Lesson Title

Diabetic Emergencies - Overview

Short and Descriptive

Although diabetes can have long lasting consequences if it is not tended to, sudden diabetic emergencies
can occur rapidly and with little to no warning. This lesson will focus on immediate diabetic emergencies,
recognizing your symptoms, and first aid. The main emergencies discussed are diabetic ketoacidosis,
hyperosmolar hyperglycemic syndrome, hypoglycemia, and preeclampsia.

Background

First we will review the two types of diabetes.

Type 1 diabetes is a genetic disorder that commonly appears in individuals at a young age. In type 1
diabetes the body’s immune system attacks insulin-producing cells in the pancreas. In this type, there is
little to no insulin because the pancreas can’t make any.

Type 2 diabetes is largely self-induced based on diet and lifestyle, and develops overtime. In type 2 the
body does not produce enough insulin for the system to function correctly, because it has chronically
been overworked.

Lesson Title

Diabetic Emergencies - Diabetic ketoacidosis

Short and Descriptive

Although diabetes can have long lasting consequences if it is not tended to, sudden diabetic emergencies
can occur rapidly and with little to no warning. This lesson will focus on diabetic ketoacidosis, recognizing
its symptoms, and first aid.

Background

Diabetic ketoacidosis is a serious diabetic condition when the body produces high levels of blood acids,
ketones.

The condition occurs when the body doesn’t produce enough insulin, so the body begins to break down
fats to replace sugar as fuel. Diabetic ketoacidosis develops when there is a buildup of ketones in the
bloodstream, leading to life-threatening complications.

Signs and Symptoms

The signs of diabetic ketoacidosis can develop quickly.

Signs and symptoms include:

Excessive thirst
Frequent urination
Nausea and vomiting
Stomach pain
Weakness and fatigue
Shortness of breath
Fruity-scented breath
Confusion

The above symptoms are common in most diabetic emergencies, although more-specific signs of diabetic
ketoacidosis can be tested with at home blood and urination testing kits, that detect:

High blood sugar levels

High ketone in urine

The medical history of the patient is important when considering your risk of developing diabetic
ketoacidosis.

Diabetic ketoacidosis is usually triggered by an illness that causes the body to produce higher levels of
certain hormones, which counteract the effects of insulin.

If an individual continues to skip your insulin doses or there is a malfunctioning of an insulin pump, they
are at a higher risk of developing diabetic ketoacidosis.

Other possible triggers include:

Physical or emotional trauma

Heart attack or stroke
Pancreatitis
Pregnancy
Alcohol or drug abuse, particularly cocaine
Certain medications, such as corticosteroids and some diuretics

You have a higher risk of diabetic ketoacidosis if you have type 1 diabetes, but it is still possible with type
2.

If you are with an individual:

Whose blood sugar level is consistently higher than 300 milligrams per deciliter (mg/dL), or 16.7
millimoles per liter (mmol/L)
Has ketones in your urine and can't reach your doctor for advice
Has many signs and symptoms of diabetic ketoacidosis

Seek emergency care right away

Management
If an individual has high blood pressure and ketone levels, immediately start treatment.

Give them fluids, through mouth or vein, until they are rehydrated and to dilute the sugars in your blood.

Give them electrolytes through a vein so your heart, muscle, and nerve cells can continue to function
properly.

If possible start them in intravenous insulin therapy, until your blood is no longer acidic.

After the event you should contact your doctor so they can run additional tests to find the cause of the
diabetic emergency and create a diabetes treatment plan.

Prevention

Diabetic ketoacidosis is a preventable diabetic emergency, with many measures an individual can take.

They have to commit to managing your diabetes through exercise, diet, and continuing to take insulin.

Continue to check your blood sugars regularly, especially if they are stressed or ill.

Keep in contact with your doctor, to adjust your dosage of insulin based on your lifestyle, such as diet,
exercise, and blood sugar levels.

When they become stressed or ill, they should check your ketone levels in your bloodstream. They should
be prepared to act fast and alert your doctor if blood sugar is high and they have excess ketones in your
urine.

Lesson Title

Diabetic emergencies - Hyperosmolar hyperglycemic syndrome

Short and Descriptive

Although diabetes can have long lasting consequences if it is not tended to, sudden diabetic emergencies
can occur rapidly and with little to no warning. This lesson will focus on hyperosmolar hyperglycemic
syndrome, recognizing its symptoms, and first aid.

Background

A serious diabetic condition that occurs when blood sugar levels are extremely high for a relatively long
period of time.

Hyperosmolar is serious because your body attempts to rid itself of the excess blood sugar by continuous
urination, leading to life-threatening dehydration.

Signs and Symptoms

The symptoms of hyperosmolar are not always fast to appear, but can take days to weeks to develop.
Possible signs and symptoms include:

Excessive thirst
Dry mouth
Increased urination
Warm, dry skin
Fever
Drowsiness, confusion
Hallucinations
Vision loss
Convulsions
Coma

Contact your doctor if blood sugar levels are consistently at or above 400 mg/dL (22.2 mmol/L) and you
have confusion, vision changes, or other signs of dehydration.

When evaluating a patient you presume has hyperosmolar, it is important to consider the risk factors that
might make them more predisposed to the syndrome. If they:

Have type 2 diabetes

Are older than 65
Have chronic health condition
Have an infection
Take certain medications (such as corticosteroids, diuretics, etc.)

Hyperosmolar syndrome needs to be taken care of because it leads to seizures, heart attack, stroke, and
a coma.

Management

If you come across someone who is suffering from hyperosmolar syndrome or is showing signs of high
blood sugar levels, give them intravenous (IV) medications.

Provide them with fluids to hydrate them.

Give them electrolytes such as potassium, to balance the minerals in the bloodstream.

If available, give them insulin through an IV first, and then through their regular method.

Continue to measure their blood sugar levels and get them to the doctor as quickly as possible.

Once at a hospital or a medical facility, the doctor will most likely treat the patient for any underlying
condition that may have caused the emergency, such as an infection or illness.

Prevention

To prevent diabetic hyperosmolar you should continue to measure your blood sugar levels and know the
symptoms of high blood sugar levels so that you can identify if you are at risk of developing the
syndrome.
If you are sick, drink plenty of fluids that are non alcoholic and caffeine-free.

Continue to follow your diabetic management plan, through healthy meals and exercise.

It is important to educate others, such as talking to family, friends, and coworkers or wearing a medical
bracelet.

Lesson Title

Diabetic emergencies - Hypoglycemia

Short and Descriptive

Although diabetes can have long lasting consequences if it is not tended to, sudden diabetic emergencies
can occur rapidly and with little to no warning. This lesson will focus on hypoglycemia, recognizing its
symptoms, and first aid.

Background

Hypoglycemia occurs when your body’s blood sugar levels are lower than normal, resulting in serious
complications.

Although hypoglycemia is commonly found in people with diabetes, drugs and other factors can also
cause low blood sugar in people without diabetes, although it is rare.

Similar to other diabetic emergencies, immediate treatment is required.

Signs and Symptoms

The first signs of low blood sugar include:

An irregular or fast heartbeat

Fatigue
Pale skin
Shakiness
Anxiety
Sweating
Hunger
Irritability
Tingling or numbness of the lips, tongue or cheek

If hypoglycemia worsens, signs include:

Confusion, abnormal behavior or both, such as the inability to complete routine tasks
Visual disturbances, such as blurred vision
Seizures
Loss of consciousness
Hypoglycemia is common right after eating in people with diabetes.
Hypoglycemia is a result of too much insulin or other diabetic medication dropping your blood sugar levels
too low.

If you eat less than you normally do after taking diabetic medication, you are also at risk of hypoglycemia.

Hypoglycemia is not just specific to people with diabetes, but can also develop in nondiabetic people,
although it can be the first sign of prediabetes developing.

Causes of hypoglycemia in people without diabetes include:

Medications
Excessive alcohol drinking
Critical illnesses
Insulin overproduction
Hormone deficiencies

If none of these apply to you, you should go see a doctor because you might be developing diabetes.

Management

As with other diabetic emergencies, regularly check your blood sugar levels.

If your blood sugar levels are below your target range or 70, eat or drink 15 to 20 grams of carbohydrates.
Good sources are juice, hard candy, or glucose tablets.

Check your blood sugar levels every 15 minutes and continue to treat after checking the levels.

If blood sugar levels remain low or symptoms persist, call 911 and get medical help.

If an individual is not responding to the sources of carbohydrates, they may have severe hypoglycemia.

Severe hypoglycemia is treated with a glucagon injection or intravenous glucose. The three approved
medications are:

Baqsimi - taken as a nasal powder

Dasiglucagon (Zegalogue) - taken by injection
Gvoke - taken through injection

Prevention

If you have diabetes, talk to your doctor about developing a diabetes management plan or revising your
old one to better fit your needs.

This may include changing your medication, your level or exercise, and/or diet.

You should also invest in a continuous glucose monitor (CGM) if needed. The CGM monitors your blood
sugar levels and can send the levels to a receiver, to better inform yourself.
The CGM can be used with or without a pump that stops delivering insulin when your blood sugar levels
get too low.

Always have access to a fast acting carbohydrate, in case your blood sugar levels go down significantly.

If you do not have diabetes, but still get frequent episodes of hypoglycemia, it is possible to stop or limit
them by eating small but regular meals throughout the day. This is a short-term solution.

If hypoglycemia becomes chronic, go to a doctor to talk about treatment plans.

Lesson Title

Diabetic Emergencies - Preeclampsia

Short and Descriptive

Although diabetes can have long lasting consequences if it is not tended to, sudden diabetic emergencies
can occur rapidly and with little to no warning. This lesson will focus on immediate diabetic emergencies,
recognizing your symptoms, and first aid of preeclampsia.

Background

Preeclampsia is a complication of pregnancy and can occur in individuals that had normal blood blood
pressure levels before pregnancy. High blood pressure levels and high levels of protein in the urine are
an indication of preeclampsia.

It can lead to serious and even fatal complications in both the mother and baby.

In most circumstances, the delivery of the baby is recommended when the mother has preeclampsia, due
to the serious consequences.

The cause of preeclampsia is based on several factors. Commonly it begins in the placenta, when the
blood vessels that develop to supply oxygen and nutrients from the mom to the fetus, don’t develop or
work properly. Due to the issue in the blood’s circulation to the placenta, the mother’s body will have
issues with regulating blood pressure levels.

Signs and Symptoms

The most common symptom of preeclampsia is high blood pressure and other signs of issues to the
kidneys.

It is possible to not have any symptoms, and commonly preeclampsia is detected in regular prenatal
check-ups.

Other signs of preeclampsia include:

Excess protein in urine or other signs of kidney problems

Decreased levels of platelets in blood
Increased liver enzymes that indicate liver problems
Severe headaches
Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
Shortness of breath, caused by fluid in the lungs
Pain in the upper belly, usually under the ribs on the right side
Nausea or vomiting

The signs for severe preeclampsia include:

Hypertensive emergency (blood pressure is 160/110 mmHg or higher).

Decreased kidney or liver function.
Fluid in the lungs.
Low blood platelet levels (thrombocytopenia).
Decreased urine production

Sudden and excessive signs of swelling or weight gain are also a possible sign of preeclampsia.

Risk factors for preeclampsia include:

Preeclampsia in a previous pregnancy

Being pregnant with more than one baby
Chronic high blood pressure (hypertension)
Type 1 or type 2 diabetes before pregnancy
Kidney disease
Autoimmune disorders
Use of in vitro fertilization

Black women and women older than 35 are more susceptible to developing preeclampsia.

Management

Individuals should seek advice or help if they begin to experience severe headaches, blurred vision,
severe stomach pain, and severe shortness of breath.

If you are pregnant and have high risk factors then you should regularly be attending prenatal check-ups.

The primary management of preeclampsia is to deliver the baby if possible or to manage the symptoms
until you are able to deliver the baby responsibly.

Although if preeclampsia is not severe, then you should just continue to monitor your blood pressure, the
health of the baby, and check-up routinely with your doctor.

If the preeclampsia is severe then you should be admitted to the hospital and prepare to give birth to the
baby.

Medications to treat severe preeclampsia include:

Antihypertensive drugs to lower blood pressure

Anticonvulsant medication, such as magnesium sulfate, to prevent seizures
Corticosteroids to promote development of your baby's lungs before delivery
Prevention

The best medication today to prevent preeclampsia is low-dose aspirin. It is recommended that an
individual with at least one risk factor of preeclampsia take an 81-milligram aspirin tablet daily 12 weeks
after pregnancy.

You should discuss with your doctor about taking any other medications or supplements, because some
can be dangerous to your health.

Individuals should try to be healthiest before pregnancy to reduce their risk of developing preeclampsia,
by maintaining a regular exercise routine, getting enough sleep, and eating foods low in sodium and
caffeine.

You should attempt to lose pre-pregnancy weight gain if are overweight/obese. You should also control
your blood pressure and manage your blood sugar levels if you have diabetes.

Diabetes References

https://www.mayoclinic.org/diseases-conditions/diabetic-hyperosmolar-syndrome/symptoms-causes/syc-2
0371501
Overview of hyperosmolar syndrome

https://www.mayoclinic.org/diseases-conditions/hypoglycemia/symptoms-causes/syc-20373685#:~:text=H
ypoglycemia%20is%20a%20condition%20in,who%20don't%20have%20diabetes
Overview of hypoglycemia

https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551
Overview of diabetic ketoacidosis

https://www.webmd.com/diabetes/diabetes-emergencies-what-to-do

https://www.webmd.com/diabetes/hypoglycemia-overview#:~:text=Hypoglycemia%20is%20a%20conditio
n%20caused,also%20get%20low%20blood%20glucose.

https://www.cdc.gov/diabetes/basics/diabetes.html#:~:text=Diabetes%20is%20a%20chronic%20

https://www.lifelinescreening.com/health-education/diabetes/type-1-type-2-diabetes

https://my.clevelandclinic.org/health/diseases/21147-hyperosmolar-hyperglycemic-syndrome

https://www.diabete.qc.ca/en/living-with-diabetes/care-and-treatment/hypo-hyper-glycemie/hyperglycemic
-emergencies/#:~:text=There%20are%20two%20types%20of,even%20death%2C%20if%20left%20untre
ated.

Key Concepts
Diabetic ketoacidosis

Body produces ketones in the bloodstream

Sign and symptoms include:

High blood sugar levels

High ketone in urine

Type 1 diabetes

Higher risk when stressed or ill

Give intravenous fluids, electrolytes, and insulin

Hyperosmolar hyperglycemic syndrome

Continuous high blood sugar levels

Leads to life-threatening dehydration

Sign and Symptoms include:

Excessive thirst

Increased urination

Common in Type 2

Provide fluids and electrolytes to hydrate

Hypoglycemia

Low blood sugar levels

Usually occurs a few hours after meals

Eat or drink fast acting carbohydrates for treatment

Common in people with either type 1 or 2

Could be the a sign of prediabetes

Questions

Question 1
You are walking with a friend on a brisk day after lunch and they start to complain about feeling shaky and
sweating. They sit down on a bench and tell you that they have diabetes. Which of the following is NOT a
reasonable course of action?

A. Give them a juice box

B. Help them administer their insulin
C. Call 911
D. Administer them a glucagon injection

Correct Response: B. Your friend is showing signs of hypoglycemia or low blood sugar. If you help your
friend administer insulin they are only worsening the condition, because insulin breaks up glucose in the
blood, lowering the individual's blood sugar. The individual’s blood sugar most likely decreased because
they recently had a meal, so you should not continue to administer insulin because insulin’s job is to
decrease an individual’s blood pressure.

Giving your friend a juice box will increase their blood sugar levels in less than 15 minutes, because fruit
contains carbohydrates. Carbohydrates are then broken down into glucose in your bloodstream. This is
the most likely course of action.

Calling 911 is a pretty good source of action that will ensure your friend’s health, but it is unnecessary if it
is a mild case of hypoglycemia that only requires quick acting carbohydrates to fix the issue.

A glucagon injection will quickly get glucagon into the individual’s blood stream, but this form of treatment
is not common so it is unlikely your friend has it on hand.

Question 2

You are backpacking with a group of people. You are in charge of the first aid kit and the medicine
because you have the most medical experience. You and two other people go hiking for the day on a
nearby hiking trail from the campsite. One of the hikers mentions quickly that they have type 2 diabetes
so they are trying to be more active. As you guys finish the hike and head back to camp, when the hiker
tells you he needs to sit down because he is experiencing hallucinations and needs a drink of water. They
then become drowsy and confused about where they are and who you are. You realize something is
wrong and ask the other person to run and grab the first aid kit. What is the best possible course of action
once you get the first aid kit and assess the patient?

A. Give them a hard candy

B. Try to get them up and walk to camp
C. Use a kit to measure blood sugar and blood ketone levels
D. Ask them about their medical history

Correct Response: C. Due to the inability to talk to the patient and know for certain that they are
experiencing a diabetic emergency, you should measure their blood sugar levels to see if they have
irregular blood sugar levels. This will allow you to determine if they are experiencing low or high blood
sugar levels. Measuring blood ketone levels will also help you identify if they are suffering from diabetic
ketoacidosis or hyperosmolar hyperglycemic syndrome.
Don’t give them hard candy if you are not sure if they are suffering from hypoglycemia, then giving them
may put them in a dangerous situation because candy will increase their blood sugar levels, which is
dangerous to people suffering from high blood sugar levels.

Don’t try to move the person if they are drowsy because they might lose balance and hurt themselves
even worse. It can also worsen their diabetic emergency.

Although asking about their medical history is a good idea and will allow you more insight on if they are
experiencing a diabetic emergency and which one, they are experiencing confusion and may not give you
the correct information.

Question 3

You are a paramedic that is called out to a popular hiking trail where a couple noticed a person
unconscious and lying on the ground. As you approach the patient you assess the situation; the individual
does not seem to have any head trauma, but based on a blood glucose test, their blood sugar is
extremely low. What is the best course of action?

A. Give them a glucagon injection

B. Wake them up by forcing them into a sitting position
C. Give them a hard candy

Correct Answer: A. If they are experiencing low blood sugar then they are suffering from hypoglycemia,
so they need to get glucose to raise their blood sugar levels. A glucagon injection will deliver glucose
quickly to the patient and they do not need to be conscious to administer it to them.

Do not try to wake them up by making them sit up, this will probably just make them more disoriented and
worsen the symptoms.

Never give an unconscious person oral glucose because they will most likely be unable to swallow it and
could be at risk of choking on it.

Question 4

You are out riding your bike when you come across a mother and her daughter. The mother waves you
down and asks if you can help them because she can’t call anyone. She explains that her daughter
became really thirsty and is now complaining about stomach aches. You assess the daughter who tells
you that she feels really nauseous and you ask her if she has recently had any fruit because she has
fruity breath, to which she replies yes. What is the next course of action from the knowledge you have?

A. Call 911 and continue on your bike ride

B. Ask the mother about her daughter’s medical history
C. Give her some fruit
D. Give her a pepto-bismol

Correct Answer: B. The best course of action would be to ask her mom about her medical history,
because nausea and stomach pains are not a definite sign of a diabetic emergency. It is best to know for
certain what she has before giving her medical treatment.
The mother has already tried to call someone and she was unable to get reception. Continuing on your
bike ride would just leave the daughter to suffer and if she does have a diabetic emergency it is putting
her at risk.

If she is suffering from diabetic ketoacidosis, or high blood sugar, then giving her fruit would only worsen
the problem as fruit is a form of carbohydrates.

The pepto-bismol might help alleviate her stomach pains and nausea, but if she is suffering from a
diabetic emergency that won’t solve the issue.

Question 5 and 6 refer to the following situation:

You are working as a camp counselor. After lunch you take your group of kids to go play in the lake. As
you are watching over them on the shore, one of the kids swims to the shore and tells you that they still
feel hungry and kind of shaky. You give them a granola bar you have and tell them to rest until they get
better. After a few minutes you take all the kids back to the camp to go on the hike. The kid continues to
complain that they don’t feel any better. You let them sleep in their cabin while everyone goes on a hike.
After a few hours you go back to check on the kid and you notice that they have pale skin and are
sweating. You ask them how they are feeling and say their lips and tongue feel tingly. You call another
counselor and they bring a medical kit and some food.

5. What should you give the child?

A. Nothing
B. Insulin
C. Hard candy
D. Avocado

Correct Answer: C. The child has all the symptoms of hypoglycemia or low blood sugar. Giving them hard
candy will increase their blood sugar and hopefully make them feel better, because it is a fast acting
carbohydrate.

6. The child continues to feel bad. The camp doctor has now come to check on the child. They measured
their blood sugar and it is extremely low. The doctor seems unsure of what to do. What advice should you
give her?

A. Give them a glucose shot

B. Give them insulin
C. Continue to give them hard candy
D. Tell them to go to sleep

Correct Answer: A. The kid continued to not get better from the small doses of carbohydrates from the
hard candy. The glucagon shot will deliver carbohydrates quickly and raise their blood sugar to
sustainable levels.

Although you could continue to give the child hard candy, they have already had low blood sugar for an
extended period of time so waiting more time could be dangerous for them. If a person suffers from low
blood sugar for too long, then they are at risk of developing a coma and possibly death.