Hyperglycemia - Causes, Symptoms and TreatmentHyperglycemia is a medical term for high blood sugar.
Hyperglycemia (High blood glucose) - American Diabetes AssociationLearn to identify the symptoms of hyperglycemia so you can treat it quickly. Hyperglycemia Symptoms, Signs, Diet - MedicineNetLearn about hyperglycemia, a serious medical problem for people with diabetes.
Symptoms of HyperglycemiaMany of the acute symptoms of diabetes are related to hyperglycemia. What Are the Symptoms of Hyperglycemia in Diabetes - MedicineNetLearn about hyperglycemia, a serious medical problem for people with diabetes.
September 12, 2012 by Brandon Oto 2 Comments Streamlining a patient’s entry to the healthcare continuum is one of our main roles in EMS, and the key step in most cases is when we transfer care at the emergency department. Jeff’s hospital saves time in all trauma, stroke, and STEMI activations by assigning patients an alias immediately upon notification by EMS.
Cath lab activations from the field are still often about trust — whether staff knows the individual provider or the particular service calling.
For stroke, neurology may be in the room when you arrive, but more often, especially in smaller hospitals, they’re available by page or teleconference.
When you walk in the room, the typical team is a doctor, a nurse, a tech, then any extras — residents or other students, surgery, pediatrics, whomever.
Written PCRs are usually not read due to difficulty obtaining them and general unfriendliness (hard to find info, obscure writing), but sometimes there’s useful stuff in there, particularly in the narrative itself. Baseline patient info from EMS is great if we know the patient well (frequent fliers); baseline info from bystanders, staff, family etc. Disagreements over patient triage or treatment: find the attending or perhaps resource nurse and voice your concern. Implementing glucometry into your overall assessment means understanding three things: when to use it, what the results mean, and when it fails. First of all, by and large the only people with derangements of their blood sugar should be diabetics.
The most correct answer is anybody with clinical indications of either hypo- or hyperglycemia. When hyperglycemia becomes severe and prolonged enough, we start to worry about diabetic ketoacidosis. With all of that said, you need to really build up some glucose before hyperglycemia becomes symptomatic, and even more than that before it becomes acutely dangerous and unstable. Despite all this, the primary manifestations of early hypoglycemia are actually not symptoms of hypoglycemia. To make a long story short, anybody with altered mental status, or any kind of general systemic complaint (weakness, fatigue, anxiety, nausea, etc.) should probably get their glucose tested, whether or not they have a known history of diabetes.
A number of years ago, there was some limited but compelling research that suggested poorly-controlled blood glucose (meaning not severe derangements but merely small deviations from the ideal range) was associated with increased mortality among an inpatient population with a wide variety of conditions. So you’ve taken a blood glucose, either by capillary finger-stick or from a venous sample. All things are also relative, in that a given BGL must be compared to the patient’s baseline to predict its effects.
Non-diabetics usually become noticeably symptomatic below a sugar of, on average, about 53. After a recent meal, diabetics may demonstrate hyperglycemia to various degrees depending on whether they ate a Cobb salad or an entire chocolate cake. Another important consideration in evaluating glucose levels is the expected trend. For instance, a BGL of 70 in a diabetic patient might not excite anybody. To make a long story short, the clinical effects of both hypo- and hyperglycemia can vary substantially.
Well over 90% of BGLs that test outside the maximum error range (remember, around 15%) are due to user error. You failed to clean the skin before lancing, contaminating the sample (not to mention creating an infection risk), or you had some D50 on your glove and it got mixed in there. The good news is that in many of these situations, internal error-checking within the glucometer will recognize the problem, and flash an error rather than a reading. Comprehensive diagnosis and treatment of syncope deserves its own dedicated series, and one of these days we’ll try and work through it from A to Z. But for now, we’ll just talk about a few take-home pearls that can pay dividends in the everyday management of your next syncope call.
Here are a few dead-simple roadsigns to help guide you through the most common and most important causes of syncope.
So, our first step should be to take the raw he passed out and sift it into a more precise description.
A prodrome is an early, sometimes subtle set of symptoms that warn of a problem developing. Vasovagal syncope is one of the most common causes of syncope, involving a transient drop in blood pressure, and vasovagal syncope is usually preceded by a prodrome. It’s one thing to hear about a prodrome from the patient, but you may get a different story from the bystanders.
Did the patient say, do, or complain of anything before or after the event, which he may no longer recall?
Was he walking and moving normally, in no distress, when he suddenly collapsed like a marionette with its strings cut, hitting the ground with no attempt to protect himself? Sometimes, the chain of events or the patient’s medical history may suggest an etiology. Has there been any recent trauma, such as a fall, motor vehicle collision, or assault with injury? This is less likely to be useful than the history, but it can help rule in or rule out major, acute emergencies.
Cardiac abnormalities may manifest with irregular pulses, and active decompensation may be revealed in the blood pressure. All syncope patients, including suspected seizures, should get a neurological workup, particularly a Cincinatti Stroke Scale. Evaluate the abdomen for signs of hemorrhage, and inquire about blood in the stool or emesis as well. Being reluctant to force Joe into an undesired ambulance ride, the crew contacted their supervisor.
The crew and supervisor approached Joe together and informed him of the circumstances; although all parties agreed that he should rightly be able to refuse transport, they felt they had been overruled by a higher authority, and if he would not come voluntarily they would be forced to compel him. He was taken to his preferred hospital and care was handed off to staff with a full description of the situation. The encounter was documented extensively and quality improvement measures involving EMS and the base physician are expected.
This case was not medically complicated, but it involved some difficult issues of consent and risk.
We were dispatched for a chief complaint of a fall — a very common mechanism of injury. Typically, a blow to the head with loss of consciousness is also considered high risk for spinal injury. The use of warfarin (trade name Coumadin), on the other hand, does significantly increase the risk of intracranial hemorrhage (ICH), especially after blunt trauma to the head.
This is an odd question, because ordinarily we assume that people are free to go where they want, and calling 911 (or having it called for them) does not surrender this right.
One complication in this case is the presence of someone who claims to be Joe’s health care proxy. In this case, the physician’s attitude was that the problem was primarily medical: does the patient need emergency department evaluation to rule out dangerous processes? Realistically, although this fundamental right does not change, it’s fair to consider the surrounding medical circumstances to help decide how pressing and high-risk the matter is. Legally, in most areas EMS providers are seen as operating under the bailiwick and legal authority of their medical director, and online medical control is an extension of this authority. A North Bergen dual-medic crew is dispatched to a pregnant, full term female in cardiac arrest. Is the moral that acting in the patient’s best interest is not always a defense against liability?


Fortunately in this case we were able to avoid getting violent at all, but it was a near thing. With everything viewed in retrospect, the situation would have been much more easily resolved had the doctor not been involved in the process.
No matter what, such a situation is highly unusual, flush with liability, and should be thoroughly documented in all respects. A seizure is an episode of chaotic, disorderly electrical activity involving part or all of the brain. Seizures are typically divided into two major types, partial seizures which involve only a portion of the brain, and generalized seizures which involve the entire brain. Febrile seizures are seizures caused by elevated temperature (usually >100 degrees), most often seen in infants and young children.
Status epilepticus describes a prolonged seizure state, customarily defined as a seizure lasting over 30 minutes or multiple seizures without a full recovery in between.
In some cases, seizures will be followed by a persistent, unilateral focal weakness in muscles that were active during the seizure. Field care for seizure generally involves preventing secondary injury, such as blunt trauma caused by hitting or landing on nearby objects. Here is an example of a simple partial seizure in a child, in this case manifesting as a repetitive facial tic.
That way registration isn’t lurking around while the team is trying to treat the patient.
Rightly or wrongly, there’s also a stricter de facto standard for activation during off hours when nobody wants to get out of bed. The rest of us are generally able to maintain euglycemia through our homeostatic mechanisms, except perhaps in critical illness causing organ failure and similar abnormal states. This can actually be detectable by chemical dip-stick, or even by odor and texture at very high levels. Although burning fat and protein is not necessarily dangerous (some popular diets actually put you into a mild ketogenic state intentionally), extensive accumulation of ketones caused by a total lack of insulin (as in type I diabetics — DKA is rarely seen in type II) creates a metabolic acidosis in the body.
In other words, if you were hospitalized with something like sepsis, you were more likely to end up dying if your sugar tended to float around 160 instead of 110. Diabetics seeking to control their condition and not have their toes falling off in a few years usually strive for tighter control of their BGL than is needed for acute care; a sugar of 175 is a little on the high side for a routine check, but a pretty meaningless elevation for our purposes.
In other words, poorly-controlled diabetics who are routinely sitting at 200 may become symptomatic of hypoglycemia at relatively high levels, whereas very well-controlled diabetics who usually run lower may be able to drop very low indeed without noticing it. For diabetics, it will depend mainly on how much and what type of medication they’re using.
For one thing, if your body has to flip that switch often, you become numbed to it, and your hypoglycemic thresholds becomes lower and lower. Particularly when peripheral perfusion is poor, always try to sample at a different limb from any running drips. The reagents in the strips will actually degrade if exposed to air for sufficient periods of time, so make sure that you keep them in their tightly-sealed case, and follow their printed expiration dates. If you draw whole blood and leave it around (much more likely to happen in the laboratory than in the ambulance), the erythrocytes will metabolize glucose at about 5-7% per hour. Primarily in meters using the glucose oxidase enzyme, alkalosis will cause falsely elevated readings, while acidosis causes falsely low readings. High levels of circulating proteins or fats can cause falsely low readings due to dilution. See our previous remarks on this, and remember that venous sources will be more accurate than capillary. Better known as Vitamin C, some people take megadoses of this stuff, thinking it’ll cure their cold or flu. Massive doses, such as might be used for intensive inotropic support, can modestly influence glucose dehydrogenase-based meters. This is a dialysate solution used for peritoneal dialysis (not hemodialysis — this is where they pump fluid into the abdomen, let it sit, then drain it out), mainly in patients with diabetes. Every etiology is unique and has its own distinct pathophysiology, presentation, and treatment considerations.
Prodromes are our friend, because although they can be very brief or non-obvious, when present they can help indicate what happened.
Closed is typical of classic syncope, such as a vagal event; open is more appropriate for a seizure. This is strongly suggestive of a cardiac event and these patients should be considered high-risk for sudden death. Less than 30 minutes later, another crew was sent back to the hospital to return Joe home; the attending ED physician had deemed his involuntary hold to be invalid and inappropriate, and refused to hold him against his will. This is under the assumption that a blow with enough force to cause LOC may also have enough force to damage the spine.
An irregularly shaped pupil as we saw here is more indicative of a structural defect, the most common of which is probably cataract surgery, which can leave the pupil off-round. However, many do carry med lists, and in most cases you can reconstruct the majority of the patient’s diagnoses based on their medications.
However, there is an attitude among those with a duty to act, such as healthcare providers and public safety officers, that individuals who are not cognitively able to understand their situation and make decisions in their best interest need to be protected from their own impaired judgment.
Any implication that you know what’s really happening to the patient or can definitively rule in or rule out any medical problem is unwise and legally risky.
A proxy (closely linked to the idea of a durable power of attorney) is a person whom, while of sound mind, you designate to make decisions for you if at a later time you are not of sound mind. If it did prove necessary, it should have been done with ample manpower and many hands; in some areas chemical sedation by paramedics may also be authorized.
It is most often seen in epilepsy, but seizure can also occur acutely due to hypoglycemia, eclampsia, stroke, head trauma, alcohol withdrawal, and other causes.
In a simple partial seizure, consciousness is maintained, but unusual sensory, motor, or emotional sensations are observed — muscular tics, visual disturbances, strange feelings, and more are all possible depending on the area of the brain affected.
They are characterized by two phases: a tonic phase, where the body becomes rigid and immobile, followed by a clonic phase, where full-body involuntary muscular jerking occurs. The individual may simply stare without moving or speaking, and after cessation of the seizure resume where he left off with no memory of the episode. They are typically tonic-clonic in nature and almost always have benign outcomes; they rarely go on to develop into adult epilepsy. Some authorities draw the line at any seizure over 10 minutes, and there is evidence that even seizures longer than 5 minutes are unlikely to end without medical intervention. This is called Todd’s paresis, and since it can closely mimic the signs of stroke (even impairing eyesight or speech), it is wise to ask about recent seizure activity in patients with a history of a seizure disorder who present with signs of stroke. During the tonic phase, respirations may be minimal, resulting in cyanosis; this is usually brief enough not to cause harm. Note the repetitive, aimless movements of the arm and head, which are known as automatisms and are wholly involuntary; if spoken to, she would not respond.
You see his awareness of its onset due to an aura, followed by gradual tonicity and then clonic jerks.
Extreme hunger and thirst are common symptoms of hyperglycemia—when your blood glucose levels are too high. If your patient is complaining of those, you might be the first one to discover their condition. Hypoglycemia again presents as altered mental status, in this case more often an inhibited rather than an elevated state: confusion, lethargy, disorientation, inability to focus or follow commands, weakness, headache, seizures, and eventually coma and death. Not only can diabetic emergencies look like anything, they can also be comorbid; it is extremely common for patients to have another problem, yet also to bring a high or low sugar along for the ride, due to the illness throwing a wrench in their normal intrinsic and extrinsic glycemic homeostatic systems. As a result, it become trendy to practice extremely tight and aggressive glucose management for virtually everybody; diabetic patients were being tested every few hours and ping-ponged around using medication to keep their numbers textbook-perfect.
The acidosis of DKA can therefore cause falsely low readings, masking the profound underlying hyperglycemia, so if the clinical picture screams DKA, don’t necessarily let the glucometer tell you different. These in particularly are highly device-dependent, with the glucose oxidase-type meters most often affected.
The effect is similar to ascorbic acid, but even more modest; it should only be considered in major overdoses, and even then the difference is unlikely to break 35.
This remains one of the best assessment aids we have, because diabetic emergencies remain some of the most common, most treatable, and most easily confused disorders that we encounter.


Did the patient truly lose consciousness, or do they claim that they remained somewhat aware? These are suggestive of vasovagal; once a horizontal position is reached, perfusion to the brain is restored and the problem resolves. Orthostatic vital signs can be considered if vagal, orthostatic, or hypovolemic etiologies are suggested. In this case, as it often is, the fall was from a standing height, and from a standstill (i.e.
These considerations are all valid, but should only be seen as some of the many factors involved in stratifying risk; they must be considered alongside other elements like the physical assessment.
The best example of this is the subdural hematoma, where cases of moderate severity sometimes take hours or days to develop, due to the venous rather than arterial source of bleeding. In this case, it would involve giving them some description of the above possibilities (spinal fracture, head bleed, etc.), and ideally having the patient then relate them back to you, demonstrating good comprehension of those facts.
Crucially, if you are still capable of decision-making, a proxy does not have the ability to override you; their role is to act on your behalf when you cannot. However, the first question actually needs to be: Is the patient capable of evaluating risk and making decisions in his own best interest? Determining that the mother is likely unsalvageable, and concerned for the health of the fetus, they contact medical control. And I would certainly not recommend acting without the doctor’s signature on a legal document. Most often, this will then proceed into a larger seizure, in which case these early effects are called an aura, and used as a warning sign.
This is usually followed by a post-ictal period, where the patient may be unresponsive, or behave unusually, appearing combative, stuporous, or otherwise impaired.
Absence seizures may also present with some outward seizure activity, in which case the distinction between types becomes blurred. Status epilepticus is a true life-threatening emergency with high mortality; the continued chaotic activity of the brain can lead to permanent brain damage or death.
The greatest concern is to maintain an open airway and prevent aspiration; when possible the patient should be placed in the lateral recovery position to help prevent soft tissue obstruction and allow fluids to drain away. We discussed how to work and play together better, including topics like handoff reports, useful histories, and typical ED courses of care. DKA causes altered mental status, usually elevated states of confusion and disorientation, and combative behavior isn’t uncommon.
The fun part is that the impairments can present as focal as well as generalized deficits: unilateral weakness of the limbs or face, speech slurring, poor gait, vision abnormalities, and more.
Wise diabetics recognize the early signs of this sympathetic response and drink some Pepsi. As levels keep dropping, these symptoms combine with the neurological effects of glucose starvation to produce a confused, sweaty, increasingly stuporous individual.
More recently a number of studies have suggested that this may be less important than was thought, and in fact that excessive paranoia leads to a lot of iatrogenic harm from accidental insulin overdoses. Finally, drugs like beta blockers that directly block sympathetic activity can seriously obscure hypoglycemia.
There’s at least one tragic and unfortunate case report of a patient death resulting from massive insulin overdose due to this effect, not noticed until the true BGL was obtained by laboratory analysis. But to a veteran provider, syncope is a deep, dark diagnostic hole—because syncope can be caused by countless different disorders, and although some are benign, a few of them are deadly. If he’s acting normally now, was there a period after the event where he demonstrated sluggish activity or unusual behavior, consistent with a post-ictal period? If he remained unconscious for a prolonged period while prone—or his initial episode occurred while already seated or reclined—this is highly unusual for vasovagal. In some systems, you may be forced to immobilize based on mechanism without other considerations. This delay is particularly common in the elderly, where (possibly due to shrinking of the gray matter, which leaves additional room for blood to collect before pressure begins compressing the brain) a classic scenario is the fall with a blow to the head, no complaints for hours afterward, and then sudden deterioration.
However, many elderly patients (and some of the younger ones, too) will attribute any fall to tripping, so this claim should be taken with a grain of salt. The legal term is implied consent, the same principle by which we transport children, drunks, and unconscious people.
Your best bet is to outline some basic possibilities, carefully inform them of the limits of your training and resources, and be smart enough that you generally know what you’re talking about in the first place. Definitive treatment is the use of anti-convulsants, which attenuate the neuronal activity; in the field these are typically benzodiazepines like lorazepam (Ativan), diazepam (Valium), or midazolam (Versed).
Almost a fifth of older Americans are diagnosed, and the older and sicker they are, the more common it is. If left untreated, finally the sugar drops until we’re looking at the picture of impaired and diminished consciousness caused by true hypoglycemia. Grab your nearest bottle of beta blockers and read the list of adverse effects: one will be hypoglycemic unawareness, a five-dollar term that means beta blockade can make it difficult to know when your sugar drops low. A low number in an asymptomatic patient, or a normal number in a patient with highly suggestive signs and symptoms, should force you to bring out your thinking cap and weigh the odds. If you maintain your equipment, learn how to do it right, and keep a few basic confounders in mind, it’ll serve you well as one of your most reliable tools.
This is often seen as the dividing line for significant versus non-significant falls; in many areas, falls from standing height or greater are considered an indication for spinal immobilization.
In others, you may be allowed to rule out immobilization based on certain findings, most of which Joe has; for instance, he denies neck or back pain or tenderness, denies peripheral parasthesias (numbness or tingling) or weakness, ambulated well, turns his head, and has no confounding factors like a distracting injury or altered mental status. Some sources state that 60% of geriatric fall patients who experience LOC from a blow to the head will eventually die as a result.
It helps to have a witness to the event, as we do here, although witnesses are not always reliable either.
Social workers, psychiatrists, and other specialists have a full battery of tests that can help further reveal cognitive capacity. Even a clearly dying man can refuse medical care based on religious views, personal preference, or any reason whatsoever (although barring a proxy or advanced directive, once he’s unconscious he can usually be treated under implied consent). Since the duration from 911 call to EMS arrival on scene is often greater than 5-10 minutes, a seizure that is still ongoing upon your arrival should raise immediate suspicion of status epilepticus; a careful history should be obtained from bystanders when possible, including time since onset and any intervening recovery. Supplemental oxygen is always appropriate, although a non-rebreather mask may not be tolerated in the post-ictal period. Interestingly, kids are particularly prone to hypoglycemia due to their gigantic heads, full of glucose-hungry brain. If they take psychotropic or other medications, are they compliant with these, or could there have been an under- or over-dose? In any case, the post-fall presentation was so benign that risk seemed low, and given the patient’s overall reluctance it is highly unlikely that he would have consented to a collar and board. Since in this case, we were delayed on scene for quite some time, there would be value in ongoing and repeated assessments of symptoms, neurological status, and vital signs while we waited around. This is different from the person who actively tries to take his own life; for philosophical reasons we view this as different from passively allowing oneself to die for lack of medical treatment. The mother is declared dead soon afterwards, but the infant lives for a number of days before dying in the hospital.
If respiration appears inadequate in prolonged seizures, positive pressure ventilation (by BVM or invasive airway) may be attempted. In the aftermath, the paramedics are cited for violating their scope of practice, and their licenses to practice are revoked in the state of New Jersey. Ibuprofen is a non-steroidal anti-inflammatory (NSAID) used for pain relief and reduction of inflammation. The physician is forced to undergo remediation training to maintain his medical control privileges. Invoking our supervisor gives us a bigger boat either way, and would be a big help to protect us from trouble coming from our employer, one of the most likely sources.



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