Notes – Hyperglycemia

Hyperglycemia

Patient Safety Considerations

  1. Overly aggressive administration of fluid in hyperglycemic patients may cause cerebral edema or dangerous hyponatremia
    1. Closely monitor for signs of altered mental status, increased intracranial pressure, and immediately discontinue IV fluids and elevate head of bed if signs of increased ICP develop
    2. Reassess and manage airway as needed
  2. Asymptomatic hyperglycemia poses no risk to the patient while inappropriately aggressive interventions to manage blood sugar can harm patients

Notes/Educational Pearls

Key Considerations

  1. New onset diabetic ketoacidosis in pediatric patients commonly presents with nausea, vomiting, abdominal pain, and/or urinary frequency
  2. Consider causes for hyperglycemia by thinking about the 3 I’s:
    1. Insulin – this refers to any medication changes for insulin or oral medications including poor compliance or malfunctioning insulin pump
    2. Ischemia – this refers to hyperglycemia sometimes being an indication of physiologic stress in a patient and can be a clue to myocardial ischemia in particular
    3. Infection – underlying infection can cause derangements in glucose control

Pertinent Assessment Findings

  1. Concomitant trauma
  2. Abdominal pain, “fruity breath,” and rapid-deep respirations (Kussmaul’s respiration) may be associated with diabetic ketoacidosis

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914121 – Medical-Hyperglycemia

Key Documentation Elements

  • Document reassessment of vital signs and mental status after administration of IV fluids
  • Document glucose level (if in scope of practice) when indicated

Performance Measures

  • When in scope of practice, point of care blood glucose checked for all patients with symptoms of altered level of consciousness, seizure, stroke, or hyperglycemia
  • When hyperglycemia documented, appropriate volume replacement given while avoiding overzealous repletion before insulin therapy at receiving center
  • 12-lead EKG obtained
  • EMS Compass® Measure (for additional information, see http://www.emscompass.org)
    • PEDS-03: Documentation of estimated weight in kilograms. Frequency that weight or length-based estimate are documented in kilograms

References

  1. Corwell B, Knight B, Olivieri L, Willis GC. Current diagnosis and treatment of hyperglycemic emergencies. Emerg Med Clin North Am. 2014;32(2):437-52.
  2. Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335–43.
  3. Funk DL, Chan L, Lutz N, Verdile VP. Comparison of capillary and venous glucose measurements in healthy volunteers. Prehosp Emerg Care. 2001;5(3):275-7.
  4. Desachy A, Vuagnat AC, Ghazali AD, et al. Accuracy of bedside glucometry in critically ill patients: influence of clinical characteristics and perfusion index. Mayo Clin Proc. 2008;83(4):400-5.
  5. Holstein A, Kuhne D, Elsing HG, et al. Practicality and accuracy of prehospital rapid venous blood glucose determination. Am J Emerg Med. 2000;18(6):690-4.
  6. Holstein A, Plaschke A, Vogel MY, Egberts EH. Prehospital management of diabetic emergencies – a population-based intervention study. Acta Anaesthesiol Scand. 2003;47(5):610-5.
  7. Jones JL, Ray VG, Gough JE, Garrison HG, Whitley TW. Determination of prehospital blood glucose: a prospective, controlled study. J Emerg Med. 1992;10(6):679-82.
  8. Kulkarni A, Saxena M, Price G., et al. Analysis of blood glucose measurements using capillary and arterial blood samples in intensive care patients. Intensive Care Med. 2005;31:142.
  9. Kumar G, Sng BL, Kumar S. Correlation of capillary and venous glucometry with laboratory determination. Prehosp Emerg Care. 2004;8(4):378-83.
  10. Roberts K, Smith A. Outcome of diabetic patients treated in the prehospital arena after a hypoglycemic episode, and an exploration of treat and release protocols: a review of the literature. Emerg J Med. 2003;20(3):274-6.