Spookster831

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How do you tell the difference between these two things in a diabetic if they come in passed out?

Like this one patient - doesn't control his diabetes, passes out at work. Has a history of hypoglycemic attacks (after taking insulin at night). He has polydipsia, polyuria, has had a few UTIs recently. His urine has ++ protein and ++ glucose. And there's evidence of diabetic complications.

So would you assume that because he often has hypoglycemic episodes that this is what this is (plus no evidence of ketoacidosis) or because he has glucose in his blood/his diabetes isn't regulated it might be hyper?

In fact, is there any good way of telling them apart in general? I always get confused...
 

silas2642

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How do you tell the difference between these two things in a diabetic if they come in passed out?

Like this one patient - doesn't control his diabetes, passes out at work. Has a history of hypoglycemic attacks (after taking insulin at night). He has polydipsia, polyuria, has had a few UTIs recently. His urine has ++ protein and ++ glucose. And there's evidence of diabetic complications.

So would you assume that because he often has hypoglycemic episodes that this is what this is (plus no evidence of ketoacidosis) or because he has glucose in his blood/his diabetes isn't regulated it might be hyper?

In fact, is there any good way of telling them apart in general? I always get confused...
I don't know. You know, if anyone is unconscious, I always assume that they are diabetic, hypoglycemic and that all they need is a cookie.
 

SomeDoc

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How do you tell the difference between these two things in a diabetic if they come in passed out?

Like this one patient - doesn't control his diabetes, passes out at work. Has a history of hypoglycemic attacks (after taking insulin at night). He has polydipsia, polyuria, has had a few UTIs recently. His urine has ++ protein and ++ glucose. And there's evidence of diabetic complications.

So would you assume that because he often has hypoglycemic episodes that this is what this is (plus no evidence of ketoacidosis) or because he has glucose in his blood/his diabetes isn't regulated it might be hyper?

In fact, is there any good way of telling them apart in general? I always get confused...
*Hyperglycemia (in DKA) will have kussmaul respirations, anion gap acidosis, psychosis, hyperpyrexia, and dehydration. A combination of the above may help in the differential of acute hyperglycemia.
 
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soonereng

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How do you tell the difference between these two things in a diabetic if they come in passed out?
How about glucose level with a simple finger prick test?
 

nogolfinsnow

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How do you tell the difference between these two things in a diabetic if they come in passed out?

Like this one patient - doesn't control his diabetes, passes out at work. Has a history of hypoglycemic attacks (after taking insulin at night). He has polydipsia, polyuria, has had a few UTIs recently. His urine has ++ protein and ++ glucose. And there's evidence of diabetic complications.

So would you assume that because he often has hypoglycemic episodes that this is what this is (plus no evidence of ketoacidosis) or because he has glucose in his blood/his diabetes isn't regulated it might be hyper?

In fact, is there any good way of telling them apart in general? I always get confused...
IF his glucose is high, then he has hyperosmotic coma (no DKA in type 2 because most of them still make insulin). If his sugars are low, then hypoglycemia.
 

PeepshowJohnny

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A blood glucose level is basically a vital sign in the ED.
 

njbmd

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How about glucose level with a simple finger prick test?
A blood glucose level is basically a vital sign in the ED.
It's true that you can get a fingerstick pretty fast in most EDs but if you are in the field (or don't have access to a fingerstick), an amp of D50 isn't going to hurt the patient if the diagnosis is in doubt. If the patient's blood sugar is 500, one amp of D50 isn't going to change the fact that they are going to need some serious insulin therapy. On the other hand, if the blood sugar is 60,that amp of D50 could be life saving.
 

soonereng

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Yeah I know you could just test the blood glucose but mostly on exams they don't give it so I was wondering if there's any way of knowing without it.
Ah, I see. When you said comes in I thought you were talking about in real life, not exam-world where no labs or DDx are allowed.
 

J-Rad

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How do you tell the difference between these two things in a diabetic if they come in passed out?

Like this one patient - doesn't control his diabetes, passes out at work. Has a history of hypoglycemic attacks (after taking insulin at night). He has polydipsia, polyuria, has had a few UTIs recently. His urine has ++ protein and ++ glucose. And there's evidence of diabetic complications.

So would you assume that because he often has hypoglycemic episodes that this is what this is (plus no evidence of ketoacidosis) or because he has glucose in his blood/his diabetes isn't regulated it might be hyper?

In fact, is there any good way of telling them apart in general? I always get confused...
In test-world things are often worded weirdly (and I'm sure you have to be vague enough in your post to not violate you institutional test integrity/"honor code"). If the patient is awake when you have him in the vignette and you're being asked to figure out if he was hypo/hyper the timing of the episode relative to the time and type of his last dose of insulin and the fact that he's now awake might lead you down one path.

IF his glucose is high, then he has hyperosmotic coma (no DKA in type 2 because most of them still make insulin). If his sugars are low, then hypoglycemia.
Incorrect. Much less common in type II, but it does happen. Remember, many type II diabetics take insulin, many because, eventually, their pancreas burns out.
 

nogolfinsnow

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In test-world things are often worded weirdly (and I'm sure you have to be vague enough in your post to not violate you institutional test integrity/"honor code"). If the patient is awake when you have him in the vignette and you're being asked to figure out if he was hypo/hyper the timing of the episode relative to the time and type of his last dose of insulin and the fact that he's now awake might lead you down one path.



Incorrect. Much less common in type II, but it does happen. Remember, many type II diabetics take insulin, many because, eventually, their pancreas burns out.
You're right, it does occasionally happen, just in relatively less frequency than in type 1. And it's probably especially necessary for "test world" where the uncommon is always tested, no matter how rare
 

AmoryBlaine

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It's already been said but bears repeating: if someone w/ DM has an altered sensorium you either need to given them D50 or check their fingerstick.

Checking a quick fingerstick is never the wrong answer in anyone with any sort of altered sensorium. As was said earlier it's another vital sign for these patients.
 
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Blesbok

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It's true that you can get a fingerstick pretty fast in most EDs but if you are in the field (or don't have access to a fingerstick), an amp of D50 isn't going to hurt the patient if the diagnosis is in doubt. If the patient's blood sugar is 500, one amp of D50 isn't going to change the fact that they are going to need some serious insulin therapy. On the other hand, if the blood sugar is 60,that amp of D50 could be life saving.
:werd: General rule is hyperglycemia may kill someone in the long run, but hypoglycemia will kill them now. Give the D50, then deal with the consequences. Chances are, no known diabetic is going to go into a sudden onset DKA coma without some forewarning. The only time this ever happens is in a new onset type 1 that is feeling sick but doesn't realize that they have the diabeetus.
 

Blesbok

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In test-world things are often worded weirdly (and I'm sure you have to be vague enough in your post to not violate you institutional test integrity/"honor code"). If the patient is awake when you have him in the vignette and you're being asked to figure out if he was hypo/hyper the timing of the episode relative to the time and type of his last dose of insulin and the fact that he's now awake might lead you down one path.



Incorrect. Much less common in type II, but it does happen. Remember, many type II diabetics take insulin, many because, eventually, their pancreas burns out.
I have never heard of a type II diabetic making NO insulin. It is possible, but not probable.
 

mjl1717

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A blood glucose level is basically a vital sign in the ED.
This is a good extrapolation! And that was a good q..

Geez part of the fight is getting a good history from the person (if ya can) or a relative..
For example: Did you take your diabetic medication today? Did you change your diabetic medication recently? Did you eat today?... How many diabetic medications did you take today?? What did you eat today?

As [psuedo knot] said in HYPOGLYCEMIA= cool, diaphorectic, also altered sensorium, lethargic, because brain absolutely needs glucose (from biochemistry). Unlike the heart which can be scavenger for nutrients..



Boy, this thing takes guts!!:sleep:
 
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DocPsychosis

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You're right, it does occasionally happen, just in relatively less frequency than in type 1. And it's probably especially necessary for "test world" where the uncommon is always tested, no matter how rare
To the contrary, standardized tests are obsessed with classical cases and findings. Anyone from the American Southwest with a fungal infection automatically has Coccidioides; any spelunker automatically has Histoplasmosis; any young athlete who has a murmur and syncope has HOCM. Never mind the 90% of cases where these aren't true.
 

NRAI2001

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Sorry (just finished M1, so no real clinical experience yet) but I have a simple question; so:

Patients with type II dont usually have DKA bc they still produce insulin? Is this bc the insulin doesnt really signal for B-oxidation and the whole ketone process?

I am assuming type I patients do show DKA bc they re is little or no insulin production, lifting any inhibition of B-oxidation by insulin??

I am I correct in my statements?
 

indo

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yeah, if you are going to go through all the trouble getting a BMP etc. you should just have the fat nurse with the hacking cough do a glucose stick.
 

rup47

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I have never heard of a type II diabetic making NO insulin. It is possible, but not probable.
Guess it depends on where you do your training. I've seen 3 type II diabetics come in with DKA over the last 6 months.
 

jilliumm

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Sorry (just finished M1, so no real clinical experience yet) but I have a simple question; so:

Patients with type II dont usually have DKA bc they still produce insulin? Is this bc the insulin doesnt really signal for B-oxidation and the whole ketone process?

I am assuming type I patients do show DKA bc they re is little or no insulin production, lifting any inhibition of B-oxidation by insulin??

I am I correct in my statements?
That's the way I understand it. Also, the cells in type 2 are usually still getting some glucose, so there is a bit more regulation too.

Anyone who isn't eating carbohydrates or properly using glucose can develop ketone bodies. But some insulin is needed to adequately regulate B-oxidation. That's why regular people can go into ketosis, but only people with very low levels of insulin have hyperglycemia and go into ketoacidosis.

Type IIs can go into nonketotic hyperglycemic coma, though, which is also really serious.
 

anatomyjane

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I don't know. You know, if anyone is unconscious, I always assume that they are diabetic, hypoglycemic and that all they need is a cookie.

haha, I'd definitely like to see an unconscious person eat a cookie.

good one!
 

agranulocytosis

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Sorry (just finished M1, so no real clinical experience yet) but I have a simple question; so:

Patients with type II dont usually have DKA bc they still produce insulin? Is this bc the insulin doesnt really signal for B-oxidation and the whole ketone process?

I am assuming type I patients do show DKA bc they re is little or no insulin production, lifting any inhibition of B-oxidation by insulin??

I am I correct in my statements?
Essentially, yes. That's all you really need to know for basic sciences:
Type 1 -> non-compliance -> DKA
Type 2 -> non-compliance -> HNKC

But as alluded to above by J-RAD, eventually the B cells of the pancreas fatigue and insulin supplementation is required for Type II diabetics. In fact, almost every single Type II diabetic I've encountered in clinicals is on insulin of some sort.
 

werd

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i agree with the advice to just give glucose when in doubt. i've often heard "glucose-naloxone-thiamine" for anyone who's randomly found down since they are relatively harmless and reverse serious conditions.
having said that, this guy has 2+ glucose in his urine... for me that's enough evidence against hypoglycemia (and for hyperglycemia) that i'd probably wait the 60 seconds to get a finger glucose. still a judgement call, i don't think you could be faulted for giving the d50 anyway.
finally, yeah - type 2 diabetics classically get HONK rather thank DKA, but there are so many more type 2's that in my experience (10-12 DKA's) about half of DKA folks are type 2's. all of the HONKS i've seen (5) have been type 2's. around here, people like to call diabetes "the sugar."
 

Scaredshizzles

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Guess it depends on where you do your training. I've seen 3 type II diabetics come in with DKA over the last 6 months.

It's definitely partly a race thing. You see young obese african americans who have developed DM2 coming in with DKA.

As far as the original question, it definitely sounds like a hyperglycemic type of state....although most vignettes won't have a type 2 diabetic developing DKA, and the classic case for HHNS is an older individual who for whatever reason might have the potential to become dehydrated chronically (poor p.o. intake/dementia/difficulty getting to food/water due to ambulation issues.) But the UTIs/infections commonly will lead to hyperglycemia, and the glucose spillage into urine suggests hyperglycemia (although chronic kidney disease and pregnancy also commonly lead to glucose in the urine without the patient necessarily being hyperglycemic.)
 
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