Acute onset abdominal pain, emesis; h/o diabetes


• Scene – VS, EKG
• En route – IV 20g, fluids, assessment
• Hospital – n/a


• Response to treatment – no changes
• Disposition – no follow-up from ER


• Elliot Williams, Paramedic Woodburn Ambulance
• David Jones, MD Associate Professor Oregon Health and Science University


• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center
• Mohamud Daya, MD Professor Oregon Health & Science University

• Hyperglycemia
• Diabetes

Differential Diagnosis

• Hyperglycemia
• Stroke
• Metabolic abnormality
• Intracranial bleeding or trauma
• Intoxication
• Diabetic ketoacidosis, hyperosmolar non-ketotic state
• Infection
• Working diagnosis: Weakness and hyperglycemia

Patient Workup

• Patient is Spanish-speaking; answered “okay” and “thank you” to almost every question.
• Caregiver states: Patient is not acting normal. The shaking is more than usual and he vomited once after breakfast. His walking gait is slower than normal.

Physical Exam

• GCS – 14, for confusion
• EKG – possible afib; patient was shaking and had some artifact
• CBG – 207
• Shaking, altered level of consciousness

Suggested Approach

• Hyperglycemia can be a manifestation of many different issues. It is often a result of poor diabetic control due to non-compliance with medications or inadequate therapy. It could also be due to an underlying stress on the body such as an associated infection or other illness (stroke, acute coronary syndrome (ACS), trauma). It is therefore important to determine why a patient is having hyperglycemia and treat the underlying cause.
• Hyperglycemia in the presence of an acute strokes is a poor prognostic marker. Although they usually present with focal neurological deficits, selected strokes can present with weakness, aphasia (inability to communicate appropriately) and confusion. Therefore, it is always important to note the last time the patient was seen as being normal. If this is a stroke, then the last time he was normal will affect the care provided at the hospital.
• Another important consideration is ACS, which can be relatively asymptomatic in the diabetic elderly patient. If available and time permits, a field 12-lead ECG should be obtained.
• The initial management of hyperglycemia usually involves administration of IV fluids since most patients are volume-depleted by the osmotic diuresis associated with the glucosuria.

Suggested references

• Hyperglycemia and What to Do About It


• Gender: Male
• Age: 74 years
• Height: Not Available


• Temperature: Not Available
• Blood Pressure: 135/71
• Heart Rate: 76
• Respiratory Rate: 16
• Pulse Oximetry: 98% RA
Signs and Symptoms
Shaking; altered level of consciousness (ALOC)


• Dementia, diabetes
• Allergies: None
• Dispatch info: Hyperglycemic


• Lives in memory care facility
• Family on scene and at the hospital


• ASA, folic acid, glipizide, isoniazid, levothyroxine, rantidine, simvastatin, Lantus, trazadone

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