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So I had this weird patient...


MedicAR

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I had a strange call recently.  Called for an unresponsive/syncopal patient.  When we roll up, he is awake and looking around but not interactive even to pain.  Family said he was completely unconscious when they found him and his eyes were closed.  He had no seizure history, oral trauma or incontinence but for all intents and purposes, he appeared postictal.  He had a diabetic history (and insulin pump) but CBG was 128.  Skin was pink, warm, and dry, and pupils were equal and reactive.  He was young (late 20s) and very fit, last seen normal two hours prior when he was complaining of a headache.  Family stated that he has never complained of a headache in his life, much less one that he would lie down for.  He moved all of his extremities but not to command and even his grunting wasn't related to painful stimuli.  Sinus rhythm in the high 80s, normotensive, SpO2 100% and….hyperventilating.  I didn't notice it initially but then caught him breathing close to 60 times per minute.  By the time he is on capnography, he is back down to 16 breaths per minute.  He has some meaningful movement as we roll him onto a sheet to move him, almost assisting with movements.  Respiratory rate continues to vary but the changes are sudden, not like Kussmaul's, with the gradual changes in depth and rate.  It really was like flipping a switch.  We move to the bus and when I am looking for an IV, he is cooperating with his arm movement.  I stick him and get no reaction.  Within a minute or two, he is awake and oriented with clear speech, initially drowsy but quickly awake and lucid.  His breathing sped back up to 40 but slowly decreased with coaching and explaining why he had carpopedal spasms.  He was cooperative and lucid.  He had no history of anxiety or respiratory issues.  He remained awake and oriented all the way to the to the hospital.  In talking about his headache prior to all of this, he described it as intense pressure behind his right eye and was easily the worst headache of his life.  He remembered walking to the bedroom and then nothing until he awakened in the bus.  
 
Now here's the problem.  Later, I get a call saying he was hypoglycemic (CBG was 28 when ER checked) and am accused of not treating it.  I checked his CBG and found it normal.  He improved without intervention and once awake, was well oriented and remained pink, warm, and dry.  His skin was also normal prior to arrival and during his time with me.  By the time we arrived in the ER, his only complaint was carpopedal spasms.  Breathing had slowed to 20 and appeared to be well controlled.  
 
Am I missing something?  Could it be an insulin pump malfunction?  If so, wouldn't the CBG continue to rise or fall until an intervention is made?  Why didn't he become cool and clammy?  By his own admission, he usually becomes diaphoretic when his CBG drops.  Where did the hyperventilation come from?  I generally associate that with hyperglycemia, and slowed or even snoring respirations with hypoglycemia, although neither are hard and fast rules.
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Interesting case.  Just a few questions:

When was the last time the glucometer on your ambulance was calibrated?  How old were the test strips?  Finger stick?  Or the old tip of the pen to the flash chamber trick?  (Not that the difference between the two should be *that* big.)

What other history does this kid have?

What else is going on with his headache?

What did the hospital tell you besides their BGL finding?  Do you know his discharge diagnosis?

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Honestly, I don't believe the glucometers are ever calibrated.* By the same token they are usually within a point or two of the readings in the ER and the one I used is still on the rig with no other unusual readings.  We did a finger stick to get the glucose level while still in the early stages of the assessment because nothing really made sense.  

No real history other than Type I Diabetes that he generally keeps well controlled.  He and his family stated that he rarely has consciousness altering episodes and has even had fewer since getting his insulin pump.  They estimated it at once a year or less and that he usually realizes what is happening and corrects it right away with no outside intervention.  The family could not specifically remember the last time he had a problem.  Otherwise healthy with no recent illness or trauma, not even as simple as bumping his head on a car door.  No meds outside the insulin.  Diet and daily habits had no recent changes.  He was fit and toned without being bulky and said that he worked out frequently, crediting his healthy lifestyle for keeping his diabetes well controlled.  He claimed that he didn't use alcohol or illegal drugs and nothing lead me down that path anyway once he was awake.  Vitals were normal aside from exhaled CO2 which was low in the mid to lower 20s which could tie to DKA if other symptoms are present.  The problem with DKA is the obvious, that it would result from an increase in glucose, not a decrease.  

He described the headache as a pressure that felt like the right side of his head would explode.  He said that he didn't have problems with his vision or nausea with the headache.  He said that he didn't feel weak or tired but felt like he should lie down.  He said he still had a headache but nothing like he had experienced earlier.  There was nothing visible that would lead me to suspect trauma to the head, no bruises, bumps, scabs, bleeding...nothing.  

ER treated and released with the sole diagnosis being hypoglycemia.  No X-ray, no CT, no MRI.  It was like the headache was completely ignored.  

*It sounds weird, but my management seems to take great joy in keeping us grunts in the dark on everything.  Their attitude seems to be, "You don't worry about it.  Just use what we give you."  It's most likely a control trait but who really knows?  

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Interesting case.  I'm wondering what happened to him after they treated the hypoglycemina.  Did the headache resolve? 

Did he have anything else with the headache?  Runny nose?  Conjunctival injection on that side?  Lots of tear production in that eye?

I know you said it's hard to follow up.  Perhaps when you get back to the same ER ask around and see what you can find.

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When blood sugar levels are low there is a potential for spontaneous glycogen release from the liver in diabetic patients. It's similar to what happens when glucagon IM is administered. Basically, what happens is that the patient is hypoglycemic and loses consciousness. Someone calls 911 and before the ambulance arrives, the liver releases the stored glycogen which converts to glucose. When the ambulance arrives the patient is alert and oriented, seems completely normal, and has a normal or near normal glucose reading. However, the glycogen is still a short tern solution and gets used up pretty quickly, so the patient bottoms out again.

 

I've simplified it tremendously here, but here are some links:

https://en.wikipedia.org/wiki/Glycogen

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442155/

http://www.diabetes.co.uk/body/glycogen.html

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This is an interesting case. When was the last time he ate or drank anything? What type of insulin was he on? Were there any signs of stroke? Facial drooping, Arm weakness, Speech difficulties etc... Also what were his vital signs? I am concerned about: 1) Stroke/TIA. 2) Migraine Headache 3) Seizures & 4) Metabolic Disorder.

 

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Was the patient taking his insulin correctly? I know of several IDDM patients who would use the wrong length needle and end up depositing insulin between layers instead of into the subcutaneous layer. As a result the insulin would sit in pockets instead of being properly absorbed at the time of injection. The patient would take increasing amounts of insulin to control their BGL not realizing what was happening. Seemingly at random these "pockets" of insulin would absorb and the patient would end up having profound and sudden drops in BGL.

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When blood sugar levels are low there is a potential for spontaneous glycogen release from the liver in diabetic patients. It's similar to what happens when glucagon IM is administered. Basically, what happens is that the patient is hypoglycemic and loses consciousness. Someone calls 911 and before the ambulance arrives, the liver releases the stored glycogen which converts to glucose. When the ambulance arrives the patient is alert and oriented, seems completely normal, and has a normal or near normal glucose reading. However, the glycogen is still a short tern solution and gets used up pretty quickly, so the patient bottoms out again.

 

I've simplified it tremendously here, but here are some links:

https://en.wikipedia.org/wiki/Glycogen

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442155/

http://www.diabetes.co.uk/body/glycogen.html

I was completely unaware of this.  I don't recall it being something that I saw in school and certainly haven't seen in any refreshers since.  I will try to learn all I can to pull together a presentation to teach my coworkers.  Your description fits better than anything I have been able to find or attribute.  It was a short ride to the ER, so I am betting that the release occurred while we were with him, giving me a good CBG when I checked but allowing it to quickly crash after dropping him off.  

Thank you!  

This is an interesting case. When was the last time he ate or drank anything? What type of insulin was he on? Were there any signs of stroke? Facial drooping, Arm weakness, Speech difficulties etc... Also what were his vital signs? I am concerned about: 1) Stroke/TIA. 2) Migraine Headache 3) Seizures & 4) Metabolic Disorder.

 

I thought I had it in the first post, but apparently that was an earlier draft.  No facial droop at any point.  Once awake and oriented enough to follow orders, he had no stroke symptoms.  He had good grips, clear speech, equal smile, normal arm strength...the works.  No signs of a stroke at all.  It was the first thought I had when given the history of headache and then unconscious.  I have seen a hemiplegic (or complex) migraine in another patient close to his age (mid 20s) that presented as a classic stroke complete with facial droop, word salad, and single sided paralysis.  It was only diagnosed after symptoms resolved and she was able to tell us she had migraines.  Well, that and the repeated CTs were completely clean.  

Nothing exciting in his vitals.  I didn't make notes, but from memory I would say a heart rate in the 80s, varying respiratory rate, BP of 110/70, and pulse ox at 100%.  No big clues there.  

I have no idea on the insulin.  I can say that it isn't refrigerated as it stays in the pump on his belt all day.  Administration is auto-regulated for the most part but the patient can make minor adjustments.  I'm still learning about the pumps but they seem to be a pretty solid technology at this point.  

 

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Was the patient taking his insulin correctly? I know of several IDDM patients who would use the wrong length needle and end up depositing insulin between layers instead of into the subcutaneous layer. As a result the insulin would sit in pockets instead of being properly absorbed at the time of injection. The patient would take increasing amounts of insulin to control their BGL not realizing what was happening. Seemingly at random these "pockets" of insulin would absorb and the patient would end up having profound and sudden drops in BGL.

Auto regulated through a tube in the lower abdomen.  They said the pump rarely gives him problems, but it's not out of the question.  

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The ER should have admitted him for observation. They should have ordered a CT Scan of his head given his signs & symptoms. They should have also ordered a 12 lead EKG plus a chest x-ray & labs.

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