The body with the help of different hormones tightly regulates the blood glucose level, such that when the glucose level gets too low, it's a problem, when it gets too high too, it's another problem. Let us look at these emergencies that occur at low blood glucose levels (hypoglycemic emergencies) and those that occur at a high level of blood glucose (hyperglycemic emergencies).
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HYPOGLYCEMIC EMERGENCIES
Hypoglycemia occurs when there is a very low level of glucose in the blood from 4.0mmol/L and below. At this point, the patient starts experiencing minor symptoms of hypoglycemia. From glucose level 3.0 down to 2.5mmol/L, autonomic symptoms like sweating, trembling, palpitations, anxiety, hunger, etc. sets in. When the glucose level goes below 2.5mmol/L, this becomes very severe and the patient starts experiencing neuroglycopenic symptoms like blurred vision, slurred speech, headache, confusion, dizziness, drowsiness, coma, etc. At this point, urgent medical attention is needed.
CAUSES OF HYPOGLYCEMIA IN THOSE LIVING WITH DIABETES MELLITUS
The commonest cause of hypoglycemia here is excess use of insulin. Insulin injections are taken by those living with diabetes mellitus to lower their blood glucose. When this is taken in excess, it crashes the blood glucose down to hypoglycemia. So, those on insulin therapy should always make sure that they take their insulin at the right dosage and timing. This also applies to insulin secretagogues like sulfonylureas.
Another common cause of hypoglycemia is when patients take their antidiabetic drugs and they do not eat or are ill. These drugs are supposed to be taken close to meal time so that the meal will supply some glucose to balance the effects of the insulin. But when people take those drugs and they don't eat within that specified time, hypoglycemia results.
Other risk factors for hypoglycemia include adolescents, the elderly, pregnancy, associated kidney diseases, etc.
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DIAGNOSIS OF HYPOGLYCEMIA
To confirm the diagnosis of hypoglycemia, these 3 criteria must be fulfilled; The first is that there must be classical symptoms of hypoglycemia which include sweating, trembling, blurring of vision, and other symptoms that I listed above. The second is that the patient's blood taken to the laboratory must have low plasma glucose. Here, a spectrophotometer is used in the lab to assess the plasma glucose, not the regular glucometer which checks capillary blood. The third criterion is that the patient responds immediately to a glucose load. We will talk about glucose load in the treatment. These 3 criteria are known as Whipple's triad.
IMMEDIATE TREATMENT
Once you notice these symptoms of hypoglycemia in a diabetic patient, immediate action must be taken. If the patient is conscious, please give glucose load. The target here is to provide a fast rise in blood glucose, however, there is a need to be careful not to raise the blood glucose too high too (rebound hyperglycemia). Oral glucose can be given (20g) which provides a faster rise in blood glucose, about 3.5mmol/L in 45 minutes. Commonly, a bottle of sprite, orange juice, honey, glucose gel, hard candies, or any soft drink can be given. If the patient cannot take it orally, an intravenous glucose infusion can be given. Injectable glucagon can also be given on a prescription in severe cases.
Hypoglycemia can be fatal but easily reversible when noticed early and treated quickly. So all patients on diabetic medications must know the early signs of hypoglycemia and what to do immediately to reverse it.
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HYPERGLYCEMIC EMERGENCIES
This is the second group of diabetic emergencies which occurs at very high levels of blood glucose. There are two of them in this category;
- Diabetic Ketoacidosis (DKA)
- Hyperglycemic Hyperosmolar State (HHS)
We will talk about each of them.
DIABETIC KETO ACIDOSIS (DKA)
This is a diabetic emergency which occurs more commonly in patients living with type 1 diabetes, especially newly diagnosed patients. It has also been found to occur in type 2 patients of African American descent and some native Americans. As well as hybrid types (ketone prone) Type 2 diabetes and latent autoimmune disease in adults.
It is commoner among young adolescents and more in females than males. This is related to social influence on keeping to their regular insulin therapy and eating disorders in these young adolescents.
The symptoms of DKA may include features of dehydration and shock, like cracked lips and furred tongues, increased heart rate, cold clammy extremities, loss of skin turgor, low blood pressure, etc. Other symptoms like a deep breath with acetone smell, blurred vision, altered level of consciousness, drowsiness, or coma.
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PRECIPITATING FACTORS FOR DKA
This hyperglycemic emergency results often in patients who miss their insulin dose. This is because those with type 1 diabetes mellitus have absolute insulin deficiency and depend on insulin therapy to lower their blood sugar since there is an autoimmune destruction of the pancreatic beta cells and therefore cannot produce their endogenous insulin.
When these patients miss taking the insulin injections, their blood glucose level rises so high that leads to diabetic ketoacidosis. That is why it is very very important for everyone living with DM to take their drugs regularly at all times.
The second precipitating factor is illnesses like respiratory tract infections, urinary tract infections, and other infections. When there is an ongoing illness, it exerts stress on the body and the body in response to this stress activates the neuro endocrine system which leads a futher increase in blood glucose. If the insulin dose is not also increased appropriately to compensate for this stress response, it leads to a high level of blood glucose and DKA.
Other conditions like vomiting, loss of appetite, surgery, and myocardial infarctions can also precipitation DKA. COVID-19 has also been found to trigger DKA in diabetic patients.
So how does DKA occur?
As the name implies, in diabetic ketoacidosis there is excess glucose in the blood (hyperglycemia), excess ketone in the blood (hyperketonaemia), and metabolic acidosis. The problem usually starts from the excess glucose in the blood which causes osmotic diuresis leading to dehydration and loss of some electrolytes like sodium and potassium.
Insulin is both an anabolic and anti-catabolic hormone. So deficiency of insulin in this patient leads to an uncontrolled breakdown (catabolism) of lipids and release of free fatty acids which are carried to the liver to produce ketone. This leads to the accumulation of acidic ketones in the blood. This results in hyperketonaemia and metallic acidosis which are cardinal features of DKA.
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THE DANGERS OF DKA
Mortality from DKA is still very high in developing and low-income countries.
The most feared complication of DKA and the commonest cause of death in adolescents and young children with DKA is cerebral edema (brain swelling). The pathophysiology of this is not well understood but studies attribute it to the movement of water from inside the cells (ICF) to the outside of the cell (ECF) due to the osmotic gradient created by the excess blood glucose.
Other complications which can be found more in adults include acute respiratory distress syndrome due to electrolyte derangement and metabolic acidosis. Also low potassium in the blood (hypokalaemia). This can cause abnormal heartbeat or even cessation of the heartbeat.
Relevant investigations include; Blood glucose level, blood or urine test for ketones, Serum electrolyte, urea and creatinine, Electrocardiogram, food blood count, blood culture, etc.
TREATMENT
This is a medical emergency and requires urgent and immediate medical intervention. The patient is usually managed in the Intensive Care Unit (ICU) or High Dependency Unit (HDU). The management of this patient focuses on 6 key areas which are initial resuscitation to stabilize the patient, fluid management, insulin therapy, potassium monitoring, Correction of acidosis, and antibiotics therapy.
HYPERGLYCEMIC HYPEROSMOLAR STATE (HHS)
This is the second hyperglycemic emergency that is commoner in type 2 diabetic patients, usually middle age and elderly. Unlike diabetic Ketoacidosis, HHS does not have features of hyperketonaemia or acidosis.
This is because unlike in type 1 diabetes mellitus where there is absolute insulin deficiency, in type 2 diabetes mellitus there is a relative insulin deficiency and therefore, the body still has a small insulin reserve. So the body buffering system here manages to prevent ketone formation and acidosis due to the presence of insulin. So the cardinal features of HHS as the name implies are hyperglycemia, hyperosmolarity, and dehydration from osmotic diuresis.
The precipitating factors here also include infections, drugs, newly diagnosed diabetes, etc. Unlike DKA, hyperglycemic Hyperosmolar State runs a worsening clinical course over a longer time and has a higher mortality rate.
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COMPLICATIONS
The most feared complication in HHS is the risk of thrombosis. Remember the Virchow's triad we discussed in pulmonary embolism. Hypercoagulability is a risk factor for thrombus formation and this patient is at the risk of stroke, heart attack, pulmonary embolism, etc. Cerebral edema is also a risk factor here.
TREATMENT
This is also a medical emergency and should be managed in the Intensive Care Unit or High Dependency Unit. The peculiarities here include less aggressive fluid management compared to DKA. A lower dose of insulin is also used here, about half of the one used for DKA. They are also given anticoagulants to prevent the risks of thromboembolism.
PREVENTION
To prevent these diabetic emergencies, all patients living with diabetes should therefore always monitor their blood glucose regularly to know when it's going off the normal range. It is also important to take the antidiabetic drugs at the right dose, and time and faithfully follow the instructions given by your doctor. Diet is also very important. Eat healthy foods, especially fruits, vegetables and others as recommended. Also, stay hydrated, avoid smoking, alcohol, and anything that will predispose you to infections. When ill, please consult your doctor to give you the right insulin dosage to take at that time.
In conclusion, diabetes mellitus is a chronic condition. When well managed, the patient will live a normal healthy life without any issues. But when not properly managed, any of these diabetic emergencies can occur and the outcome is not always good. Therefore, all persons living with diabetes mellitus and their relatives should be aware of these emergencies, how to recognize them and how to prevent them because
PREVENTION IS BETTER THAN CURE
Thanks so much for reading.
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