I started to write this week’s blog on November 14th which was World Diabetes Day. This is a global event and official United Nation’s World Health Day that unites the global diabetes community. November 14th date was chosen because it was the birthday of Sir Frederick Banting, who co-discovered insulin along with Charles Best in 1922. For 2020, World Diabetes Day campaign focuses on nurses in the prevention and management of diabetes.
World Diabetes Day is also a day for us warriors to thank ourselves, our families, friends and the researchers, health providers, community and support groups for helping us make diabetes a livable condition. Despite all this, people are still dying from Diabetic Coma and diabetes related complications. We think it will never happen to us but we actually know it can and this sort of sad news gives us that boost to be more diligent about our diabetes management.
There are two types of diabetic emergencies associated with hyperglycemia:
· Diabetic ketoacidosis (DKA)
· Hyperosmolar hyperglycemic state (HHS).
In both of these cases, blood glucose is elevated. These situations require emergency medical attention because if left untreated serious conditions such as Diabetic Coma and even death could result.
The lack of insulin is the cause for both of the above conditions. Common causes include:
1. Infections (pneumonia, skin, urinary, etc)
2. Heart related issues (stroke, heart attack, etc)
3. Pregnancy
4. Dietary nonadherence
5. Nonadherence to taking insulin (forgot) or insulin pump failure
6. Certain medications such as steroids or some antidepressants, etc.
Diabetic ketoacidosis:
Occurs mostly in type 1 diabetes
Blood glucose levels are often greater than 20mmol/L (360mg/dl)
Ketones can be found in the blood and/or urine. (Ketones are produced from the breakdown of fats and their accumulation is toxic to the body)
Criteria to diagnose DKA is not simple and thus the health care team should take this into consideration when a known type 1 or perhaps an undiagnosed diabetic comes to the emergency room with such symptoms as:
Deep, rapid breathing
Breath smells fruity (often described as an acetone odour)
Nausea, vomiting ,abdominal pain
Altered level of awareness (confusion, agitation, decreased consciousness)
Flushed, hot, dry skin, blurred vision
I have experienced DKA twice in my 47 years with diabetes. These two events occurred in the summer months when I was first diagnosed and home from university. I had the nausea, vomiting, abdominal pain, thirst, urinating frequently but no confusion or effect on my level of consciousness. Now this was in the days before blood glucose meters, multiple daily injections of insulin, pumps and before improved insulins (faster onset) came to the market. It certainly was not a pleasant experience. I like to think that this happened because I did not fully understand the consequences of poor glucose control. As they say, nothing like learning the hard way.
Once you arrive at the hospital, the doctors and nurses will do a lab workup checking your blood counts, kidney function, ketones and electrolytes. Electrolytes are minerals that are in the body and proper balance is important for bodily functions. Two examples of these electrolytes are sodium and potassium. Most hospitals have a protocol (management algorithm) to follow when a patient is admitted and DKA is diagnosed. Management involves intensive monitoring of blood glucose and organ system functions. Your immediate symptoms of nausea, vomiting and pain will be treated promptly if they exist.
The goal of treatment is to block ketone production due to low circulating levels of insulin and the correction of the electrolyte imbalance. The insulin is used to reduce ketone production and not the correction of hyperglycemia. (1) Keep in mind that it could take several days before your sugar level returns to a normal range.
Hyperosmolar hyperglycemic state (HHS):
o Occurs primarily in type 2 diabetes
o Blood glucose levels often greater than 30mmol/L (540mg/dl) with severe fluid loss
o Extreme fluid loss could cause a drop in blood pressure and decreased consciousness
o Could lead to coma and death if not treated
The lack of insulin is the cause. However, in HHS there is often no significant level of ketones in the urine or blood. This is because in type 2 diabetes, there is not a total loss of insulin.
Symptoms are typical of hyperglycemia such as frequent and abundant urination, increase thirst, dry mouth, dry skin and easily becoming tired/fatigued.
HHS is found more often in patients that have pre-existing kidney disease since their kidneys are less efficient in eliminating the large amounts of glucose in the blood .
Management will consist of replacement of fluids, insulin infusion, and restoring acid-base (electrolyte) balance.
Diabetic Coma could result from either of these hyperglycemic emergencies. If you are in diabetic coma, you can’t awaken or respond to sights, sounds or any other type of stimulation. If left untreated death could occur.
Actions to take to prevent hyperglycemic emergencies include (not all inclusive):
Treat infections early (whether it be a urinary tract, a skin infection, pneumonia)
Know your symptoms of high blood sugar. Keep the list of symptoms handy. It is possible that sometimes the symptoms are not that evident, thus keeping track of your blood glucose testing values is important. If you see a series of continuous highs then DKA could be or close to being evident
Teach others at work, home, friends about the symptoms of high blood sugar. Teach them to call 911 if you are unresponsive
Wear medical identification such as a bracelet or necklace. Be sure to have it engraved with your diabetes type and a phone number to call if an emergency does arise. Medical identification has saved me from a couple of severe hypoglycemic events over the years. I am a strong believer in wearing medical identification no matter what health problem you experience
If you take insulin, measure for ketones when sugars are high
If remembering to take your medication is a problem, for those on oral medication only, a pill container with days of week and time of day may prove useful. The pharmacy may be able to blister pack your medications. Don’t be afraid to ask this question to your pharmacist
For insulin users, try to develop a standard routine to remember your insulin injections or setting your pump ahead of time to alarm so you won’t forget
Diabetes management today includes living in the real world. Our nurses and educators try to make life the best they can with the tools currently available so if you are planning a fun night out with friends/family, celebrating a special occasion, please have someone check in on you if you live alone. This could save your life.
Thank you for your time today. I welcome any feedback.
The information provided here is not intended to replace medical advice.
References :
(1) Emergency Medicine Cases – accessed on line November 14th,2020
(2) Hyperglycemic Emergencies - accessed on line November 14th,2020
(3) Diabetic Coma- accessed on line November 14th,2020
(4) Diabetic Ketoacidosis (DKA)- accessed on line November 14th,2020
Please stay safe and respect everyone's safety.