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
As someone with late onset type 1 I would point out a few things here:
Apologies in advance for the length here:
First, well done. This is actually better than most articles written strictly about
diabetics and for diabetics. Kudos on that!
On to the quibbles!
NOTE: What follows is mostly MY OPINION. THIS IS NOT MEDICAL ADVICE. I’m just a diabetic, not a doctor or endocrinologist.
First off, sugar under the tongue for someone in a hypoglycemic coma isn’t going to be very effective. Gross as it is, if you can’t inject them with sugar or a special kit, chew up a sugar tab or hard candy, or take gulp of soda into your mouth and spit it into the unconscious person’s mouth and assist them in “swallowing it”. 15g of sugar should do this. Wait 15 minutes. If they don’t wake up, rinse and repeat 15g sugar every 15 minutes until they wake up.
Avoid candy bars, the fat in them means the sugar adsorption will be slowed.This is a race against their cells pulling out enough sugar from the blood to kill them. You gotta win that race. Speed, in this case, saves. Liquid SUGAR is the fastest way to bring them back up. Anything else is slower.
A Glucacon kit is nice for this situation. It will impede the action of the insulin they have on board and give them a dose of sugar. If you don’t have one, the advice above is about as good as you can do.
Secondly, DKA. This won’t be brought on by stress in 99% of circumstances. It’s a lack of insulin, infection or injury.
If you have insulin on hand, that will treat it. Re-hydrate as necessary. Sugar free Gatorade or, preferably, an IV are best. The real problem with DKA is that the cause is controllable and controllable within 48 hours. The issue is that the dehydration issue will throw their electrolyte balance off. I was diagnosed as a Type 1 at 34 years old because I was in SEVERE DKA (My first, and so far only, time in the ICU!). They actually were not sure how I was alive never mind talking. That’s not the point, the point is that my potassium levels were way, way off. Insulin gets rid of the problem that’s the root cause here but doesn’t get rid of the dehydration. If you give insulin and simply re-hydrate with water the person will die because they’re no longer in DKA and they don’t have anywhere near enough electrolytes to keep up with the water you’re pumping into them. You have to pump potassium and sodium into them at the same time. If you overdo the electrolytes the person will excrete them via urine. If you underdo the electrolytes the person will die. How you do this without lab tests and IV potassium, I’m not sure. DKA, like KA from the Keto diet, once it’s past a certain point… well you need a hospital because otherwise the chances of survival are close to none.
Really, the best way to deal with DKA is to avoid it. Once it’s there to the point the symptoms are obvious… well, it’s a huge problem. Just avoid it. If you can’t the person is probably screwed anyway over the longer time frame. Sorry, that’s just the way it is.
Something to keep in mind here, and it’s something you’ll find from an endocrinologist rather than a regular doctor: In the short term high blood sugar is not harmful. Averages are what matter here because of the way sugar causes damage (which I’m not going to get into). So, for example: If I’m at 300mg/dl right after a meal I don’t care because the insulin I took will deal with that. Also, little known is that everyone spikes in glucose levels. Eat half a chocolate cake and even non-diabetics will probably spike to 200mg/dl or more for a couple of hours. This is normal. Insulin, natural or injected, does not act instantly.
When it becomes worrisome is based on the drugs that person takes and I am not competent to discuss all of them. I will say that my short acting insulin is called Humalog, it hits max effect in 1-2 hours and wears off in about 4. So, if I’m at 300 two hours after a meal, OK, because that drug is going to keep working for another two hours. If it gets to four hours after the meal and I’m still up there, I need more. No biggie.
Even if someone tests at 600mg/dl they are not in danger if they don’t stay there for a long time. If you’ve given insulin and they’re that high the questions are when was that insulin given and how long does it take to act? If it was an hour ago, depending on the type of insulin, you need to wait because otherwise you run a serious risk of “stacking” insulin doses in a way that drops them into hypoglycemia. High blood sugar is dangerous over the long term but low blood sugar will kill you now.
Also, not all insulins are the same. They have various speeds of action and are designed completely differently. I personally take two types of insulin a 24 hour insulin (glargine, trade name Lantus) and a short acting insulin for meals (lispro, trade name Humalog).
Now, what I’m about to say is NOT medical advice but it’s useful to know. Long acting insulin is meant to create a baseline level of insulin known as a “basal dose”. Short acting insulin is meant to take care of spikes in blood sugar following food, this is called a “bolus dose”. In an absolute catastrophe you need to know which is which and how much the person needs. Long acting insulin will not act right away BUT if given in too large a dose will drag them down for a full 24 hours meaning you have to fight hypoglycemia for a whole day. Like a bullet, you cannot take insulin back once it’s given. Now, Bolus insulin is more powerful in the short term but easier to counter because it wears off more quickly. In a REAL pinch, where you have NO other option, basal insulin can be increased to the point that it will help deal with blood glucose OVER TIME. The person will run high, probably quite high, but physical activity will burn blood sugar off because there IS insulin on board. While I cannot recommend relying on basal insulin, in a pinch where you have no other choice, it can get your through for a while. It’s no where near ideal but, if help can be reached, you can buy some time with this. Unfortunately how to do it is probably best left up to the person who has diabetes and takes the drugs, so you best hope they listened to their endocrinologist because a regular doctor, generally, has no clue how to manage this kind of thing.
As for you giving them the insulin. Jeeze, I hope they gave you an outline because there are a zillion things that can affect how much of each type they need and the only reliable way to know is personal experience. Someone really sensitive to insulin… that’s hard. They could drop from 350 to 300 with a certain dose or drop to 50 with that same dose.
A few other things here:
1) If you correct low blood sugar and the person rapidly spikes higher than you thought, don’t panic. Sugar works for us like it does for you, pure sugar hits fast and wears off fast. It is likely they’ll jump from 50 to 200 and then over the next hour or so slide back down to 130 or so as their on-board fast acting insulin does it’s job. Well done. Do not give them more insulin unless they remain high for a prolonged period of time. If you do not know when they last took insulin wait at least four hours before giving more. This is not dangerous. This situation is like driving on ice. Don’t slam the brake or hit the gas, slowly release control, let the car settle and bring it to a stop. Trying to correct things too fast ensures you’ll really lose control.
2) Test strips. Screw these things. Doctors are, on this topic, dumb. They want you to work out at a gym grabbing all sorts of germ covered items that lots of other people touch without cleaning AND punch holes in your hands before during and after your workout. If you have a diabetic in the family, get a Continuous Glucose Monitor (CGM) such as a Freestyle Libre or a Dexcom. They are far better than a fingerstick system for a bunch of reasons, give you better data and more control. They use a sensor that works for 5-14 days depending on the brand and model. Reduced infection chances, waterproof, shock resistant (I use mine in Brazilian Jiu Jitsu all the time), better data and more control. The reader unit is wireless and just as robust as anything you’d get as a fingerstick system. Same downfalls in terms of batteries and whatnot but that can’t be avoided. In comparison to a “traditional” glucometer a CGM has all the same downsides and a ton of serious benefits, including being cheaper. The Dexcom is more expensive, the Libre is cheaper. Just know that if you get the 14 day Libre then you have to have the reader at this point unless you have an Apple phone because the data from the sensor is encrypted and cannot be read from an app on your phone. There is an app made by Abbott Labs (they make the Freestyle meters) for APPLE phones, but it’s not yet out for Android. The Libre 10 day and Dexcom systems will talk to both phones. Be careful about the app. Some of the 3rd party apps don’t work well and if it’s reading wrong you won’t know how to correct the situation (or even if there is one).
3) Ketone test strips are stupid, don’t bother. Everyone goes into ketosis sometimes and these things will pop positive for that too. Working out puts you into ketosis, how do you think it helps you burn fat? Long story short: these things will serve no real purpose but to scare you with extra data you don’t need. If the person is in DKA, they’re probably screwed anyway if SHTF, and the answer is always insulin, electrolytes and hydration regardless. Further, they have to test positive on those strips for quite awhile before they actually go into DKA so… what’s the point? Your glucometer tells you if the sugar level is high, so act on that. On top of that if you have someone in ketosis because of hard work, but at 130mg/dl, there is no threat to them since this is normal, natural ketosis from hard work and if you give insulin, well, hypoglycemia. IMHO, you can learn nothing of value from these strips and if you get the data from them may well overreact to it creating a problem where there was none. Plus they’re an extra thing to carry/keep track of. Discard these things.
4) Finally, I would say that if you’re in a bad situation, give less insulin rather than more. A couple reasons: Someone running at 200mg/dl all day is really in no danger right now but someone unconscious at <30mg/dl is a problem we have to deal with immediately. Also, you can take care of that high glucose number with dinner/time to sleep/rest whatever. It can wait until the end of the day. Further, keep in mind that the problems associated with diabetes, of which there are many and they're all very bad, take a long time to develop. High blood sugar numbers over time do cause everything from kidney failure to blindness to nephropathy to stroke and heart problems. This takes years, like decades of poorly managed diabetes. If you're in a situation where the person is going to be running that high day-to-day for that long they're screwed anyway because they're going to die when the insulin runs out and that's going to be long before they have any of these kind of issues. A1C is what matters here, that's average blood sugar. This has to do with the physical crystalline nature of sugar and the way it sticks to A1C hemoglobin. If the A1C never gets real high that hemoglobin never has big layers of crystals on it and we don't have a problem.
If you made it this far, thanks for reading, hope I imparted something useful. Thanks for reading my rant.
Thanks for taking the time and trouble, strych9. That’s a lot of good information not found in the books. Folks, I’m just passing this along as he wrote it; it’s a mix of things I had and hadn’t previously known and he’s so right on the parts I’m familiar with I’ve got confidence in passing on the whole lot. In fact, pending strych9’s approval, we’ll reformat it as a separate article. Too much good info to leave hidden in a comments section.