Prehospital management of diabetic emergencies--a population-based intervention study.

BACKGROUND: Diabetes-related emergencies are frequent and potentially life-threatening. A study was performed to obtain reliable data about the prevalence of diabetic emergencies and to improve the quality of prehospital care of patients with diabetes-related emergencies. METHODS: A prospective population-based study in a German emergency medical service district in the period from 1997 to 2000 was conducted. After initial diabetes training for the entire emergency team, a standardized protocol was introduced for prehospital emergency therapy of severe hypoglycaemia (SH) and severe hyperglycaemic disorders. A rapid blood glucose test was performed on all emergency patients with the exception of resuscitations and deaths. Indicators of treatment quality before and after these interventions were compared. RESULTS: A rapid blood glucose test was performed in 6631 (85%) of the 7804 emergencies that occurred during the period investigated. The prevalence of acute diabetic complications was 3.1%, and 213 cases of SH and 29 severe hyperglycaemic disorders were recorded. Education of the emergency team led to a significant improvement in the quality of treatment. Larger volumes of iv 40% glucose solution (50 +/- 20 ml (1997-2000) vs. 25 +/- 17 ml (1993-96); P < 0.0001) were administered to patients with SH. Insulin-treated patients who were well educated about their diabetes were more often treated only at the emergency scene, after SH (25% vs. 8%; P = 0.007), and without complications. In 50 patients who experienced sulfonylurea-induced SH, the mandatory additional glucose infusions and hospitalization for further observation reduced mortality from 4.9% to 0% (P = 0.2). CONCLUSION: Training of the emergency team is an effective and efficient intervention to improve quality of treatment and prognosis outcome for patients with diabetic emergencies. Treatment of SH at the emergency scene only was demonstrated to be safe in type 1 diabetic patients who had previously received structured patient education.

Practicality and accuracy of prehospital rapid venous blood glucose determination.

Blood glucose testing plays an important role in emergency medicine. Although the use of visual reagent test strips is widely established in this setting, the accuracy of reflectometric blood glucose determinations under emergency conditions has rarely been investigated. In a prospective study, 522 of a total of 3,217 patients undergoing emergency blood glucose testing had parallel blood glucose measurements performed using a specific enzymatic method. These 522 patients (aged 61.4 years, 54% men, 90 cases of severe hypoglycemia) had an intravenous access placed at the scene of the emergency. Venous whole blood from the introducer needle of the access was applied to the test strip and the glucose measured with a GlucoTouch reflectometer (LifeScan, Inc.). A blood sample from the intravenous access was then immediately collected in a monovette for subsequent glucose determination in a chemical laboratory (hexokinase method) within 20 to 40 minutes. The emergency glucose measurements (mean: 7.3 mmol/L [95% confidence interval [CI] 6.9 to 7.7]; range: 0.55 to 27.7) correlated well with the reference laboratory results (Pearson's r = .98; linear regression analysis: slope 1.0, axial intercept 1.74). Error grid analysis also showed good agreement between corresponding measurements: zone A 96.7%, B 2.5%, C 0% and D 0.8%. The mean difference using the Bland-Altman method was 0.14 mmoVL; 2 SD 1.8 mmol/L; minimum -7.0 mmol/L; maximum 4.4 mmol/L. The accuracy of the rapid venous blood glucose determination by constantly changing emergency teams was high. Especially in 90 hypoglycemic patients, there were no deviations from the reference method that could have led to clinically relevant wrong decisions. The method of collecting whole blood directly from the venous access is simple and robust, and is independent of the hemodynamic status of the patient.