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March 27, 2016

Diabetes and Emergency Medicine

In the emergency room such as FRONTLINE ER, when patients say they are getting abnormally high readings of blood glucose in the absence of increase food intake and change in medication, the next questions are: is there an infection somewhere that is decreasing the patient’s glucose tolerance? Are they producing ketones because their bodies cannot push the glucose into their cells to be used? Based on their risk factors, is there another acute process going on that is notoriously asymptomatic in diabetics such as a silent myocardial infarction?

The stress response from an infection or a heart attack can increase blood glucose levels, and increased blood glucose levels can increase the severity of infections, leading to a vicious circle that can deteriorate a patient’s health very quickly. Urinary tract infections in diabetics can have no symptoms before proceeding into septic shock and organ failure.

High Blood Glucose from Uncontrolled Diabetes

High blood glucose from uncontrolled diabetes can severely impair the immune system’s ability to fight off infections in patients and even open up the patient to pathogens that would never been seen in nondiabetic patients.  Elevated blood glucose decease immune cell’s ability of chemotaxis, phagocytosis (engulfing bacteria and foreign material), and killing of pathogens. Long term diabetes causes macro and microvascular damage in the blood vessels that decreases tissue perfusion and the ability to fight off local infections. Think of this as not being able to send desperately needed troops and supplies  to a raging battle because the roads are so damaged and even if you manage to get your troops there, their overall fighting ability have been handicapped. Fortunately, with better blood glucose control, scientists observed a restoration of the immune cell’s ability to fight off infections, however the damage from long term diabetes to the vascular system seem not so reversible.

Damage to the micro and macrovascular system from long term uncontrolled blood glucose increases the risks of strokes and heart attacks in diabetics as the blood vessels get sclerotic and narrow. Narrowing blood vessels, along with diabetic nerve damage, make patients with diabetes susceptible to silent heart attacks.

In the emergency department, based on your medical examination and history, your physician may order a urinalysis to look for ketones and signs of a urinary tract infection. You may get a chest x-ray because diabetic patients are more susceptible to atypical pneumonia. Blood work such as a blood count and an electrolyte panel are useful. EKG and a cardiac panel will alert the physician to a silent heart attack in patients with diabetes.  As long as the dangerous causes of unexplained blood glucose elevation have been rule out, your emergency physician may give you an extra shot of insulin if your glucose is too high, or have you see your primary care physician for long term medication adjustment.

References

Casqueiro, Julian. Casqueiro, Janine. Alves, Cresio.  (2012)Infections in patients with diabetes mellitus: A review of pathogenesis. Indian J Endocrinol Metab. 2012 Mar; 16 (suppl1): S27-S36.

Chiariello, M., Indolfi, Ciro. (1996). Silent Myocardial Ischemia in Patients with Diabetes Mellitus. American Heart Association Journal 93,2089-2091.

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