Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Wilderness and Rescue Medicine

almost always low blood glucose, also known as hypoglycemia. The symptoms of hypoglycemia can develop rapidly and result in brain failure, usually starting with easily observable mental status changes. Your patient may be behaving normally one minute and then become irritable, forgetful, or otherwise inappropriate the next. If hypoglycemia is not cor- rected, the patient can become combative, com- pletely disoriented, or unconscious. Tachycardia and profound sweating are also commonly seen. Hypoglycemia is sometimes mistaken for intoxi- cation or traumatic brain injury, delaying treat- ment until it is too late. You are much less likely to see the opposite prob- lem: hyperglycemia. The problem of too much sugar in the blood develops slowly over hours or days. Signs and symptoms include frequent urina- tion, extreme thirst, weakness, and a fruity odor on the patient’s breath. Most diabetics are aware that it is happening, and will adjust their insulin dose accordingly, or seek medical care before seri- ous problems develop. Field treatment is limited to aggressive hydration and urgent evacuation. Treatment of Hypoglycemia A diabetic with altered mental status is considered to be hypoglycemic until proven otherwise. The treatment is to administer easily absorbed sugar. For the patient who is still awake, the easiest route is orally in the form of a glucose gel kept in a first aid kit for that purpose. One dose is 15 grams of sugar. It is also fine to give granulated sugar, honey, candy, juice, or any other sweet food. Sugar substitutes like saccharin will not work. If the patient’s level of consciousness has decreased to the point that airway protection is a concern, intravenous sugar is preferred. If IV therapy is not available, glucose, honey, or granulated sugar can be rubbed on the mucous membranes inside the mouth where some will be directly absorbed into the blood. Sugar, diluted in warm water or D50, can also be given rectally in the form of an enema. Your unconscious patient may be carrying a glucagon injector. This is a kit (available by

prescription) containing a vial of powdered glu- cagon that is mixed with a solution, drawn up into a syringe, and injected into the upper arm, thigh, or buttocks. Glucagon can also be admin- istered as a nasal spray, and autoinjectors are under development. Glucagon is a hormone that increases blood glucose levels by releasing glyco- gen, a concentrated form of glucose, from the liver. Improvement should be seen within 10 minutes. As the patient regains consciousness, sugar should be given orally.

General Principles

Glucagon Injector

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This glucagon injector contains a syringe of ster- ile water that is manually infused into the vial of powder to reconstitute the drug. If your client is carrying a glucagon injector or atomizer, be sure that you examine it before you need it. Know where it is kept and consider instructing someone else in the group in its use. Like epinephrine, a glucagon kit should not be allowed to freeze. The administration of sugar, and glucagon if necessary, should result in rapid resolution of symptoms. If not, emergency evacuation should be initiated. Never give insulin to a diabetic with altered mental status, even if you have reason to believe that the problem is high blood glucose (hyperglycemia). The primary field treatment for that is aggressive hydration. You should also remind yourself of the STOPEATS mnemonic; low blood sugar may not be the only cause of the patient’s condition.