Diabetes, as discussed in this chapter, will refer to a condition known as Diabetes Mellitus.  A metabolic disorder which affects the body's ability to process simple carbohydrates.

In a 'non-diabetic' body, a hormone called insulin is produced by the pancreas to 'help' glucose cross the cell wall of various body cells.  Glucose is an energy source for all cells in the body, carried throughout the body by the circulatory system in the blood. (referred to as "blood glucose.) 

Without the 'help' of insulin, blood glucose remains in the blood, where it accumulates (turning the blood into the consistency of pancake syrup,) which creates a blood 'viscosity' that hampers the movement of blood into the smaller blood vessels.  Over a long period of time, the results of this 'thickened' blood present as:  visual problems, kidney problems, an increased likelihood of stroke, and problems with the extremities (particularly the smaller blood vessels in the feet and toes.)  The body attempts to excrete this excess blood glucose, but this requires large amounts of fluid (water) and consequently, a patient with developing hyperglycemia will present with frequent urination, persistent thirst, and in rare cases, over-eating.  Concurrently, as it is starved of glucose as an energy source, the body adapts and uses the next most abundant source of energy, fat.  The metabolic processing of fat, however, produces keytones and fatty acids, which are hard for the body to excrete, and they also accumulate in the blood.  The 'condition' that is developing here, is Diabetic Ketoacidosis (DKA.)  A patient with developing DKA will present, initially, with a increase in respiratory rate, and eventually develop a deep, rapid respiratory pattern called Kussmaul Respirations (an ill-fated effort of the body to 'blow off' the excess acidity.)  The developing metabolic acidosis will eventually lead to cellular failure, unconsciousness, diabetic coma, and death.  This patient needs proper hydration (IV Fluids) and insulin to help balance the acidosis and restore the use of glucose as an energy source.  The amount of insulin will be determined by the patient's physician after considering the patient's body weight, age, activity level, and adherence to diet.  The endogenous variable, here, is the amount of blood glucose present.  If the patient's metabolism remains constant, and dietary carbohydrates are controlled, the amount of insulin administered will most likely remain constant, as well.  If, however, the patient's metabolism changes (as a result of advancing age, illness, changes in activity, etc,) the amounts of dietary carbohydrates and/or insulin will need adjustment.  For example, if the patient engages in some energy-consuming activity in the summer months, that might be avoided or ignored during the winter, the patient may need to increase the amounts of dietary carbohydrates in order to 'prepare' for the activity.  Without this 'adjustment' the patient will 'burn up' the available blood glucose, creating a condition called hypoglycemia where there is, now, not enough glucose to meet the body's needs.  The organ of primary concern here, is the brain (VERY dependent on glucose.) 

How dependent?

An article in the New England Journal of Medicine, dated December 28, 1995, states that patients with IDDM where unaware of impending hypoglycemia because they maintained normal glucose uptake in the brain, which preserves cerebral metabolism, during the impending hypoglycemic event.

There are many logical (non-medical, unproven) conclusions that can be drawn from these findings, two such conclusions are:  The brain utilizes stores of glucose from within;  and/or, the brain is able to 'draw' glucose from the blood when blood-glucose levels are below those at which other 'body cells' are unable.

Whatever the case the brain "demands" the final amounts of systemic glucose during a hypoglycemic event.

And what about a hypoinsulinemic event?

There is a common belief among some researchers that some tissues do not require insulin for efficient uptake of glucose: important examples are brain and the liver.

This not only serves as an indication of the high degree of dependency of the brain on glucose, but also serves as good news for the DKA patient, because it means that the 'health' of the brain is not affected by the lack of insulin.  It may, however, be threatened by inadequate perfusion secondary to the circulation of "pancake syrup" (a less-emergent situation.)

For the patient of hypoglycemia, however, the lack of available blood glucose represents an IMMEDIATE threat to the "health" of the brain, and subsequently an IMMEDIATE life threat as glucose storage is depleted.  This patient needs sugar (glucose, dextrose, fructose, etc.)  And they need it NOW!  A patient with developing hypoglycemia will present with respirations that are normal (or slightly faster than normal,) and most likely shallow.  The rest of the presentation will most likely mimic DKA. 

For that reason, we would like to highlight the differences between some of the signs and symptoms of Insulin Shock and Diabetic Coma.  A patient in Insulin Shock will experience a RAPID onset of symptoms (within minutes) and will probably be breathing at a near-normal rate, while the patient in Diabetic Coma will most likely report that the development of symptoms has taken several hours (or even days) and will be breathing rapidly and deeply (impending Kussmaul Respirations.)  The "rapid onset" of symptoms associated with Insulin Shock should remind you that the condition demands a "rapid treatment."  Patients in Insulin Shock have very little time before permanent brain damage may occur.

Left unchecked, both conditions can (and will) lead to unresponsiveness.  It is very possible that you will encounter an unresponsive patient, with a history of diabetes, and be unable to determine if it is Insulin Shock or Diabetic Coma, without the aid of a glucometer.  Assume the worst (Insulin Shock) and make IMMEDIATE arrangements for transport to the nearest facility, or transport to intercept the responding ALS Paramedics.  This unconscious patient needs immediate IV Dextrose. If this were a conscious, but confused, diabetic patient and again you were unable to determine the cause (hypo or hyperglycemic) again, assume the worst, and administer some oral glucose, and closely monitor the patient for changes.  Recovery from Insulin Shock is almost as quick as the onset of symptoms.

Your text will explain the proper method for administering oral glucose to a patient, and probably goes into detail on the different types of diabetes (type I and type II,) but we wanted to add something different to the 'mix' by giving you some of the "inside scoop" on what was happening to your patient in Diabetic Emergency.  We feel it gives you a better basis from which to make treatment decisions.