Diabetes Medical Emergencies

Uncontrolled diabetes may lead to three main types of medical
emergencies:
• Low blood sugar, also called called hypoglycemia or low blood
sugar reaction
• Abnormal increase of acids in the blood, a condition called diabetic
ketoacidosis (DKA)
• Very high blood sugar, referred to as hyperosmolar hyperglycemic
state (HHS)
All the above conditions are called acute complications of diabetes because
they are usually transitory and are corrected by timely treatment. However,
delay in treatment of these medical emergencies can be disastrous, which in
extreme cases can lead to death.
LOWBLOOD SUGAR (HYPOGLYCEMIA). Sugar provides energy to all the
cells and muscles in your body. If your blood sugar falls too low, your body
cannot function properly. The level of blood sugar at which hypoglycemia
develops varies among individuals. Many laboratories rank blood sugar
level below 60 mg/dL as hypoglycemia or low blood sugar. But a person
whose blood sugar usually remains high may experience symptoms of low
blood sugar even at higher levels. In contrast, people who keep their blood
sugar low through tight control, may not feel the symptoms of low blood
sugar until sugar in their blood drops down as low as 30 mg/dL. In rare
cases, some people with diabetes who have developed low blood sugar
unawareness, a condition resulting from damage caused to their nervous
system by diabetes, may even fail to recognize the symptoms of low blood
sugar. This is a dangerous situation, which if not properly handled, may
become life-threatening.
CAUSES OF LOW BLOOD SUGAR. In diabetes, your blood sugar may
become low for any one or a combination of the following factors:
• Injecting an excess dose of insulin or taking large doses of diabetes
pills such as sulfonylureas, which stimulate secretion of insulin
from the pancreas. With excess insulin, the cells in the body pull in
too much sugar from the blood, leading to low blood sugar.
• Taking long-actinginsulin that peaks its action during the middle of
the night.
• Delaying or missing a meal or eating too little food to match the
amount of injected insulin.
• Unexpected or unusual exercise. Enhanced insulin action resulting
from unusual and vigorous exercise may contribute to low blood
sugar. Also, exercise helps rapid absorption of insulin in the body.
Thus, exercising after injecting insulin will accelerate the absorption
of insulin that may cause severe drop in blood sugar.
• Alcohol consumption. Under normal conditions when sugar in the
blood begins to fall, sugar produced by the liver prevents it from
falling too low. But when you drink alcohol, your liver’s function
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Symptoms of Low Blood Sugar
The symptoms include:

  • Nervousness – Hunger
  • Trembling – Headache
  • Fatigue – Nausea
  • Anxiety – Slurred speech
  • Irritability – Blurred vision
  • Sweating – High pulse rate
  • Dizziness – Sudden rise from sleep
  • Light-headedness – Drowsiness
  • Mental confusion – Unconsciousness
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    of releasing sugar in the blood will be depressed. In such a situation,
    the liver may not be able to offset the fall in blood sugar.
    • Delayed digestion. Nerve damage in the stomach, a complication of
    diabetes, causes delayed emptying of food from the stomach into
    the intestines (gastroparesis). As a result, food takes time to be
    absorbed as sugar in the blood. But the injected insulin, peaking its
    action earlier than food absorption will cause low blood sugar.
    • Menstruation. Women with diabetes who use insulin may experience
    low blood sugar during their menstruation cycle. This may
    be due to changes in the hormonal activity during menstruation.
    Self-Treatment of Low Blood Sugar
    When you experience any of the symptoms of low blood sugar,
    you should immediately eat some food or drink a beverage, containing
    10 to 15 grams of carbohydrate, for example:
    • 10 to 15 grams of oral glucose or 2 to 3 glucose tablets.
    Glucose works fastest; 10 grams of glucose will raise
    your blood sugar by about 40 mg/dL in about 30 minutes.
    • 1 tablespoon (3 teaspoons) of honey or sugar dissolved in
    water.
    • 1/2 cup of orange or apple juice.
    • 1 cup of regular or skimmed milk.
    • 1/2 cup (4 oz) of regular soda drink.
    • 3 Graham crackers.
    After 15 to 20 minutes of the above treatment, recheck your blood
    sugar. If blood sugar is still low (less than 60 mg/dL) or symptoms
    still persist, take an additional 15 grams of carbohydrate that
    should solve the problem. Recheck in 60 minutes; if blood sugar
    is still low, seek medical help.
    Injecting Glucagon. When your blood sugar falls too low, you may
    become unconscious and unable to self-treat low blood sugar. Oral feeding
    should be avoided under this situation or the food will get stuck in your
    lungs and cause pneumonia. In such a condition, you should immediately
    receive a shot of glucagon. Glucagon, as noted in Chapter 1, is a hormone
    produced by alpha cells of the pancreas, which stimulates the release of
    stored sugar or glycogen from the liver and raises blood sugar.
    Glucagon as an injectable drug is chemically identical to human glucagon
    and is a safe drug. Glucagon is available by prescription in pharmacies in
    the United States. A glucagon injection comprises 1 milligram (1 unit) of
    glucagon powder and 1cc of water-like solution for dilution.
    To inject glucagon is easy. It is injected anywhere under the skin; the
    result is fast; the patient regains consciousness within 5 to 10 minutes after
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    Preventing Low Blood Sugar
    The best way to prevent low blood sugar is to manage those controllable
    factors that contribute to its fall. To prevent low blood sugar:
    • Take your diabetes medication at the proper time and in right doses.
    • Take your meals at regular times every day.
    • If you are prone to low blood sugar after exercise, take a sugarcontaining
    snack such as sweet crackers or orange juice before you
    start exercising.
    • Recognize the symptoms of low blood sugar and treat falling blood
    sugar before it falls too low.
    • Keep glucose (such as glucose gel or glucose tablets) handy for use
    in an emergency situation to treat low blood sugar.
    the injection is given. Someone at home or work should know how to inject
    you with glucagon, because when your blood sugar is running too low you
    will not be able to self-inject. As a side effect, glucagon injection may cause
    nausea and vomiting. If low blood sugar does not improve even by injecting
    glucagon, somebody should rush you to a hospital where intravenous
    glucose (dextrose) may be administered.
    DIABETIC KETOACIDOSIS. DKA or diabetic ketoacidosis is a serious
    medical condition in which blood sugar becomes very high (400 to 1,000
    mg/dL), the body starts burning its own fat, poisonous substances called
    ketones are produced in the body, and acids in the blood become very high.
    How does this happen?
    Insulin, as noted before, helps sugar move from the blood to enter into
    muscles and cells in your body where it is needed for energy. When,
    however, the body does not produce enough insulin or the insulin it
    produces is ineffective, sugar remains trapped in the blood and is not delivered
    to the cells of your body. As a result, the cells do not get energy and
    begin to starve. In such a situation, the body looks for an alternate source of
    energy that it finds in its stored fat reserves. The body burns this fat to get
    energy and, in this process, poisonous substances called ketones are
    produced that accumulate in the blood. Too many ketones cause an
    abnormal increase of blood acids.
    The kidneys try to get rid of excess ketones through increased urination.
    Excretion of large amounts of urine, called diuresis, causes severe loss of
    water, sodium, potassium, and other nutrients. Loss of these nutrients may
    disturb heart rhythm and impair functions of other organs. Loss of fluids
    caused by excessive urination in DKA is harmful in other ways also. First,
    the body becomes short of water and cannot excrete more urine to eliminate
    sugar and ketones that may still be present in excess in the blood. Second,
    due to the loss of fluids, sugar and ketones in the blood become highly
    concentrated. Both these conditions tend to prolong ketoacidosis.
    DKAis different from a condition called ketonuria, which occurs when
    you do not eat food for 12 to 18 hours, and your body tries to derive energy
    from its own fat reserves. In this process, fat reserves in the body tend to
    break, producing ketones (acids) that are excreted in the urine in small
    amounts. This is a normal phenomenon and is sharply different from DKA.
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    TYPES OF DKA. DKA can be mild, moderate, or severe. Its severity is
    determined by the relative increase of sugar in the blood, ketones in the
    urine, and the degree of acidity in body fluids. Usually, you are not confused
    in mild DKA, confused/drowsy in moderate DKA, and unconscious or in a
    coma in severe DKA. A severe condition of DKA with extreme blood
    acidity can even lead to death.
    CAUSES OF DKA. The main cause of DKA, as noted before, is an insulin
    disorder in which insulin is either lacking in the body, or it is unable to work
    properly, or both. As a result, blood sugar is not controlled and it rises too
    high. Any or a combination of the following factors can cause a lack of
    insulin or blunt insulin action in your body, contributing to DKA:
    • Taking insulin injections of a lower dose than required.
    • Skipping your insulin injection.
    • Using expired and bad insulin.
    • Avoiding insulin injections although injecting insulin may be
    essential for controlling blood sugar.
    • Insulin requirement may increase during illness such as the flu or
    other infections, but a sufficient quantity of insulin is not injected.
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    Symptoms of DKA
  • High blood sugar – Nausea and vomiting
    (400 to 1,000 mg/dL) – Abdominal pain
  • Excessive urination – Drowsiness
  • Ketones in the urine – Fever
  • Deep rapid breathing – Severe weakness
  • Dehydration – Flushed face
  • Excessive thirst – Cloudy thinking
  • Excessive hunger – Fruity smell in breath
  • Dry mouth – Loss of consciousness
    • Certain factors tend to diminish insulin action in the body, resulting
    in raised blood sugar levels. These factors include stress, shock,
    excessive consumption of alcohol, certain drugs such as water pills
    (thiazides), nasal decongestants (terbutaline), and cortisonecontaining
    medications, including medicated skin creams and
    ointments.
    • Raised blood levels of certain hormones such as glucagon, cortisol,
    and growth hormones.
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    Preventing DKA
    You can prevent DKA by taking these precautions:
    • Do not allow your blood sugar to exceed 250 mg/dL.
    • If you normally do not take insulin to treat diabetes, take it to regulate
    uncontrolled blood sugar levels. Take rapid-acting insulin (see
    chapter 14) to bring down high blood sugar.
    • Do not miss your insulin dose.
    • You may need to increase your insulin dose when you are stressed.
    • Follow the sick-day rules:
    – Test your blood sugar frequently.
    – Take your insulin dose even when you are not eating or
    you are vomiting when ill.
    – If your blood sugar remains high, take an additional dose
    of insulin immediately.
    – Drink plenty of fluids, at least 1/2 to 1 cup every hour to
    avoid water deficiency in the body.
    – Use a dipstick such as ketostix to check the urine for
    ketones; if ketones remain high, notify your doctor.
    – Call your doctor if your blood sugar remains above 250
    mg/dL and the urine has ketones.
    – If your blood sugar remains above 300 mg/dL on 2 to 3
    tests, call the doctor even if the urine is free from ketones.
    Generally, an untreated infection is the immediate cause of very high
    blood sugar levels, leading to DKA.
    WHO GETS DKA. Although DKA can occur both in people with type 1 and
    type 2 diabetes, it typically occurs in people with type 1 whose bodies do
    not produce insulin (absolute deficiency of insulin). DKA can develop very
    quickly when these people are stressed out or ill due to a cold, the flu, or
    some other infection. People with type 2 diabetes may develop DKA when
    they are under stress or have some severe infection.
    TREATMENT OF DKA. Being an emergency condition, DKA needs to be
    treated in a hospital or under the care of a professional with regular monitoring.
    Treatment of DKA in a hospital may include:
    Insulin Treatment. To lower high blood sugar in DKA and reduce the
    resulting raised levels of ketones in the blood, administration of insulin is
    essential. Insulin treatment of DKA in an adult person may start with intravenously
    injecting a dose of regular insulin such as 0.15 unit per kilogram
    of body weight. (When insulin is injected intravenously, that is, in a
    vein, it begins to work quickly. Normally, insulin is injected in the skin.)
    After this dose, a smaller dose of regular insulin such as 0.1 unit per
    kilogram of body weight, per hour, may be continuously infused until
    blood sugar is brought down to less than 200 mg/dL.
    Fluid Replacement. To replace fluid loss caused by frequent urination and
    vomiting in DKA, you should drink plenty of water. Adiet beverage, herbal
    tea, or some other drink preferably with an artificial sweetener may also be
    used. If drinking by mouth is not possible due to frequent vomiting, saline
    water solution may be slowly injected intravenously. Low blood pressure
    caused by dehydration improves with fluid replacement. Care is taken in
    fluid replacement because excessive administration of fluids can lead to
    brain swelling, causing dysfunction in the brain.
    Potassium Replacement. Continuous administration of insulin and infusion
    of fluids to treat water loss in DKA may dilute potassium in the blood and
    drop its level. Potassium deficiency may produce irregularities in the
    rhythm of heartbeats (arrhythmia) and cause breathing problems. To
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    resolve its deficiency, potassium is infused intravenously.
    Administration of Antibiotics. If infection is present, it is treated by
    administering antbiotics.
    Regular Monitoring. When you are treated for DKA in the hospital, your
    condition is frequently monitored to assess that your blood sugar has been
    controlled, urine has become ketone-free, fluid loss has been treated, and
    electrolytes, including potassium and chloride in the blood, have normalized.
    Usually, emergency treatment of DKA takes less than 12 hours in
    a hospital.
    HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS). The condition in
    which blood sugar rises greater than 900 mg/dL, making the blood too
    sticky, is called hyperosmolar hyperglycemic state or HHS for short. HHS
    can happen in both type 1 and type 2 diabetes, but it typically occurs in
    people with type 2 diabetes who do not take insulin to control their blood
    sugar. Excess sugar in the blood, as noted before, causes frequent urination,
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    Symptoms of HHS
    HHS shares some of the common symptoms of DKA: excessive thirst,
    frequent urination, fluid loss, acute weakness, drowsiness, and mental
    confusion. But HHS has certain symptoms that distinguish it from
    DKA. In HHS:
    • Blood sugar may exceed 1,000 mg/dL.
    • Because the body does not burn fat in HHS, ketones are not
    produced and the blood has no increased acidity.
    • The urine is almost ketone-free.
    • Blood pressure is generally very low.
    • Risk for seizures and stroke increases.
    • Loss of consciousness is much more common.
    leading to severe loss of fluids in the body. Loss of fluids makes the blood
    thicker and more concentrated. Too much thickness of the blood in HHS
    poses a high risk for blood clotting, a condition that may lead to a stroke or
    heart attack.
    Because HHS typically occurs in people with type 2 diabetes in whom
    the pancreas is still making some insulin, their bodies do not break down
    their fatty cells for energy. As a result, unlike the condition in DKA, there is
    no excessive increase of blood acids in HHS. However, HHS is more
    dangerous than DKA: the mortality rate in HHS is about 15 percent
    compared to less than 5 percent in DKA.
    CAUSES OF HHS. Any of the factors below may contribute to HHS:
    • Persistently high blood sugar due to poor control of diabetes.
    • An untreated infection, as in DKA, is usually the immediate cause
    of raised blood sugar levels in HHS.
    • High concentration of sugar in the blood. As people with diabetes
    grow older, their kidneys become weak and do not excrete excess
    sugar from the body as they should. As a result, sugar tends to
    concentrate in the blood. (At a young age when your blood sugar
    rises to about 180 mg/dL, your kidneys excrete excess sugar
    through the urine. As the kidneys become weak with age, they are
    not able to excrete excess sugar properly.)
    • Stress. It decreases the action of insulin, raising blood sugar levels.
    • Blood pressure-lowering drugs of the diuretic class. These drugs
    increase the amount of urine (see chapter 19). Excessive urine
    shrinks the volume of water in the body, leading to concentration
    of blood sugar.
    • Drinking too little water. Restricted intake of water decreases
    dissolved sugar in the blood and increases its concentration.
    • Raised hormones. As in DKA, raised blood levels of certain hormones
    such as glucagon and cortisol may raise your blood sugar.
    TREATMENT OF HHS. Treatment of high blood sugar in HHS is almost the
    same as in DKA (noted before). In HHS, ketones are found in a small
    amount and, therefore, their treatment is not a problem. The main problem
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    in HHS is the presence of very high levels of sugar in the blood. To bring
    down high blood sugar levels in HHS, insulin is administered in a dose that
    may be about 50 percent of the dose used in treatment of DKA. (This is
    because HHS typically occurs in people with type 2 diabetes, who are
    more sensitive to insulin than people with type 1 diabetes getting DKA).
    HHS is a medical emergency to be handled in a hospital.
    PREVENTING HHS. The measures for preventing HHS are almost the same
    as that for preventing DKA.
    The medical emergencies of low blood sugar, very high blood sugar,
    and an abnormal increase of acids in the blood are preventable crises. Keep
    your blood sugar under control and avoid the causes that lead to these
    events. When, however, these emergencies do occur, they can be successfully
    resolved by taking timely action as outlined in this chapter.
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