EMS Diabetic Protocols for Treat and Release

Introduction

Prehospital providers must consider multiple etiologies in patients with altered mental status or unconsciousness, including the conditions represented by the mnemonic "AEIOU TIPS," which stands for the following:

• Alcohol and acidosis
• Endocrine, epilepsy, electrolytes, and encephalopathy
• Infection
• Opiates, overdose
• Uremia and underdose
• Trauma (head injury and blood loss)
• Insulin
• Poisoning and psychosis
• Stroke, seizure, and syncope

Hypoglycemia, defined as a low blood glucose level, constitutes one of the most common causes of altered mental status in patients with and without diabetes. Estimates indicate that 1% to 2% of prehospital encounters and 7% of refusals are attributable to hypoglycemia.[1][2]

Diabetes mellitus, often referred to as “diabetes” or “sugar” by laypersons, is the most common endocrine disorder. The condition involves either insufficient insulin production or resistance to circulating insulin. Persistently elevated blood glucose levels characterize the disorder over prolonged periods. The 3 main types of diabetes are the following:

• Type 1 (T1D), previously referred to as "insulin-dependent diabetes mellitus" or "juvenile-onset diabetes mellitus"
• Type 2 (T2D), formerly called "noninsulin-dependent diabetes mellitus" or "adult-onset diabetes mellitus"
• Gestational [3]

Insulin is an anabolic hormone produced in the β cells of the pancreatic islets. The primary function of this hormone is to regulate carbohydrate, protein, and fat metabolism by facilitating the uptake of glucose from the bloodstream by the liver, adipose tissue, and skeletal muscle. These glucose molecules are subsequently converted into larger molecules and stored for later use.

Type 1 Diabetes

This condition accounts for approximately 5% to 10% of all diabetes cases. The pathogenesis involves autoimmune destruction of insulin-producing β cells in the pancreatic islets, with contributing factors including genetic susceptibility, viral infections, toxins, alcohol-induced pancreatitis, and certain dietary exposures. The affected population typically includes children and adolescents. However, adult-onset T1D also occurs. The designation “insulin-dependent” reflects the requirement for subcutaneous insulin administration via intermittent injections or continuous pump infusion.[4]

Patients with T1D have an increased risk of developing diabetic ketoacidosis and hypoglycemia. Diabetic ketoacidosis results from impaired glucose transport into cells, producing a starvation-like metabolic state. The body subsequently generates ketone bodies, which serve as substrates in the citric acid (Krebs) cycle for energy production.

Insulin therapy is also associated with an increased risk of hypoglycemia. Contributing factors include excessive insulin administration, increased insulin sensitivity, reduced oral glucose intake during insulin use, and insulin pump malfunction.

Type 2 Diabetes

This disorder accounts for approximately 90% of all diabetes cases. The pathophysiology involves insulin resistance, characterized by diminished cellular response to insulin in peripheral tissues. Early disease is associated with increased insulin production, followed by a progressive decline over time. T2D most commonly presents in individuals older than 45 years. However, an increasing incidence is observed in children, adolescents, and younger adults, largely driven by rising obesity rates, physical inactivity, and energy-dense diets.[5] Management typically includes oral pharmacologic agents that increase insulin sensitivity or stimulate pancreatic islet cells to enhance insulin secretion.

Gestational Diabetes

Hyperglycemia first identified during pregnancy is classified as gestational diabetes mellitus (GDM), which may occur at any stage of pregnancy but most commonly develops during the 2nd and 3rd trimesters. The American Diabetes Association reports that GDM complicates approximately 7% of all pregnancies. Women with this condition and their offspring carry an increased risk of developing T2D later in life. Screening for GDM is typically performed between 24 and 28 weeks of gestation.

Types of Antihyperglycemic Therapies

Therapy for hyperglycemia depends on endogenous insulin production and the effectiveness of insulin action. Patients with T1D are treated with long-acting insulin combined with short-acting insulin via a sliding scale, intermediate-acting insulin combined with short-acting insulin via a sliding scale, premixed insulin formulations, or continuous insulin delivery via an insulin pump.[6] In contrast, most patients with T2D are treated with oral pharmacologic agents, which are classified according to their mechanism of action, as follows:

• Sulfonylureas: Chlorpropamide, glipizide, glimepiride, glyburide, tolazamide, tolbutamide
• Meglitinides: Repaglinide, nateglinide
• Biguanides: Metformin
• Thiazolidinediones: Rosiglitazone, pioglitazone
• α-Glucosidase inhibitors: Acarbose, miglitol, voglibose
• Dipeptidyl peptidase 4 (DPP-4) inhibitors: Sitagliptin, saxagliptin, vildagliptin, linagliptin, alogliptin
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors: Dapagliflozin, canagliflozin
• Cycloset: Bromocriptine

Each class of antihyperglycemic therapy demonstrates distinct adverse effects. Recognition of these adverse effect profiles is essential in the prehospital setting, where altered mental status, hemodynamic instability, or atypical presentations may reflect medication-related complications rather than primary metabolic derangements.

Hypoglycemia 

A major public health concern in diabetes mellitus care involves unintended complications associated with reductions in blood glucose levels, including hypoglycemia.[7][8] The condition is defined as a plasma glucose concentration below 70 mg/dL, with most patients remaining asymptomatic until it falls below 55 mg/dL.[9] Plasma glucose levels requiring assistance from another individual are classified as severe hypoglycemia; by definition, all emergency medical services (EMS) encounters fall within this category.[10] Severe hypoglycemia is associated with increased morbidity, including reduced quality of life, recurrent falls or motor vehicle accidents, dementia, and hospitalization, as well as increased mortality.

Based on 2015 data from NEMSIS (National Emergency Medical Services Information System), prehospital activations for diabetes-related cases account for approximately 2.3% of all activations, with hypoglycemia representing the most common EMS encounter.[11] Patients experiencing severe hypoglycemia or other diabetes-related emergencies typically activate emergency services by calling 911, resulting in the dispatch of a fire department or EMS agency, depending on jurisdictional protocols. Care is then provided by the first arriving on-scene provider, who may be an emergency medical technician (EMT), an intermediate or advanced EMT, or a paramedic.

Disposition decisions, including whether to treat and release or transport patients with hypoglycemia, are guided by state or regional clinical guidelines and protocols established by medical directors. Patients with severe hypoglycemia are at increased risk for complications related to the hypoglycemic state. Villani et al reported that approximately 50% of patients with severe hypoglycemia required transport to the hospital, with 41.3% of transported individuals requiring hospital admission.[12][13][14]

One of the earliest studies addressing treat-and-release strategies for individuals experiencing hypoglycemia in the prehospital setting was Development and Evaluation of Criteria Allowing Paramedics to Treat and Release Patients Presenting with Hypoglycemia: A Retrospective Study, published in Prehospital and Disaster Medicine in 1991. The study proposed 5 criteria to identify patients appropriate for release without the need for additional prehospital intervention:

• Presence of a history of T1D or T2D
• Blood glucose prior to treatment below 4.4 mmol/L (80 mg/dL)
• Blood glucose after treatment of at least 4.4 mmol/L (≥80 mg/dL)
• Return to normal mental status within 10 minutes following treatment
• Absence of complicating factors requiring emergency department evaluation, including alcohol intoxication, chest pain, dyspnea, injury related to falls, or renal dialysis dependency

A 2016 study by Rostykus et al reviewed prehospital clinical guidelines for hypoglycemia across 185 EMS agencies in the US. Findings demonstrated that less than half of the agencies permitted nontransport of patients with hypoglycemia after correction of low plasma glucose levels.[15] A study by Moffet et al evaluated individuals with hypoglycemia treated by EMS in Alameda County from 2013 to 2015 and reported a transport rate of 13.5%. Demographic trends among nontransported patients included adults younger than 60, male sex, fingerstick blood glucose levels greater than 60 mg/dL, and EMS arrival times between 1800 and 0600.

Issues of Concern