3.8. HYPERGLYCEMIA

Related Names

Diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic condition, hyperosmolar non-ketonemic coma, diabetes

Purpose of assistance

Reduce the negative impact of hyperglycemia by:

a) correct application of glucose monitoring;
b) correct rehydration in hyperglycemia.

Patient description

Inclusion criteria

1. Adult or juvenile patients with impaired consciousness (see instruction “Violation of the mental state”).
2. Adult or juvenile patients with stroke symptoms (e.g. – hemiparesis, dysarthria) (see instruction “Suspected stroke/Transient ischemic attack”).
3. Adult or juvenile patients with seizures (see instruction “Convulsions”).
4. Adult or juvenile patients with symptoms of hyperglycemia (e.g., polyuria, polydipsia, weakness, dizziness, abdominal pain, tachypnea).
5. Adult or minor patients with a history of diabetes and symptoms of other diseases.

Exclusion criteria

None.

Patient care

Condition assessment

1. Monitoring.

Check glucose levels.

2. Secondary blood glucose test:

a) general: evaluate the presence of tachycardia, hypotension, tachypnea;
b) eyes – evaluate the presence of “depression” of the eyes due to dehydration;
c) nose/mouth/ears – assess the presence of drying of the mucous membrane or bite of the tongue due to seizures;
d) neurological:

• • • • assess the state of consciousness by GCS;
      • assess the presence of focal neurological deficiency – motor and sensory

3. Assess for possible concomitant sepsis and septic shock (see instruction “Shock”).

4. Take a 12-lead ECG to assess for the presence of elevated TB or other abnormalities associated with hyperkalemia.

Treatment and intervention

1. For altered levels of consciousness, stroke, or sepsis/septic shock, provide care according to the instruction “Impaired mental state,” “Suspected stroke/Transient ischemic attack,” or “Shock.”

2. If there are signs of hyperkalemia, start IV injection of fluids and apply:

a) calcium chloride – 1 g IV for 5 minutes, make sure the system is passable and do not exceed the dose above 1 ml per minute
OR
b) calcium gluconate – 2 g IV for 5 minutes with constant monitoring of heart rhythms.

3. If hyperkalemia is present, inject 1 mmol/kg sodium bicarbonate (maximum dose 50 mmol) iv bolus for 5 minutes and apply salbutamol 5 mg in small portions through a nebulizer.

4. If the glucose index is above 14 mmol/l (250mg/dL) with signs of dehydration, vomiting, abdominal pain or altered state of consciousness.
Enter additional bolus volumes of saline:

a) adults: normal saline 1 liter of bolus IV; re-examination and re-infusion of 1 liter if necessary;
b) children: normal physiological saline 10 ml/kg bolus IV; repeated examination and repeated administration, if necessary, with a maximum dose of up to 40 ml/kg.

5. Re-evaluate the patient::

a) re-evaluate the state of consciousness, vital signs and signs of dehydration;
b) if there are changes in the state of consciousness, re-evaluate the glucose indicators and provide appropriate assistance if hypoglycemia develops.

6. Hospitalization.
Transport to the nearest receiving room.

Patient safety

1. Too aggressive administration of fluids in hyperglycemia can cause cerebral edema or dangerous hyponatremia:

a) carefully monitor the change in consciousness, signs of increased intracranial pressure and immediately stop the infusion of liquids, raise the head of the bed if there are signs of increased intracranial pressure;
b) re-examine and monitor the respiratory tract.

2. Asymptomatic hyperglycemia does not pose a threat to the patient, while improper, aggressive interventions to control blood sugar levels can cause harm.

Useful information for training

Key points

1. The onset of HCA in children is usually manifested by nausea, vomiting, abdominal pain and/or frequent diuresis.

2. To identify the causes of hyperglycemia, use the rule of three AND:

a) insulin – this applies to any changes in the intake of insulin or oral medicines, including non-compliance with the intake or malfunction of the insulin pump;
b) ischemia – due to the fact that sometimes hyperglycemia acts as an indicator of physiological stress in the patient and may indicate myocardial ischemia;
c) infection – infection can cause disturbances in the control of blood sugar levels.

Relevant evaluation results

1. Concomitant injury.
2. Abdominal pain, “fruity smell when breathing” and rapid deep breathing (Kussmaul breathing) may be associated with DKA.

Key elements of documentation

1. Documentation of the facts of re-assessment of vital signs and state of consciousness after the introduction of IV fluids.
2. Documentation of glucose level (if within practice) if necessary.

Criteria for the effectiveness of care

1. With a sufficient level of preparation, measurement of blood glucose should be made for each patient with symptoms of changes in the level of consciousness, convulsions, stroke or hyperglycemia.
2. If hyperglycemia is confirmed, correct fluid resuscitation should be performed in order not to create excessive fluid administration before insulin therapy is performed in the admission department.
3. 12-lead ECG measurements.