Diabetes affects nearly 10% of Americans. Normal day to day management of the disease is tricky enough. Add in the disturbances of an emergency and Bad Things can happen. What kinds of problems does a diabetic or a friend of one need to look out for, and what can be done about them?
Notes: An earlier article with some ideas for general management of diabetes in crisis situations can be found here. Also, I’m not a physician, so this is information, not medical advice.
Flavors of diabetic crises
Diabetes is a metabolic problem with handling blood sugar. In Type I diabetes, which is rare, the person quits making the hormone insulin that allows the cells to pick up and use the sugar. In Type II, there’s insulin around (at least early in the disease), but the cells ignore it.
Be it Type I or II, you get two basic problems. One is that blood sugar gets really high, so it ends up being lost in the urine and taking your body water with it, dehydrating you. The other is that the cells can’t have the sugar, so they are essentially in starvation mode.
Diabetic crises occur when the blood sugar gets either really high or really low.
Hypoglycemia is when blood sugar gets too low
Really low blood sugar is a problem because it’s the primary fuel for your brain. Other tissues can often get by decently on fats or other fuels. The brain’s a prima donna and demands its sugar.
Symptoms of hypoglycemia may be familiar to athletes as the feeling known as ‘bonking’ or ‘hitting the wall’. It feels, in short, nasty. You get anxious, irritable, confused, tired, shaky, hungry. You might even get hungry and nauseous at the same time, Yay! Breaking a cold sweat while you have heart palpitations and tremors is common. When it gets worse, their may be seizures and coma. If the sugar stays very low for long, it can cause death.
If you’re diabetic, I sure hope you have blood glucose (sugar) test strips. Values are below 70 mg/dl when you’re feeling real hypoglycemia; often 55 mg/dl or less.
Getting and getting rid of hypoglycemia (1)
How does hypoglycemia develop in a diabetic? Overtreatment. Diabetes naturally produces high blood sugar. Oral drugs (in Type II) or insulin (always in Type I, sometimes needed in Type II) encourage cells to use the sugar and levels in the blood drop.
The trick is that there is no ‘right dose’ of insulin or other diabetic drugs. There’s a right dose for a particular grouping of food intake, exercise, stress, and health. Mess with any one of those, and the right dose changes.
What’s most likely to cause hypoglycemia, if the dose of drug is normal? More than usual exercise, or less than usual food. Vomiting will do it too; eating only counts if you get to keep the food. Heavy alcohol intake also causes hypoglycemia, since it distracts the liver from making the usual amount of sugar.
Overdoing alcohol is an invitation to develop DKA.
Getting rid of hypoglycemia is straightforward. Eat. Quick-hitting sugar sources are good. Many diabetics keep hard candy (or more expensive emergency packs) on their persons. I would. If you’re helping someone who’s hypoglycemic and not coherent, I’ve been told you can put some sugar under their tongue.
Regular candy eating for a diabetic, not so good. Having a stash for a crisis, Much Better.*
Diabetic ketoacidosis (DKA)
DKA is a combination of high blood glucose and high blood ketones. The liver makes ketones when you’re breaking down fat like crazy and the liver’s also trying to make sugar for the blood. It’s mostly a Type I thing. It develops reliably when they run out of insulin.
Type IIs get DKA much less often. Usually it’s when something else is going very badly with them. Serious infections are the most common trigger. A very prepper-relevant situation is DKA triggered by high stress. The hormones of the stress response (like epinephrine) counteract the actions of insulin. (2)
How do you know when someone’s got DKA when there’s no lab around? Blood glucose is usually really high. This makes the person pee a lot, which makes him very thirsty. Weight loss, nausea, vomiting, dehydration, weakness, and abdominal pain are common. Drowsiness is common in moderate DKA. When it gets worse, coma is possible. (3) Breathing may be a bit shallow and fast and the breath smell of cheap wine.
One can buy urine test strips. People with DKA would score high on both glucose and ketones. Not sure I’d bother with this as a prep though, given that being certain wouldn’t much affect treatment.
Dealing with DKA
Management of diabetic ketoacidosis without lab tests is … tricky. Most of the recommendations require advanced medical support. The first answer, improving hydration, works for preppers. Isotonic saline by IV is suggested, by any rehydration method would be better than none, I expect. Blood sugar drops to normal faster than the ketones. They (4) suggest treating with insulin to bring the sugar down, then adding 5% dextrose to the next IV so you can give a little more insulin to help bring down the ketoacids.
Hyperosmolar hyperglycemic syndroms (HHS)
HHS is rare, and when it is seen it’s mostly in the elderly and people with other serious health problems. It’s a Type II thing, when fat breakdown isn’t that fast so you don’t get ketoacidosis. However, when glucose gets Sky high, it can be really dehydrating. It also causes water shifts from cells to blood, making the brain cells get wacky.
Color test strips for blood glucose testing are old school but effective. High glucose is found in both DKA and HHS.
Dehydrating a diabetic in garden variety ways – like not drinking enough – makes HHS more likely. So do infections and trauma. Stress makes it more likely, too. (2)
In fact it’s like DKA in a lot of ways. You can tell them apart, but it’s not worth going into here. A doctor would treat them differently but it doesn’t look different from the prepper end. Rehydration is the biggest thing. If there is insulin available, it could be given to bring the glucose down somewhat.
References
1) Cryer PE, Davis SN. Hypoglycemia. In: Longo DL, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012:3003-3009.
2) Kitabchi, Abbas E., et al. “Hyperglycemic crises in adult patients with diabetes.” Diabetes Care, July 2009, p. 1335+. General OneFile, http://link.galegroup.com/apps/doc/A205091099/ITOF?u=north1010&sid=ITOF&xid=dd49cbe8. Accessed 8 Mar. 2019
3) Matz R. Hypothermia in diabetic acidosis. Hormones 1972;3:36-41.
4) Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001;24:131-153
*Photo by Ylanite Koppens from Pexels
