Metabolic Emergencies in the Prehospital Setting: Demographic and Clinical Patterns in Aotearoa New Zealand
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Corrin, Kirsty
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Todd, Verity
Dicker, Bridget
Penney, Sarah
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Auckland University of Technology
Abstract
In Aotearoa New Zealand (AoNZ), over 348,000 people are living with diabetes. Suboptimal glycaemic control is associated with an increased risk of acute complications, including diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS), and long-term complications such as end-stage renal disease. These acute complications can be accompanied by significant electrolyte disturbances, which may worsen clinical outcomes. Emergency medical services (EMS) play a role in enabling early interventions and management of diabetic emergencies and any associated electrolyte disturbances, particularly in rural and remote locations.
The demographic and clinical characteristics of patients presenting to EMS in AoNZ with diabetic-related or electrolyte-related emergencies are currently unknown. In addition, the intersection between diabetic emergencies and electrolyte disorders in the prehospital setting has not been examined. The primary aim of this thesis was to examine associations between ethnicity, specifically Māori compared with non-Māori, and the demographic and clinical characteristics of patients attended by EMS for specific metabolic emergencies in AoNZ. The secondary aim was to determine the frequency of concurrent diabetic-related emergencies and electrolyte-related disturbances among these patients.
To address these aims, a systematic literature review was conducted to determine the frequency of electrolyte disorders (dysnatraemia and dyskalaemia) in patients with diabetes or diabetic emergencies presenting to the Emergency Department (ED) or attended by EMS. Fifteen studies were included. Eight examined diabetes or diabetic emergencies with a concurrent electrolyte disorder diagnosis, and seven examined electrolyte disorders in patients with diabetes. In DKA, dyskalaemia was observed in up to 38% of patients, and dysnatraemia in up to 84%. Diabetes as a comorbidity was most common among patients presenting with hyperkalaemia (35.6%) and hypernatraemia (34.9%). Severe electrolyte disturbances were associated with increased intensive care admission and prolonged hospital stays. No studies examined the intersection of diabetic emergencies and electrolyte disturbances in the prehospital environment, which is identified as a gap in the existing literature.
Secondly, a retrospective observational cross-sectional study analysed patients transported by ambulance to ED who had an in-hospital diagnosis of a metabolic emergency. This study examined 10,267 patients, of whom 21.9% were Māori. Compared to Māori, age distribution showed lower proportions of non-Māori aged under 45 (Māori 40.8%, non-Māori 18.3%, p<0.001). Increasing deprivation was associated with higher rates of diabetic emergency presentations overall (Quintile 5: Māori 56.7%, non-Māori 29.9%, p<0.001). Māori were more frequently diagnosed with DKA or HHS, and with hyperkalaemia (p<0.001). Non-Māori had fewer status 1 and 2 presentations (Status 1 and 2: Māori 33.1%, non-Māori 24.7%, p<0.001), and a higher 30-day mortality rate (Māori 4.7%, non-Māori 6.5%, p<0.003).
In patients with a primary electrolyte-related diagnosis, 20.36% had a concurrent diabetes- related diagnosis. A secondary diabetes-related diagnosis was most common in patients with hyperkalaemia (46.6%, p<0.001), with differences observed by ethnicity (non-Māori 17.7%, Māori 37.2%, p<0.001). In patients with a primary diabetes-related diagnosis, 9.18% of patients had a concurrent electrolyte-related diagnosis. Of these, 50.5% were observed in diabetes with DKA or HHS (p<0.001).
This thesis provides the first description of the demographic and clinical characteristics of patients presenting to EMS in AoNZ with concurrent diabetic emergencies and electrolyte disturbances. It establishes baseline knowledge of the intersection between these metabolic conditions in the prehospital setting. The findings highlight an important association between clinical and demographic factors and support the need for prehospital clinicians to maintain a high index of suspicion for concurrent diabetic and electrolyte emergencies.
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Keywords
Prehospital, ambulance, diabetes, electrolyte, ethnicity