hyperglycemia and muscle spasms

[funkytomtom]

So...I have begun to delve into the world of ems and am starting to see some patients (scary I know). I was working a concert the other night (an abba cover band :confused) when we were called to an older woman who feeling faint and self checked here bgl-it came up at about 260. I wasn't the head emt on this particular call, so my roll was relegated to fighting apparently quite painful involuntary muscle spasms in both her legs. They would both extend for periods of about two minutes, relax for about ten seconds, and then spasm again. The bgl level is too low for anything like dka, and she claimed to have been hydrating properly throughout the day...so what gives? If it helps (or complicates) the picture she had some obvious edema in her lower legs that she claimed was "normal" for her. What I'm wondering is the actual pathophysiology...thanks!

[tniuqs]

Ok so why would you believe that with a BGL of 260 mg/dL would not show signs of DKA ?

Norms are 70 to 110 mg/dL or in our SI units 3.9 to 6.1 mmol/L.

Was the patient Resp Rate rapid and deep as in Kussmaul Respirations .. please note I did NOT say Hyperventilating (not the correct term)

If this patient was Hyperventilating (EMS definition) one could observe tetanic contractions of any/ all limbs, more typically carpal spasm.

Next question was the patient a Diabetic ?

At any "concert" what other rx on board is my next question ... you just never know till the labs come back .

Pedal oedema ... what is that telling you ?

cheers

[funkytomtom]

Resp rate was normal, pt was diabetic, and I was under the impression (purely from the textbook) that dka needed a much higher bgl, as in over 400 mg/dL? Pedal edema (not so much feet as lower legs, so pedal?) would suggest congestive heart failure or some other problem with the right side of the heart. Thanks for the thought provoking in your response!

[chbare]

Any number of pathologies can cause muscle spasms. This person is elderly, diabetic, and most likely had multiple medical problems and takes multiple medications.

Therefore, your differential must take many other pathologies into consideration. Do not focus on an elevated blood sugar, as you have multiple concepts to consider. Unfortunately, a pre-hospital work up is unlikely to reveal the cause of her signs and symptoms. If you can obtain patient follow up, you can turn this into a learning experience.

Edit: A side note regarding the blood sugar. DKA has been diagnosed in people with blood sugars in the 200's. Do not use the blood sugar as the endpoint for your clinical decision making.

Take care,

chbare.

Edited July 26, 2009 by chbare

[crotchitymedic1986]

Also consider electrolyte imbalances ---- a diabetic who has a dstick of 260, is probably not being very compliant.

[funkytomtom]

Thanks for the respones, it seems I will never really find the answer, just more questions...but this all helps with my "real world" learning which is great!

[mobey]

Whenever I have calls like this I always like to research all the differentials, I feel it makes me a more competent medic.

On that note, you should check out - Dystonic reactions, and Myoclonic seizures.

Or not..... It's just how I roll.

[tskstorm]

You should follow up with the hospital you transported to, specifically the Dr. that cared for her.

Just a thought.

[funkytomtom]

I was working the concert through the venue itself, so we passed her off to the fd, which took her to the hospital...follow up might be hard.

[speedygodzilla]

The lack of a follow up is one of my least favorite things about my job, as I seldom find out the definitive diagnosis.

I though maybe dystonic reaction (maybe a history, or a medication), heat cramps, dehydration as the increase blood sugar would cause increase urine output, as it could be a number of things.

What did her skin signs tell you?

Was this an outdoor event in the heat?

If so, how long has she been there?

You know the usual OPQRST questions as they do help with a possible field diagnosis. Either way it sounds like supportive care is all that is needed in prehospital setting.

Nate

EMT-B

EMT-P Student