1
Scene Size-Up & BSI ▼
- Gloves, eye protection — BSI before patient contact
- Look for medical alert bracelet or ID — diabetic identification is critical for unconscious patients
- Note environment: insulin pen/vials, glucagon emergency kit, glucose tablets, food wrappers, alcohol
- Check for medication bottles: insulin, metformin, sulfonylureas, SGLT-2 inhibitors
- Determine # of patients; note if patient is alone and unable to care for themselves
- Request ALS immediately if patient is unconscious or unresponsive
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2
Initial Assessment + Blood Glucose Level
- ABCs: Airway (patent?), Breathing (rate/depth), Circulation (pulse quality, skin)
- AVPU: Alert / Verbal / Pain / Unresponsive — determine LOC quickly
- ⚠ CHECK BLOOD GLUCOSE IMMEDIATELY — this is the single most important diagnostic step for any altered LOC patient with possible DM history
- Skin assessment: Diaphoresis + pallor = hypoglycemia classic triad; dry/flushed = hyperglycemia
- Vital signs: HR, RR, BP, SpO2 — tachycardia present in both hypo- and hyperglycemia
- Check breath: Fruity/acetone odor = ketoacidosis (DKA)
- Respiratory pattern: Kussmaul respirations (deep/rapid) = metabolic acidosis (DKA)
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BGL < 60 mg/dL?
Critical hypoglycemia threshold
Critical hypoglycemia threshold
YES — Hypoglycemia
Treat immediately. Assess LOC — conscious vs. unconscious determines route of treatment
NO — Continue Assessment
Could be DKA, HHS, hyperglycemia, or other cause. Continue SAMPLE history and condition classifier below.
3
SAMPLE History ▼
- Type 1 vs Type 2 DM — important for DKA (T1DM) vs HHS (T2DM) likelihood
- Insulin type, dose, and timing — when was last injection? Correct dose? New insulin?
- Last meal — did patient take insulin without eating? Missed a meal?
- Last BGL check — was it already out of range before symptoms?
- Recent illness, stress, or exercise — all increase glucose demand; illness often triggers DKA
- Alcohol use — masks hypoglycemia symptoms; causes hypoglycemia via gluconeogenesis inhibition
- Missed medications — omitted insulin dose is the #1 precipitant of DKA
- Allergies (especially to glucagon or latex in some medical devices)
- Events: new illness, recent infection, increased stress, dietary changes, new medications
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🧠 Step 4 — Interactive Condition Classifier
🧭 Select presenting features to identify likely condition
Blood Glucose Level
Onset & Duration
Clinical Signs (select all that apply)
Patient Profile
Select features above to classify the condition
🩺 Step 5 — Management by Condition
🍬 Hypoglycemia — Conscious
BGL <70 mg/dL + Alert + Can swallow safely
- BLS Oral glucose 15–24g:
- Glucose gel (1 tube = 15g)
- Orange juice 4oz (15g)
- Glucose tablets x4 (16g)
- Regular soda 6oz (~15g)
- Reassess BGL in 15 minutes
- Repeat if still <70 mg/dL
- Give complex carbs after initial treatment (crackers, peanut butter)
- Transport even if symptom resolution — determine underlying cause
🚨 Hypoglycemia — Unconscious
BGL <60 mg/dL + Unconscious / Cannot protect airway
- ⚠ NOTHING by mouth — aspiration risk
- ALS D50W (25g dextrose) IV push — definitive treatment
- BLS Glucagon 1mg IM (deltoid or thigh)
- Recovery position if no spinal concern
- O2 via NRB if SpO2 <94%
- ALS intercept — immediate
🌡️ DKA Management
BGL 250–600 mg/dL, Type 1, Kussmaul, Fruity breath
- O2 titrate to SpO2 ≥94%
- ALS IV fluid resuscitation (NS 1L/hr initial)
- Monitor vitals & cardiac rhythm
- ⚠ Do NOT give insulin in field
- Anticipate electrolyte imbalances (K+)
- Transport to ED — definitive care requires insulin drip
- Note: Electrolyte monitoring critical before/during insulin
💧 HHS Management
BGL >600 mg/dL, Elderly T2DM, Extreme dehydration, No ketones
- O2 titrate to SpO2 ≥94%
- ALS Cautious IV fluid rehydration — these patients are severely dehydrated (10–12L deficit) but rapid correction causes cerebral edema
- Close neurological monitoring
- Cardiac monitoring — electrolyte shifts
- Transport — ICU level care required
- ⚠ Do NOT aggressively rehydrate in field
NEVER ADMINISTER INSULIN IN THE FIELD: Administering insulin without continuous glucose monitoring and electrolyte management risks fatal hypoglycemia. DKA and HHS require hospital-based insulin protocols.
🚨 ALS Intercept Triggers
🔴 Request ALS for Any of the Following:
- Unconscious or unable to protect airway — cannot give oral glucose safely
- Persistent hypoglycemia after 2 rounds of oral glucose treatment
- BGL > 400 mg/dL — likely DKA or HHS requiring IV management
- Altered LOC with any blood glucose reading
- Signs of DKA: fruity breath, Kussmaul respirations, severe dehydration, abdominal pain
- Signs of HHS: extreme dehydration, BGL >600, elderly patient, very gradual onset
- Hypotension (systolic <90 mmHg) — indicates severe volume depletion
- Seizure activity — hypoglycemia-induced seizure
- Suspected alcohol-related hypoglycemia — complex physiology
📋 Clinical Reference: Condition Comparison
| Feature | Hypoglycemia | DKA | HHS |
|---|---|---|---|
| BGL | <70 mg/dL (critical <60) | 250–600 mg/dL | >600 mg/dL (often 900–1200) |
| Onset Speed | Minutes | Hours to 1–2 days | Days to 1–2 weeks |
| Skin | Diaphoretic, pale, cool, clammy | Warm, dry, flushed | Markedly dry, poor turgor |
| Breath Odor | Normal | Fruity / acetone | Normal (no ketones) |
| Breathing | Normal or slightly fast | Kussmaul (deep, rapid) | Variable; may be rapid |
| Mental Status | Anxious, confused, combative, or unconscious | Drowsy to confused; rarely unconscious | Drowsy to coma; often profoundly altered |
| Patient Type | Any diabetic; any age | Type 1 DM; younger | Type 2 DM; elderly |
| Dehydration | None | Moderate (2–4L deficit) | Severe (10–12L deficit) |
| Treatment Priority | IMMEDIATE — glucose | Urgent — fluids, then insulin (hospital) | Urgent — cautious rehydration (hospital) |