Emergency Complications
Hypoglycemia
People with diabetes who need to intensively control glucose levels are at risk for hypoglycemia (also called insulin shock). The condition develops if blood glucose levels fall below normal and may also be caused by insufficient intake of food, excess exercise, or alcohol intake. Usually the condition is manageable, but occasionally, it can be severe or even life threatening, particularly if the patient fails to recognize the symptoms. Mild hypoglycemia is common among people with type 2 diabetes, but severe episodes are rare, even among those who are taking insulin. Still, all patients who are intensively controlling glucose levels should be aware of warning symptoms.
Risk Factors for Severe Hypoglycemia. People at highest risk for severe hypoglycemia are those who intensively control blood glucose and also have one or more of the following conditions:
- Long-term diabetes.
- Less education on their condition.
- A previous history of severe hypoglycemia.
- Hypoglycemia unawareness. This is a condition in which people become insensitive to hypoglycemic symptoms. It affects about 25% of those who use insulin, nearly always type 1 diabetics. In such cases, hypoglycemia appears suddenly, without warning, and can escalate to a severe level. Even a single recent episode of hypoglycemia may make it more difficult to detect the next episode. With vigilant monitoring and by rigorously avoiding low blood glucose levels, such patients can often regain the ability to sense the symptoms. Note that even very careful testing may fail to detect a problem, particularly one that occurs during sleep.
Symptoms. Mild symptoms usually occur at moderately low and easily correctable levels of blood glucose. They include the following:
- Sweating.
- Trembling.
- Hunger.
- Rapid heartbeat.
Severely low blood glucose levels can precipitate neurologic symptoms:
- Confusion.
- Weakness.
- Disorientation.
- Combativeness.
- In rare and worst cases, coma, seizure, and death.
Preventive Measures. The following tips may help avoid hypoglycemia or prepare for attacks.
- Patients are at highest risk for hypoglycemia at night. Bedtime snacks may be helpful.
- Patients who intensively control their blood sugar should monitor blood levels as often as possible, four times or more per day. This is particularly important for patients with hypoglycemia unawareness.
- In adults, it is also particularly critical to monitor blood glucose levels before driving, when hypoglycemia can be very hazardous.
- Diabetic patients on therapies that put them at risk for hypoglycemia should always carry hard candy, juice, sugar packets, or commercially available glucose substitutes designed for diabetic individuals.
Family and friends should be aware of the symptoms and be prepared:
- If the patient is helpless (but not unconscious), family or friends should administer three to five pieces of hard candy, two to three packets of sugar, half a cup (four ounces) of fruit juice, or a commercially available glucose solution for diabetics.
- If there is inadequate response within 15 minutes, additional oral sugar should be provided or the patient should receive emergency medical treatment, including the intravenous administration of glucose.
- Family members and friends can learn to inject glucagon, a hormone, which, in contrast to insulin, raises blood glucose.
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Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is a life-threatening complication caused by insulin depletion. Until recently, it has been a complication almost exclusively of type 1 diabetes. In such cases, it is nearly always due to noncompliance with insulin treatments. However, DKA is being reported increasingly in type 2 diabetes, especially among Hispanic and African Americans. It is not clear, however, what causes total insulin depletion in these patients. Research is needed to find which individuals are at particular risk.
Diabetic ketoacidosis often develop as follows:
- The process is usually triggered in insulin-deficient patients by a stressful event, most often pneumonia or urinary tract infections. Other triggers include alcohol abuse, physical injury, pulmonary embolism, heart attacks, or other illnesses.
- Severely low insulin levels cause excessive amounts of glucose in the bloodstream (hyperglycemia).
- Fat breakdown then accelerates and increases the production of fatty acids.
- These fatty acids are converted into chemicals called ketone bodies, which are toxic at high levels.
Symptoms and complications include the following:
- Nausea and vomiting.
- Breathing may be abnormally deep and rapid with frequent sighing.
- The heartbeat may be rapid.
- If the condition persists, coma and, eventually, death, may occur, although over the past 20 years, death from DKA has decreased to about 2% of all cases.
- Other serious complications from DKA include aspiration pneumonia and adult respiratory distress syndrome.
Life-saving treatment employs rapid rehydration using a saline solution followed by low-dose insulin and potassium replacement.
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