otherwise TKO - Transport to closest appropriate facility

Thiamine: If thiamine deficiency suspected (chronic alcohol use, radiation therapy, malnourishment): THIAMINE 100 mg slow IV/IO or IM (adult), 10–25 mg slow IV/IO or IM (pediatric) — prior to or with glucose administration to avoid precipitating Wernicke's encephalopathy

NREMT Relevance¶

High-frequency exam topic. Common question angles: - Three criteria for oral glucose: AMS + known diabetic + ability to swallow (all three required) - Do NOT give oral glucose to unconscious patients - BGL threshold: <60 mg/dL = hypoglycemia - Oral glucose brand names: Glutose, Insta-Glucose - Hyperglycemia presentation: Kussmaul respirations, fruity breath, gradual onset, hot dry skin - Hypoglycemia presentation: sudden onset, diaphoresis, pale cool moist skin, AMS - "If in doubt, give glucose" — hypoglycemia is immediately treatable; hyperglycemia will not worsen with a small glucose load

oral-glucose — pharmacology and administration details for oral glucose
history-taking — SAMPLE drives the glucose decision; last meal, insulin history
secondary-assessment — glucometry as part of vital signs set
stroke — hypoglycemia mimics stroke; check BGL before treating suspected stroke
altered-loc — all altered LOC patients need glucometry
seizure — hypoglycemia can cause seizures

Sources¶

raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Diabetic Emergencies protocol (p. 38–39)