Acute onset, diabetic with altered mental status part 2


• Scene – vitals
• En route – refusal
• Hospital – refusal


• Disposition – refusal. I contacted patient’s PCP and confirmed that orders for new insulin scale were being sent. Advice RN I spoke with said that they would be faxed ASAP.
• Follow up – We were dispatched back to the facility a couple hours later to transport this patient to the hospital. The doctor who was supposed to write the new orders for insulin refused to increase dose and ordered patient transported to hospital for evaluation. Patient’s CBG down to 349 after insulin dose at 1645.


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


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

• Hyperglycemia
• Diabetes

Differential Diagnosis

• Hyperglycemia
• Misuse of medication
• Stress
• Inappropriate diet
• Trauma (physiologic stress)
• Infection (physiologic stress)
• Myocardial infarction/stroke/pulmonary embolism (physiologic stress)
• Refusal of care
• Social reason
• Fear of medical system
• Fear of medical diagnosis
• Misunderstanding of situation
• Hypoxia
• Hypoglycemia
• Metabolic derangement
• Intoxication
• Head trauma
• Working diagnosis: Hyperglycemia due to insufficient anti-hyperglycemic medications

Patient Workup

• Patient states – chronic pain but no other complaints. Patient refused transport. Patient feels that he does not get good care from his new doctor.
• Caregiver states – patient has been running CBG over 400 for about 6 days now. Care facility team is waiting to get new sliding-scale orders for insulin, but it’s taking too long, so 911 was called. States that patient is non-compliant with special diet as well.

Physical Exam

• CBG – 449
• GCS – 15
• EKG – SR
• Patient is missing left leg due to diabetic complications
• Right leg is swollen and hard, discolored, with decreased sensation. Patient has been instructed to wear compression garment on right leg but won’t pay for one.

Editor’s Notes

This patient seems to have altered mental status, which might be secondary to the hyperglycemia or another underlying illness such as an infection. Diabetic ketoacidosis must always be considered in these patients as well. -David M. Spiro, MD, MPH Professor of Pediatrics, University of Arkansas Medical Center

Suggested Approach

• Refusals are some of the most challenging calls encountered in the field. Patients may have valid reasons (cost, do not feel that this is needed, etc.) why they do not wish to be treated or transported by ambulance to the hospital. An important aspect of patient assessment in these instances is to determine if the patient has decision-making capacity. Capacity involves more than being alert and oriented to person, place, time. It requires that the patient demonstrate an understanding of the risks of refusing care and the potential consequences of their actions. Someone who is unable to understand the consequences of their decisions, whether due to disease or external factors, does not have the capacity to refuse care, and should be transported to the hospital.
• 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 can also lead to bad outcomes. Chronic hyperglycemia and poor diabetic control increases the risk of complications such as strokes or heart attacks. Acute hyperglycemia can result in diabetic ketoacidosis (a state where cells don’t get the sugars that they need and begin to produce excess acids) or hyperglycemic, hyperosmolar, non-ketotic state (HHNK, the body becomes dehydrated due to the high sugar that results in lots of excess urination). Both states can make people very sick.
• Diabetic ketoacidosis (DKA) can present as a confused patient taking deep, deliberate breaths (hyperpnea), which is an compensatory mechanism to remove excess acid.
• Hyperglycemic, hyperosmolar, nonketotic states (HHNK) often present with someone who has been hyperglycemic for days, is confused, very dry, possibly hypotensive. It is more common in the elderly, whereas DKA is more common in the younger diabetic patient.

Suggested references

• Diabetic Ketoacidosis
• Hyperglycemia and What to Do About It


• Gender: Male
• Age: 52 years
• Height: Not Available
• Weight: Not Available


• Temperature: Not Available
• Heart Rate: 86
• Blood Pressure: 120/75
• Respiratory Rate: 18
• Pulse Oximetry: 94% RA
Signs and Symptoms
6 days severely high blood sugar


• Diabetic w/ neuropathy; hypertension; anxiety; schizophrenia; sleep apnea; chronic pain; left leg amputee
• Allergies: Haldol, Abilify, penicillin, chlorpromazine, codeine, vancomycin
• Dispatch info: High blood sugar


• Lives at care facility


• Lasix, clonidine, clonazepam, methadone, Protonix, promethazine, lisinopril, Geodon, Lotrimin AF, oxycodone, Tylenol, Lantus, Humalog

Related videos