Prehospital Management of Hypoglycemic Emergencies: Evidence-Based Review for Collegiate-Based Emergency Medical Services

by the patient or the device to accommodate the intake of carbohydrates.T1DM accounts for approximately 5-10% of diabetes cases across all age groups.5 While recent data is lacking, trends show that the incidence of T1DM in youth ages 0-19 is increasing.6 It is estimated that over 53,000 students with T1DM attend college in the United States.7 Type 2 diabetes mellitus (T2DM) is characterized by chronically elevated blood glucose levels and is thought to occur as a result of the interaction of genetic and lifestyle-related factors.It is primarily characterized by insulin resistance in various tissues, necessitating abnormally high insulin levels in order to maintain euglycemia, and T2DM may be further complicated by abnormal insulin secretion.T2DM can be managed by a wider variety of medications; primary treatment involves oral metformin therapy and lifestyle changes.These can be supplemented with other medications including insulin or insulin secretagogues, which increase insulin secretion from functional beta cells.8,9 Even with a history of good glycemic control, the process of adapting to a college environment presents unique challenges to the student with diabetes that can lead to an increased risk of hypoglycemia.7,10 In addition to changing daily routines, living away from home typically decreases the amount of diabetes management support and oversight provided by family members, who may be accustomed to frequently reminding the patient to check their blood sugar or asking about recent management trends.The purpose of the current review is to discuss the pathophysiology and varied patient presentations of hypoglycemic emergencies, and to examine variations in the scope of practice of EMS providers when responding to hypoglycemic emergencies.We also explore the implications of assessment and treatment protocols for CBEMS providers and organizations.While recent hypoglycemia research has tended to focus on variations in treatment protocols for providers at the Intermediate Life Support (ILS) or Advanced Life Support C ollegiate-based emergency medical services (CBEMS) providers must be vigilant in searching for potential causes of altered mental status in patients who appear to be intoxicated.Despite the high prevalence of alcohol usage in young adults, estimated at approximately 57% of those aged 18 to 25, 1 hypoglycemia is one of the most common causes of altered mental status in the prehospital setting. 2 It is most often a complication of medications used to treat diabetes mellitus ("diabetes"); hypoglycemia may also occur acutely in the setting of reduced food intake in non-diabetics, and other less common causes include alcohol consumption, critical illnesses such as organ failure or sepsis, hormone deficiency, nonislet cell tumors, and endogenous hyperinsulinism. 3 Concern for hypoglycemic emergencies is increasingly relevant -the prevalence of diabetes continues to increase globally 4 and, as of 2015, the prevalence of diabetes in the United States in the 18-44 age group is estimated at 2.6%.5 Type 1 diabetes mellitus (T1DM) results from the destruction of insulin-producing beta cells, which is typically immune-mediated, requiring patients to administer insulin subcutaneously via intermittent injection or insulin pump infusion in order to maintain normal blood sugar levels (euglycemia).These insulin doses are calculated Elizabeth V. Woodburn, BS, NREMT is a student at the Carle Illinois College of Medicine and former Director of Education for Illini Emergency Medical Services.She has also worked as a Wilderness EMT while leading youth adventure trips.Her research interests include curriculum development and evaluation, as well as innovative point-of-care diagnostic devices.Paul S. Rostykus, MD, MPH, FAEMS has been an EMS medical director for numerous ambulance and fire agencies in Southern Oregon over the past twentyfive years spanning large and small, rural and urban, as well as paid and volunteer organizations.In addition, Dr. Rostykus has been active in EMS at the regional, state, and national levels and is a member of the National Association of Emergency Medical Services Physicians (NAEMSP). ABSTRACTTreatment of hypoglycemic emergencies may present a unique challenge to collegiate-based emergency medical services providers due to variations in patient presentations and available management options.While hypoglycemia can occur in a variety of settings, it is most commonly a complication of the treatment of diabetes.As the prevalence of diabetes in the general population continues to increase, providers are more likely to encounter patients experiencing hypoglycemic emergencies, necessitating familiarity with relevant protocols and treatment.This review discusses the pathophysiology and presentation of hypoglycemic emergencies, as well as assessment and treatment options across different scopes of practice for emergency medical services providers.Additional recommendations are provided for collegiate-based agencies regarding training and prevention.