hyperglycemia and muscle spasms

[HERBIE1]

I'd also add these factors-

Ambient temperature-ie heat related symptoms? Alcohol? Underlying PMH? Compliance with meds? Undiagnosed problems? Drugs(elderly or not, it's still a possibility)?

I'd also echo the fact that a person with a glucose level of 260 could easily be in DKA. We'd have no way of knowing.

An ABBA type concert doesn't generally sound like a haven for illicit drugs, but you never know.

Years ago, I moonlighted at a local venue and the Grateful Dead was playing. Mass chaos, but that's another story. We had a 16 year old girl who worked at a concession stand who was brought to us, exhibiting bizarre behavior. Her friends/coworkers swore this kid was as straight laced as they came. We checked her out, and it turned out one of the "dead-heads" thought it would be funny to slap a plastic sticker on the girl's upper arm, which was probably laced with LSD or PCP. During a lucid moment, the girl recalled having a brief conversation with another girl in the bathroom about 30 mins earlier, and as they parted, she recalls getting a hug from the dead head, which she thought was odd. It must have been the moment the dead head applied the sticker- a Smiley face, of all things.

Point is, expect the unexpected in this business.

[speedygodzilla]

I'd also add these factors-

Ambient temperature-ie heat related symptoms? Alcohol? Underlying PMH? Compliance with meds? Undiagnosed problems? Drugs(elderly or not, it's still a possibility)?

I'd also echo the fact that a person with a glucose level of 260 could easily be in DKA. We'd have no way of knowing.

An ABBA type concert doesn't generally sound like a haven for illicit drugs, but you never know.

Years ago, I moonlighted at a local venue and the Grateful Dead was playing. Mass chaos, but that's another story. We had a 16 year old girl who worked at a concession stand who was brought to us, exhibiting bizarre behavior. Her friends/coworkers swore this kid was as straight laced as they came. We checked her out, and it turned out one of the "dead-heads" thought it would be funny to slap a plastic sticker on the girl's upper arm, which was probably laced with LSD or PCP. During a lucid moment, the girl recalled having a brief conversation with another girl in the bathroom about 30 mins earlier, and as they parted, she recalls getting a hug from the dead head, which she thought was odd. It must have been the moment the dead head applied the sticker- a Smiley face, of all things.

Point is, expect the unexpected in this business.

Acute dystonic reaction to a

NICE

[FL_Medic]

Differential:

- Leg pain

- Muscle spasms

- Seizures

- Foot spasms

- Muscle injury

- Nerve irritation

- Nummular eczema

- Nerve compression

- Hypocalcaemia

- Electrolyte abnormality

- Sciatica

- Leg injury

The most common cause (in my opinion) would be dehydration. You noted this as a consideration. You asked about her fluid intake, and this was good. I am slightly partial to this diagnosis because I am in South Florida, and everyone is dehydrated. If possible, I would have tried to obtain a HR while the patient was at ease. An elevated HR would also indicate dehydration.

What about anxiety? Did the sight of the elevated blood sugar induce hyperventilation? Hyperventilation syndrome may lead to abnormal potassium release, causing cramping and/or numbness in the extremities. I have had patient's with anxiety induced by the sight of their blood sugar.

Whatever you think the cause is, I would try and do a follow up. Usually the high priority calls are the easier ones to follow up on at a busy hospital; simply because they are the ones the nurses and docs remember. Welcome to the world of EMS, you seem like the type of EMT we are looking for. I always try to figure out what is going on with the patient by using simple rules of physiology, just don't get tunnel vision.

Here is an example from my shift yesterday:

Responded to 65 y/o male that was "sleeping too much" for the past 3 weeks.

Wife stated that he is suppose to get a sleep study performed. She states that he is a loud snorer, and the patient looked like he could easily have sleep apnea. He was about 300 lbs.

Room air O2 sat was initially 98%. The patient fell asleep frequently. All other VS, including BG was normal. We grabbed the big bag-o-meds and packaged the patient.

During transport the patient's O2 saturation while awake was 91% and in the 60's when sleeping. This alerted me quite a bit. Lungs were clear. I attached ETCO2. The patient was normocapneic while awake and ETCO2 read 62 mmgh when asleep. Respirations were 22 when awake and 10 while asleep. I had damn near done my own sleep study and diagnosed sleep apnea before I looked at all his meds.

Rx: Oxycontin, Oxycodone & Hydrocodone.

I still withheld the Narcan, because the patient was still breathing and I was able to oxygenate him. I didn't want a kicking & screaming 300lb man in the back of my ambulance when the ER was less than 5 min. away. The ER doc concurred and administered 1mg of Narcan to an unhappy recipient.

I still wouldn't be surprised if the patient has sleep apnea, but he presented with classic S/S of opiate OD.

Ps. Just because there are cases of DKA with BG levels around 200 doesn't mean you will ever see it. You are right, DKA is much more common in patient's with BG levels > 400. Then again, they can have a sugar that high and not be in DKA. It is a complicated process, and every body has different levels of cellular metabolism.

[HERBIE1]

Differential:

- Leg pain

- Muscle spasms

- Seizures

- Foot spasms

- Muscle injury

- Nerve irritation

- Nummular eczema

- Nerve compression

- Hypocalcaemia

- Electrolyte abnormality

- Sciatica

- Leg injury

The most common cause (in my opinion) would be dehydration. You noted this as a consideration. You asked about her fluid intake, and this was good. I am slightly partial to this diagnosis because I am in South Florida, and everyone is dehydrated. If possible, I would have tried to obtain a HR while the patient was at ease. An elevated HR would also indicate dehydration.

What about anxiety? Did the sight of the elevated blood sugar induce hyperventilation? Hyperventilation syndrome may lead to abnormal potassium release, causing cramping and/or numbness in the extremities. I have had patient's with anxiety induced by the sight of their blood sugar.

Whatever you think the cause is, I would try and do a follow up. Usually the high priority calls are the easier ones to follow up on at a busy hospital; simply because they are the ones the nurses and docs remember. Welcome to the world of EMS, you seem like the type of EMT we are looking for. I always try to figure out what is going on with the patient by using simple rules of physiology, just don't get tunnel vision.

Here is an example from my shift yesterday:

Responded to 65 y/o male that was "sleeping too much" for the past 3 weeks.

Wife stated that he is suppose to get a sleep study performed. She states that he is a loud snorer, and the patient looked like he could easily have sleep apnea. He was about 300 lbs.

Room air O2 sat was initially 98%. The patient fell asleep frequently. All other VS, including BG was normal. We grabbed the big bag-o-meds and packaged the patient.

During transport the patient's O2 saturation while awake was 91% and in the 60's when sleeping. This alerted me quite a bit. Lungs were clear. I attached ETCO2. The patient was normocapneic while awake and ETCO2 read 62 mmgh when asleep. Respirations were 22 when awake and 10 while asleep. I had damn near done my own sleep study and diagnosed sleep apnea before I looked at all his meds.

Rx: Oxycontin, Oxycodone & Hydrocodone.

I still withheld the Narcan, because the patient was still breathing and I was able to oxygenate him. I didn't want a kicking & screaming 300lb man in the back of my ambulance when the ER was less than 5 min. away. The ER doc concurred and administered 1mg of Narcan to an unhappy recipient.

I still wouldn't be surprised if the patient has sleep apnea, but he presented with classic S/S of opiate OD.

Ps. Just because there are cases of DKA with BG levels around 200 doesn't mean you will ever see it. You are right, DKA is much more common in patient's with BG levels > 400. Then again, they can have a sugar that high and not be in DKA. It is a complicated process, and every body has different levels of cellular metabolism.

Good post, Fl. I've been seeing more and more narcotic intoxications/OD's in unlikely patients. Not too long ago I had an intentional Vicodin OD from a 65 year old. SHe had just found out she had terminal pancreatic CA with metastasis. She damn near suceeded- it took a ton of Narcan just to get her breathing again.

Like I said before- expect the unexpected, and as hard as it may be sometimes, we cannot allow ourselves to get tunnel vision.

[funkytomtom]

The pulse was too faint to palpate radially. BP was 160 over 110. It's hard for me to know all the vitals because I wasn't really "patient guy." Dehydration sounds very possible, it had been in the 90's all day, but about 1800 hours the temperature dropped significantly and it rained for a bit (call at about 1930 hours), this plus the fact she said she had been keeping hydrated throughout the day makes me wonder about all the different possibilities. I talked a bit with the intermediates on ski-patrol I work with and they didn't have much to say except possible dehydration. I don't know if their medical assessments are the greatest because they deal with so much trauma and pretty much ship anyone serious right away. It seems like there is a lack of in depth assessment both places I work, hopefully I get the job on the rig I just applied for!

Thanks for the replies, and the obvious thought put into them!

[2wheelinemt]

just another quick thought thrown in i know im not as smart as the rest of you but i do know that my husband was working outside and was drinking all day like he thought he should and right before his 12hrs shift is over he starts getting legs cramps just as you decribed. he dranked water all day and thinned his electrolites out thus becoming dehydrated. so just because she was drinking all day like she thought she was suppose to that could have been the problem just a thought

2wheelie

[tniuqs]

'2wheelinemt'

just another quick thought thrown in i know im not as smart as the rest of you.

Disagree your just as smart already you present a great observation so please don't underestimate yourself, its a matter of life long continuing education in EMS but perhaps some capitalizing and using a thing called the paragraph would help out a bit in representation.

but i do know that my husband was working outside and was drinking all day like he thought he should and right before his 12hrs shift is over he starts getting legs cramps just as you decribed.

I hope his shift was not "hung over on a rig" ... minimum of 12 hours bottle to throttle.

he dranked water all day and thinned his electrolites out thus becoming dehydrated.

Thinned out not quite the correct medical term, Sodium or Potassium depletion is far more likely than dehydration in your "hubbys case" and one must use electrolyte replacements when rehydrating a ratio of 3 to 4 liter of H20 to one juice or electrolye supplement, Thiamine/ Vitamin B 1 assists in metabolizing glucose as well ... btw .... I have some field experiance in this area myself ....

so just because she was drinking all day like she thought she was suppose to that could have been the problem just a thought

A thought yes, but the scenario with pedal oedema and spasms, hyperventilation and a diabetic too, and the possibility of being on medications such as lasix (water pill) this is a loop diuretic and depletes potassium.

Bit more complex medically that just "tying one on" by a health adult.

Cheers and Welcome.

ps hey those ABBA concerts can be CRAZY .... LOL.

[funkytomtom]

It wasn't even ABBA haha, it was an ABBA cover band Anyways, I've been reading some of my intermediate textbook before class starts on August 24th, and due to this call I skipped ahead to the chapter on diabetic emergencies, which brought up MORE QUESTIONS!!!! I was reading about hyperglycemia and came across something not addressed in my basic class: hyperglycemic hyperosmolar nonketotic coma. I believe I understand the concept, but these lines gives me pause: "high levels of glucose in the cerebrospinal fluid leads to dehydration of the brain and decreased levels on consciousness," and "it is a relatively common cause of hyperglycemia." How do high levels of in the glucose in the csf lead to a dehydrated cns? Decreased levels of consciousness meaning disorientation, syncope, or all out coma as the name suggests (I'm betting on a wide range)? And it seems to me it is caused by not a cause of hyperglycemia? I decided to post these questions with my previous diabetes question thread...I hope someone sees it! Thanks

[medic82942003]

could be a electrolyte problem low potassium.

Edited July 29, 2009 by medic82942003

[HERBIE1]

After seeing the replies and the added info like ambient temp, I am more likely to think dehydration. Hyperglycemia, heat(remember, heat effects are cumulative), and the fact that many older folks are chronically dehydrated, I'm leaning towards cramps due to dehydration.

Good thread. It's fun playing detective- one of my favorite parts of the job. Maybe I'm a frustrated internist?