|Year : 2016 | Volume
| Issue : 2 | Page : 64-72
|Traumatic injuries in patients with diabetes mellitus
Ayman El-Menyar1, Ahammed Mekkodathil2, Hassan Al-Thani3
1 Department of Clinical Medicine, Weill Cornell Medical College; Department of Surgery, Trauma Surgery Section, Clinical Research, Hamad General Hospital, Doha, Qatar; Department of Internal Medicine, Ahmed Maher Teaching Hospital, Cairo, Egypt
2 Department of Surgery, Trauma Surgery Section, Clinical Research, Hamad General Hospital, Doha, Qatar
3 Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
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|Date of Submission||26-May-2015|
|Date of Acceptance||08-Feb-2016|
|Date of Web Publication||31-Mar-2016|
| Abstract|| |
Diabetes mellitus (DM) is associated with increased in-hospital morbidity and mortality in patients sustained traumatic injuries. Identification of risk factors of traumatic injuries that lead to hospital admissions and death in DM patients is crucial to set effective preventive strategies. We aimed to conduct a traditional narrative literature review to describe the role of hypoglycemia as a risk factor of driving and fall-related traumatic injuries. DM poses significant burden as a risk factor and predictor of worse outcomes in traumatic injuries. Although there is no consensus on the impact and clear hazards of hyperglycemia in comparison to the hypoglycemia, both extremes of DM need to be carefully addressed and taken into consideration for proper management. Moreover, physicians, patients, and concerned authorities should be aware of all these potential hazards to share and establish the right management plans.
Keywords: Diabetes, fall, hyperglycemia, hypoglycemia, traffic injury, trauma
|How to cite this article:|
El-Menyar A, Mekkodathil A, Al-Thani H. Traumatic injuries in patients with diabetes mellitus. J Emerg Trauma Shock 2016;9:64-72
| Introduction|| |
Diabetes is a major public health problem worldwide.,, A systematic analysis of health examination surveys and epidemiological studies had estimated the global prevalence of diabetes mellitus (DM) to be 347 million in the year 2008. Higher prevalence was reported from South Asia, Latin America, Caribbean, Central Asia, North Africa, and Middle-eastern region. Age-standardized prevalence of DM was 9.8% in adult men and 9.2% in women. The World Health Organization estimated that 3.4 million people died annually from the consequences of DM and 80% of these deaths occur in low- and middle-income countries. Type-2 DM accounted for more than 90–95% of these cases which are usually associated with old age, obesity, physical inactivity, and family history of Type-2 DM or a personal history of gestational diabetes.
Traumatic injuries in DM patients are often associated with increased hospital length of stay and mortality.,,, Motor vehicle crashes (MVCs) and falls are common causes of traumatic injuries and deaths, and hence these two injury mechanisms are of major concern among diabetics. Evidence suggests that poor mobility and cognitive and visual impairment are major risk factors for MVCs in DM patients. Similarly, decreased peripheral nerve function, impaired vision, and renal dysfunction are the main. risk factors attributed to falls. These risk factors are primarily related to hypoglycemic conditions associated with antidiabetic therapy.,,, Herein, we reviewed the current published literature to describe the role of hypoglycemia as a risk factor for driving and fall-related traumatic injuries.
| Methods|| |
A traditional narrative literature review was conducted for peer-reviewed articles published between January 2000 and December 2015. Electronic databases such as PubMed, MEDLINE, and Google Scholar were used for the literature search using keywords such as “Diabetes,” “Hypoglycemia,” “Driving,” “Motor vehicle crash,” “Road traffic injury,” “Falls,” and “Trauma.” Additional manual bibliographic search of identified relevant articles and web searches were also performed. The literature search yielded 131 potential articles; 68 were MVC-related and 63 were fall-related injuries which were reviewed for inclusion. The study included original articles based on hospital data; ten MVC-related ,,,,,,,,, and nine falls-related articles ,,,,,,,, were considered for analysis. The study population in MVC-related studies was mainly drivers in which the driving impairment caused by diabetic complications was addressed. Studies based on self-reported driving impairment, self-reported falls, community-based surveys, and qualitative studies were excluded from the study. All the MVC-related studies were based on case–control analysis, whereas 5 out of 9 fall-related studies had controlled study design. Interestingly, around half of the articles included were originated from the United States [Table 1].
|Table 1: Studies related to traumatic injuries from motor vehicle crashes and falls in diabetic patients|
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| Discussion|| |
Prevalence and outcomes of hypoglycemia
Hypoglycemia refers to the low blood glucose level which is the most significant complication of DM. Severe hypoglycemia while driving may result in neuroglycopenia that disrupts cognitive motor function which increases the risk of injury and mortality. It may also induce adrenergic symptoms such as nervousness, tremor, tiredness, confusion, and retarded mental function.
Hypoglycemia is often associated with intensive insulin treatment in DM patients. A three-fold increase in severe hypoglycemia was reported in intensively treated patients when compared with conventionally treated patients. Approximately 90% of the patients receiving insulin therapy are likely to be experienced hypoglycemic episodes. Insulin therapy in Type-1 DM may cause 10 episodes of symptomatic hypoglycemia per week whereas severe hypoglycemia causing temporary disability occurs at least once in a year. Hypoglycemia is responsible for 2–4% of deaths in DM patients and 6-10% in Type-1 DM. The risk of death is not only limited to the Type-1 DM patients undergoing intensive therapy but also occurs in Type-2 DM. In clinical trials, the prevalence of hypoglycemia in insulin-treated Type-2 DM is estimated to be 70–80%.
Pathophysiology of hypoglycemia
Variations of blood glucose level may influence the cognitive brain function. Brain is the first organ to be affected with deprivation of energy due to hypoglycemia. Under such conditions, a sequence of responses will be initiated to protect the brain. The normal physiologic range of plasma glucose is 4.4–4.7 mmol/L. When it falls below this range, insulin secretion by the pancreatic β-cells will decrease. This favors increased production and decreased utilization of glucose by tissues other than the brain. Lowering of blood glucose level below the physiologic range (3.6–3.9 mmol/L) results in a release of hepatic and epinephrine glucagon which favors glycogenolysis and gluconeogenesis. Consequently, glucose utilization by insulin-sensitive tissues will be limited. Further lowering of glucose concentrations below 2.8–3.0 mmol/L cause neurogenic (sweating, shakiness, tachycardia, anxiety, and sensation of hunger) and neuroglycopenic (weakness, tiredness, or dizziness; inappropriate behavior; confusion; and impaired vision and concentration) symptoms of hypoglycemia. Brain dysfunction (coma and death in extreme cases) will occur at levels <2.8 mmol/L. However, these thresholds shift to higher blood glucose levels in individuals with poorly controlled diabetes and lower concentrations in patients who experience recurrent hypoglycemia. Notably, recurrent hypoglycemia is more likely to occur in patients with well-controlled diabetes or with endogenous hyperinsulinism.
Motor vehicle crash-related injuries in diabetic patients
Several investigators have recognized the association between MVCs and DM.,,, A recent meta-analysis demonstrated that diabetic patients were at 12–19% higher risk of MVCs. Impaired vision caused by retinopathy or cataract formation as well as neuropathy that affects the ability to feel foot pedals contribute to this increased risk of MVCs in DM patients. The risk in Type-1 DM patients is almost twice that of nondiabetic drivers. However, some studies revealed that patients with other medical conditions such as attention deficit/hyperactivity disorder and obstructive sleep apnea are at increased risk of MVCs than DM patients.,
Early reports by Crancer and McMurray  and de Klerk and Armstrong  revealed increased risk of MVCs in young diabetic population. A high-risk ratio of hospital admission was reported in DM drivers as well as pedestrians under the age of 55 years. Head injury was often reported among DM patients of this age group.
Mortality was slightly higher than expected for men; however, no evidence for increased risk of trauma was reported in women and older men with DM. McGwin et al. reported no increased risk of MVCs among elderly DM patients except those with prior history of MVC.
A Norwegian prospective follow-up study reported that 24 out of 1000 MVCs occurred in DM patients. This study included all Norwegians aged 18–69 years (3.1 million) and followed for more than 2 years. Young DM patients (18–34 years) were more likely to be involved in MVC. The authors concluded that there is no evidence for increased risk of MVCs in elderly DM patients.
Case–control studies published in the last 15 years also demonstrated that DM patients are at increased risk for MVCs than non-DM controls., [Table 1]. Laberge-Nadeau et al. demonstrated that diabetic patients controlled for risk exposure have an increased crash risk of 1.76 when compared to nondiabetics. Songer and Dorsey also demonstrated that crash frequency in DM was significantly higher than controls. The study by Laberge-Nadeau et al. included a large sample size of diabetic truck-permit holders whereas Songer and Dorsey study surveyed a smaller group of Type-1 DM patients. In contrast, Joseph et al. demonstrated that MVC involvement within the prior 2 years of the study was the strongest predictor of future MVCs. In this study, DM was not listed as a risk factor, but depression, falls within the previous year, sleep apnea, and lower baseline systolic blood pressure were observed as associated risk factors for MVCs.
Hypoglycemia as a major risk factor for motor vehicle crashes
Hypoglycemia is one of the major risk factors for traumatic injuries in DM patients.,,, It is associated with inefficient driving performance due to compromised psychomotor skills, visuospatial functions, rapid information processing, vigilance, and satisfactory judgment. Therefore, hypoglycemic attacks with giddiness or fainting may lead to attention dysfunction resulted in fatal MVCs., This issue becomes further complicated when some individuals with DM decide to drive when they are aware of their hypoglycemic state.
Insulin-induced hypoglycemia in Type-1 DM during intensive insulin therapy is a common clinical finding. A multinational survey conducted by Cox et al. demonstrated that drivers with Type-1 DM experienced frequent hypoglycemic episodes during MVCs when compared with Type-2 DM drivers. This study added that Type-2 DM patients on insulin treatment had similar risk of MVCs than non-DM individuals. A prospective study by these researchers found 52% of the Type-1 DM drivers had at least one hypoglycemia-related MVCs and 5% reported six or more incidents. These accidents were related to driving duration, history of severe hypoglycemia, and use of insulin pump therapy. A multinational survey by the same group revealed that MVCs among Type-1 DM drivers were associated with frequent hypoglycemic attacks while driving, infrequent blood glucose monitoring before driving, and use of insulin injection therapy instead of pump therapy.
Cox et al. also investigated the relationship between blood glucose level and driving performance in 25 drivers with Type-1 DM. Blood glucose levels were manipulated using intravenous insulin administration. Participants were blind to their actual blood glucose levels. Impaired driving performance was not observed with mild hypoglycemia (mean blood glucose, 3.6 ± 0.33 mmol/l) but was evident for moderate hypoglycemic state (mean level of 2.6 ± 0.28 mmol/l). Global driving performance impairment was observed in 35% of the study participants. Weinger et al. demonstrated that the proportion of patients to judge their safe driving ability decreased with reducing serum glucose levels (70% at 6.7 mmol/l to 22% at 2.2 mmol/l) in patients underwent insulin therapy. The study showed that males and middle-aged subjects considered driving to be safe with hypoglycemia as compared to females and subjects under the age of 25 years.
A simulation study revealed that Type-1 DM drivers adopted corrective measures with self-treatment only when blood glucose reduces below 2.8 mmol/l. Self-treated drivers experienced less neuroglycopenia during driving when compared to untreated drivers. Driving impairment was not associated with age, sex, duration of diabetes, average miles driven in the past years, driving experience, and self-reported crashes.
Redelmeier et al. study adjusted the potential confounders such as blood glucose monitoring, complications, and treatments and then found that the glycosylated hemoglobin (HbA1c) level was lower for DM patients involved in MVCs. They reported 26% increase in the relative risk for MVC for each 1% reduction in HbA1c. History of severe hypoglycemia requiring outside assistance and delayed diagnosis of diabetes were the two other significant risk factors for MVCs. The investigators pointed out that hypoglycemia-related neuroglycopenia disrupts cognitive-motor functioning that impairs driving performance. Cox et al. found that Type-1 DM drivers with a history of recurrent hypoglycemia had more autonomic and neuroglycopenic symptoms than those without any history of recurrent hypoglycemia.
An earlier study identified that previous episode of severe hypoglycemia, history of hypoglycemia while driving, low HbA1c, and absence of blood glucose monitoring prior driving are some of the factors that could increase the risk of MVC in diabetics. Campbell et al. revealed that poor neurocognitive function was associated with multiple recent hypoglycemia-related driving mishaps in Type-1 DM patients.
Oral antidiabetic drugs associated hypoglycemia
Metformin is the first-line drug of choice for the treatment of Type-2 DM. This is often prescribed in overweight and obese patients with normal kidney function. Sulfonylurea is another oral antihyperglycemic drug prescribed for patients who cannot take metformin or if the patient is not overweight. Hypoglycemia was reported nearly 3 times more with sulfonylurea when compared to metformin. Zammitt and Frier demonstrated that hypoglycemia in Type-2 DM is a significant problem associated with insulin or sulfonylurea therapy. Signorovitch et al. observed a significantly higher risk for MVCs in Type-2 DM patients with hypoglycemia receiving antidiabetic drugs other than insulin. Increased hazards for accidents were seen in DM patients younger than 65 years and greater risk of fall in elderly (>65 years). In contrast, Skurtveit et al. showed no difference in MVC incidence between sulfonylurea or metformin users within the general population. They showed that the increased risk for MVCs associated with insulin use was similar to that of drugs used for peptic ulcer and gastroesophageal reflux disease.
Hypoglycemia unawareness as a risk factor for trauma
Awareness of an early hypoglycemic state in drivers with Type-1 DM is crucial to sustain driving performance. The time span between the detection of hypoglycemic symptoms requiring self-treatment and the onset of neuroglycopenia is too short while driving. Neuroglycopenia affects negatively on the ability to make judgments and causes decrements in mean reaction time. Cox et al. showed that less than half (44%) of Type-1 DM drivers were aware of their hypoglycemia, and only one-third of them were involved in self-treatment to avoid poor driving performance.
The physician advice patients who are unaware of hypoglycemia to stop driving until the condition is reversed. If the risk is confirmed, the physician should also consider informing about this condition to the concerned authorities. Therefore, knowledge about hypoglycemia awareness among the healthcare professionals is crucial and requires regular educational newsletters. A Scottish study revealed that 62% of the healthcare professionals believe that insulin-treated drivers should check their blood sugar levels before driving; whereas 13% consider safe to drive with blood glucose <72 mg/dl and 8% did not know that hypoglycemia might affect safe driving. Therefore, facilitating awareness of healthcare professional about the contraindication of driving during hypoglycemic state may improve the hypoglycemia awareness in patients. Harsch et al. reported that nearly half of drivers with Type-1 DM never discussed driving issues with their physicians. However, this issue was more prominent in Type-2 DM as 75% patients have not discussed their conditions with the physician. It has been reported that unawareness of hypoglycemia in Type-1 DM patients was related to increased incidence of MVCs. On the other hand, some investigators considered unawareness of hypoglycemia to be a relevant issue.
Evidence-based driving restrictions in diabetic patients
Considering the risks for MVCs associated with DM, some authorities reviewed their guidelines for driving fitness assessment and implemented some licensing restrictions on drivers known for DM. In some countries, DM patients on insulin therapy are prohibited from driving trucks, heavy goods vehicles, buses, and minibuses. In addition, need for license renewal for DM patients is more frequent than the healthy subjects (<10 years). However, the extent to which DM as a relevant factor for determining driver ability and eligibility to obtain a license is still under discussion.
In an earlier report, epileptic attack and cardiovascular events are considered as the major causes of sudden illness among drivers. Some studies have suggested no incremental risk for road safety by insulin-treated DM patients., Similarly, a retrospective study showed that diabetic drivers treated with insulin and attending clinics had no greater risks for MVCs than nondiabetic subjects. Nearly 31% of insulin-treated DM patients had recognized hypoglycemic symptoms while driving, and only 11.7% reported hypoglycemia as a cause of accident. The register-based prospective study reported a major excess of injuries in insulin-treated patients mainly related to low falls (62.3%). However, this excess was not significant for MVCs as only 15.2% of insulin-treated were involved in MVCs.
Lonnen et al. estimated the annual incidence rate of MVCs for non-DM and DM populations as 1469 and 856 per 100,000 DM patients, respectively. The authors observed nonsignificantly statistical difference in the accident rate between the insulin-treated DM and non-DM subjects. The recent history of severe hypoglycemia irrespective of the type of diabetes or treatment is the most significant factor associated with MVCs.,
Therefore, National Highway Traffic Safety Administration (NHTSA) recommended glycemic evaluation of all DM patients who seeks for a license. Contrarily, the American Diabetes Association (ADA) being a patient advocacy group in the United States opposed the notion of screening of all diabetic patients. They advocated that many people with DM do not experience hypoglycemia because of their treatment regimen. Hypoglycemia is mainly observed in individuals taking insulin or certain classes of oral medications. In addition, NHTSA identified hypoglycemic unawareness to be related with driving incompatibility. This was opposed by ADA, arguing that a 2–3-week period of careful avoidance of hypoglycemia is enough to regain hypoglycemic awareness.,
Moreover, a person with hypoglycemic unawareness can drive safely with precautions, such as blood glucose monitoring before driving and continue to test on hourly basis during longer drives. It has been recommended that drivers should interrupt their trip if they feel symptoms nearing hypoglycemia or the blood sugar reduces below 4 mmol/dl., In general, it is agreed that DM patients are at increased risk for MVCs as hypoglycemia causes driving impairment, retinopathy, or cataract (impaired vision) and diabetic neuropathy affecting the ability to feel foot pedals. Therefore, it is important to minimize MVCs in DM patients through education, public awareness, law enforcement, and adopting new technology. For instance, Kerr and Olateju proposed the development of in-vehicle medical monitoring which will have potential impact on safe driving.
Diabetes and risk of fall-related injuries
Falls remain a major public health problem with significant morbidity and mortality, especially in the elderly population. According to WHO (2007), fall can be defined as “inadvertently coming to rest on the ground, floor, or other lower level, excluding intentional change in position to rest in furniture, wall, or other objects.” The probability of traumatic injury in a fall is determined by the distance of the fall, orientation on falling, landing surface, and whether the fall was broken. Falls from heights are common in the occupational settings which depend on faulty equipment (ladders) and human factors (inattention and intoxication). Fall-related head, spine, and extremities injuries are more frequent and even low-level falls may result in serious head injuries.,,, Falls from a height of more than 20 feet usually triaged in trauma centers, and approximately 10% of all falls resulted in fractures, lacerations, head injuries, and even death.
Inadequate glycemic control as well as insulin use in diabetics increases the risk of fall-related fractures. Duration of DM and presence of complications are also important factors for additional risk of injuries. Microvascular complications associated with DM also increases the risk of falls in elder population. Notably, peripheral neuropathy that leads to postural instability is an independent risk factor for falls. Further, diabetic retinopathy is the leading cause of impaired vision which increases the risk of falls. In addition, renal dysfunction was also identified as a risk factor of falls.
Elderly individuals are more likely to have DM which increases the risk of falls.,,,, Together with poor bone health, microvascular complications of DM may result in devastating consequences such as bone fracture, deteriorating quality of life, and among elderly population. An earlier study showed that females above 60 years of age with diabetes are more likely to fall (1.6 times) as compared to nondiabetic females. Another prospective cohort study showed an increased risk of falls in elderly diabetic patients over 60 years of age. The incidence rate of falls during the mean follow-up period (299 days) was significantly higher in patients with DM as compared to non-DM patients (78% vs. 30%, P < 0.001).
Hypoglycemia and risk of falls
Insulin therapy has been identified as a risk factor for falls in the elderly population along with other risk factors such as age, imbalance, prior history of cardiovascular disease, osteoarthritis, peripheral neuropathy, higher body mass index, and poor performance of lower extremities.,,
Johnston et al. conducted a case–control study which compared of 344,274 DM patients with hypoglycemia and 16,936 DM patients without hypoglycemia. The authors found that hypoglycemic events were independently associated with an increased risk of fall-related fractures in DM patients. Similarly, Yau et al. reported that DM patients underwent insulin therapy were at increased risk of fall-related traumatic injuries than those without diabetes. Kennedy et al. attributed the increased risk of accidents in DM patients to falls from a short distance (<2 m). Insulin-treated DM patients had 62.3% excess of risk for accidents in comparison to 47.1% in control population (P < 0.01).
Signorovitch et al. also showed increased hazards for accidental falls among Type-2 DM population. The study revealed that in Type-2 DM patients receiving noninsulin drugs, hypoglycemia was associated with a significantly higher risk of falls leading to hospital visits. However, Schwartz et al. demonstrated that oral hypoglycemic medications were not associated with frequent falls in elderly population. Rather, it was HbA1C level (≤6%) that increases the risk of falls in these patients. The increased risk of fall-related injuries in older DM patients was also evident in another study suggesting that the risk was mainly associated with poor glycemic control. A recent, retrospective, cohort study also demonstrated worst fall-related outcomes in elderly patients with Type-2 DM. Kachroo et al. reported that hypoglycemic patients had elevated risk for head injuries, fall-related outcomes of fractures, hospital admissions, and longer duration of care.
Fu et al. recently showed an increased risk for hypoglycemia-related hospitalizations in older patients using both insulin and sulfonylurea drugs. It has been demonstrated that Type-2 DM was associated with reduced mobility and visual acuity and these patients are at increased risk for falls even at young age with shorter duration of DM. In line with this study, Lu et al. reported an increased risk of falls in patients with DM. In addition, the excessive risk for traumatic injuries was more evident in individuals younger than 65 years of age. This comparative study included 31,049 DM patients in each group such as DM without severe hypoglycemia, DM with severe hypoglycemia, and non-DM patients. The study demonstrated that age, sulfonylurea use, insulin use, and renal disease predict hospitalizations associated with hypoglycemia. Vaz et al. found postural control and functional strength deficits in DM patients when compared with non-DM subjects. These deficits were evident in DM patients regardless of the presence of diabetic neuropathy.
Although hyperglycemia is related to cognitive, visual, balance, and mobility impairments, the evidence for linking hyperglycemia to fall-related injuries is limited due to lack of controlled clinical trials.
Several study designs adopted to establish the relationship between DM and MVCs or fall-related injuries have potential strengths and biases. The advantage of retrospective cohort studies is that the exposure to risk factors is documented prior the occurrence of the outcome. However, these observational studies often depend on self-reporting and therefore fail to distinguish between types of diabetes. Further, in observational studies, only association could be inferred from the results but not the causality. Therefore, the observed association between DM and MVCs or fall-related injuries may have been biased by unknown confounding factors. On the other hand, experimental studies such as controlled clinical trials subjects are randomly enrolled either to the study or control group which minimize selection bias and also control for other confounding factors right from the beginning. Hence, lack of randomized controlled clinical trials is an important barrier to establish these associations. Hence, the risks for MVCs or fall-related injuries in hyperglycemia were inadequately addressed due to lack of comparative data.
The incidence of MVCs increases with increasing number of road users over time and even a decade old study may reflect findings that are very much different from today. In addition, 20–30 years old studies may not represent current practices on diabetes management. Therefore, we assume even a decade old study may not capture the rapidly increasing number of road users and fast advancements in diabetic management. Therefore, it is clearly seen that in many countries, the incidence of both DM and MVC is increasing exponentially which poses a great challenge for healthcare authorities and resources.,,,
Another limitation is the lack of consensus on the definition of falls in earlier studies. Most investigators fail to specify the operational definition of falls. In addition, interpretation of falls was left to study subjects and consequently the validity of studies is often challenging. The most vulnerable group for the occurrence of falls is elderly population which describes its occurrence due to loss of balance. Meanwhile, healthcare professionals refer to the consequence of falling such as injury and reduced quality of life. It is clear that even a small change in definition may have high impact on the findings of a study. Therefore, an operational definition of falls is crucial along with explicit inclusion and exclusion criteria.
Most studies used a retrospective design and primarily focused on elderly population. Knowledge of the symptoms of hypoglycemia in this population is often poor. In addition, mild hypoglycemia remains unrecognized by patients, relatives, or healthcare providers. Moreover, underreporting and recall bias among elderly are other issues limiting the observational findings. The impact of hyperglycemia during hospitalization also needs to be addressed as it may alter the clinical picture through development of complications such as severe infection, cardiovascular emergencies, and acidosis. Despite high prevalence of DM (17%) and greater burden of road traffic accidents and fatalities in our region, there are only a few published studies that highlighted the impact of DM on the trauma.
| Conclusions|| |
DM poses significant burden as a risk factor for trauma and is considered a predictor of worse outcomes in traumatic injuries. Hypoglycemia is one of the major risk factors for traumatic injuries in DM patients. It is associated with inefficient driving performance due to compromised psychomotor skills, visuospatial functions, rapid information processing, vigilance, and satisfactory judgment. In addition, falls remain a major public health problem with significant morbidity and mortality, especially in the elderly population. In general, it is agreed that patients with DM are at increased risk for traumatic injuries (MVCs and falls) due to neurogenic (sweating, shakiness, tachycardia, anxiety, and sensation of hunger) and neuroglycopenic (weakness, tiredness, or dizziness; inappropriate behavior; confusion; and impaired vision and concentration) symptoms of hypoglycemia. Therefore, it is important to minimize the incidence of MVCs and falls in DM patients through education of health care professionals, public awareness, law enforcement, adopting newer technology (in-vehicle medical monitoring devices) and focuses injury prevention programs for geriatric population. Although there is no consensus on the impact of hyperglycemia in trauma patients as compared to the clear hazards of hypoglycemia, both extremes of diabetes need to be carefully addressed and managed. The unfavorable impact of hyperglycemia may be more evident during hospitalization. Moreover, physicians, patients, and authorities should be aware of all the potential risk and should contribute in establishing effective injury prevention strategies.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al.
National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: Systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants. Lancet 2011;378:31-40.
Ahmad R, Cherry RA, Lendel I, Mauger DT, Service SL, Texter LJ, et al.
Increased hospital morbidity among trauma patients with diabetes mellitus compared with age- and injury severity score-matched control subjects. Arch Surg 2007;142:613-8.
Liu-DeRyke X, Collingridge DS, Orme J, Roller D, Zurasky J, Rhoney DH. Clinical impact of early hyperglycemia during acute phase of traumatic brain injury. Neurocrit Care 2009;11:151-7.
Griesdale DE, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A, et al.
Intensive insulin therapy and mortality among critically ill patients: A meta-analysis including NICE-SUGAR study data. CMAJ 2009;180:821-7.
Ley EJ, Srour MK, Clond MA, Barnajian M, Tillou A, Mirocha J, et al.
Diabetic patients with traumatic brain injury: Insulin deficiency is associated with increased mortality. J Trauma 2011;70:1141-4.
Asim M, El-Menyar A, Al-Thani H, Abdelrahman H, Zarour A, Latifi R. Blunt traumatic injury in the Arab Middle Eastern populations. J Emerg Trauma Shock 2014;7:88-96.
Seeger R, Lehmann R. Driving ability and fitness to drive in people with diabetes mellitus. Ther Umsch 2011;68:249-52.
Schwartz AV, Hillier TA, Sellmeyer DE, Resnick HE, Gregg E, Ensrud KE, et al.
Older women with diabetes have a higher risk of falls: A prospective study. Diabetes Care 2002;25:1749-54.
Briscoe VJ, Davis SN. Hypoglycemia in type 1 and type 2 diabetes: Physiology, pathophysiology, and management. Clin Diabetes 2006;24:115-21.
Workgroup on Hypoglycemia, American Diabetes Association. Defining and reporting hypoglycemia in diabetes: A report from the American Diabetes Association Workgroup on Hypoglycemia. Diabetes Care 2005;28:1245-9.
Ahmed AA. Hypoglycemia and safe driving. Ann Saudi Med 2010;30:464-7.
Hypoglycemia in the diabetes control and complications trial. The Diabetes Control and Complications Trial Research Group. Diabetes 1997;46:271-86.
Laberge-Nadeau C, Dionne G, Ekoé JM, Hamet P, Desjardins D, Messier S, et al.
Impact of diabetes on crash risks of truck-permit holders and commercial drivers. Diabetes Care 2000;23:612-7
Kennedy RL, Henry J, Chapman AJ, Nayar R, Grant P, Morris AD. Accidents in patients with insulin-treated diabetes: Increased risk of low-impact falls but not motor vehicle crashes – A prospective register-based study. J Trauma 2002;52:660-6.
Cox DJ, Penberthy JK, Zrebiec J, Weinger K, Aikens JE, Frier B, et al.
Diabetes and driving mishaps: Frequency and correlations from a multinational survey. Diabetes Care 2003;26:2329-34.
Songer TJ, Dorsey RR. High risk characteristics for motor vehicle crashes in persons with diabetes by age. Annu Proc Assoc Adv Automot Med 2006;50:335-51.
Lonnen KF, Powell RJ, Taylor D, Shore AC, MacLeod KM. Road traffic accidents and diabetes: Insulin use does not determine risk. Diabet Med 2008;25:578-84.
Skurtveit S, Strøm H, Skrivarhaug T, Mørland J, Bramness JG, Engeland A. Road traffic accident risk in patients with diabetes mellitus receiving blood glucose-lowering drugs. Prospective follow-up study. Diabet Med 2009;26:404-8.
Redelmeier DA, Kenshole AB, Ray JG. Motor vehicle crashes in diabetic patients with tight glycemic control: A population-based case control analysis. PLoS Med 2009;6:e1000192.
Cox DJ, Kovatchev BP, Anderson SM, Clarke WL, Gonder-Frederick LA. Type 1 diabetic drivers with and without a history of recurrent hypoglycemia-related driving mishaps: Physiological and performance differences during euglycemia and the induction of hypoglycemia. Diabetes Care 2010;33:2430-5.
Campbell LK, Gonder-Frederick LA, Broshek DK, Kovatchev BP, Anderson S, Clarke WL, et al.
Neurocognitive differences between drivers with type 1 diabetes with and without a recent history of recurrent driving mishaps. Int J Diabetes Mellit 2010;2:73-7.
Signorovitch JE, Macaulay D, Diener M, Yan Y, Wu EQ, Gruenberger JB, et al.
Hypoglycaemia and accident risk in people with type 2 diabetes mellitus treated with non-insulin antidiabetes drugs. Diabetes Obes Metab 2013;15:335-41.
Schwartz AV, Vittinghoff E, Sellmeyer DE, Feingold KR, de Rekeneire N, Strotmeyer ES, et al.
Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care 2008;31:391-6.
Johnston SS, Conner C, Aagren M, Ruiz K, Bouchard J. Association between hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes. Diabetes Obes Metab 2012;14:634-43.
Oliveira PP, Fachin SM, Tozatti J, Ferreira MC, Marinheiro LP. Comparative analysis of risk for falls in patients with and without type 2 diabetes mellitus. Rev Assoc Med Bras 2012;58:234-9.
Vaz MM, Costa GC, Reis JG, Junior WM, Albuquerque de Paula FJ, Abreu DC. Postural control and functional strength in patients with type 2 diabetes mellitus with and without peripheral neuropathy. Arch Phys Med Rehabil 2013;94:2465-70.
Yau RK, Strotmeyer ES, Resnick HE, Sellmeyer DE, Feingold KR, Cauley JA, et al.
Diabetes and risk of hospitalized fall injury among older adults. Diabetes Care 2013;36:3985-91.
Fu H, Xie W, Curtis B, Schuster D. Identifying factors associated with hypoglycemia-related hospitalizations among elderly patients with T2DM in the US: A novel approach using influential variable analysis. Curr Med Res Opin 2014;30:1787-93.
Lu CL, Hsu PC, Shen HN, Chang YH, Chen HF, Li CY. Association between history of severe hypoglycemia and risk of falls in younger and older patients with diabetes. Medicine (Baltimore) 2015;94:e1339.
Zhao Y, Kachroo S, Kawabata H, Colilla S, Mukherjee J, Fonseca V, et al.
Association between hypoglycemia and fall-related fractures and health care utilization in older veterans with type 2 diabetes. Endocr Pract 2016;22:196-204.
Kachroo S, Kawabata H, Colilla S, Shi L, Zhao Y, Mukherjee J, et al.
Association between hypoglycemia and fall-related events in type 2 diabetes mellitus: Analysis of a U.S. commercial database. J Manag Care Spec Pharm 2015;21:243-53.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:837-53.
Sprague JE, Arbeláez AM. Glucose counterregulatory responses to hypoglycemia. Pediatr Endocrinol Rev 2011;9:463-73.
Herner B, Smedby B, Ysander L. Sudden illness as a cause of motor-vehicle accidents. Br J Ind Med 1966;23:37-41.
Crancer JA, McMurray L. Accident and violation rates of Washington's medically restricted drivers. J Am Med Assoc 1968;205:272-6.
Leyshon GE, Elliott RW, Lyons J, Francis HW. Diabetics and motorway crashes. Br Med J 1972;2:405.
de Klerk NH, Armstrong BK. Admission to hospital for road trauma in patients with diabetes mellitus. J Epidemiol Community Health 1983;37:232-7.
ECRI. Diabetes and Commercial Motor Vehicle Safety (Federal Motor Carrier Safety Administration). June 2011 Update. Plymouth Meeting. Pennsylvania: ECRI; 2011.
Cox DJ, Singh H, Lorber D. Diabetes and driving safety: Science, ethics, legality and practice. Am J Med Sci 2013;345:263-5.
Jerome L, Habinski L, Segal A. Attention-deficit/hyperactivity disorder (ADHD) and driving risk: A review of the literature and a methodological critique. Curr Psychiatry Rep 2006;8:416-26.
Tregear S, Reston J, Schoelles K, Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: Systematic review and meta-analysis. J Clin Sleep Med 2009;5:573-81.
McGwin G Jr., Sims RV, Pulley L, Roseman JM. Diabetes and automobile crashes in the elderly. A population-based case-control study. Diabetes Care 1999;22:220-7.
Joseph PG, O'Donnell MJ, Teo KK, Gao P, Anderson C, Probstfield JL, et al.
The mini-mental state examination, clinical factors, and motor vehicle crash risk. J Am Geriatr Soc 2014;62:1419-26.
Cox DJ, Gonder-Frederick L, Clarke W. Driving decrements in type I diabetes during moderate hypoglycemia. Diabetes 1993;42:239-43.
Cox DJ, Gonder-Frederick LA, Kovatchev BP, Julian DM, Clarke WL. Progressive hypoglycemia's impact on driving simulation performance. Occurrence, awareness and correction. Diabetes Care 2000;23:163-70.
McAulay V, Deary IJ, Ferguson SC, Frier BM. Acute hypoglycemia in humans causes attentional dysfunction while nonverbal intelligence is preserved. Diabetes Care 2001;24:1745-50.
Cox DJ, Kovatchev B, Vandecar K, Gonder-Frederick L, Ritterband L, Clarke W. Hypoglycemia preceding fatal car collisions. Diabetes Care 2006;29:467-8.
Kerr D, Olateju T. Driving with diabetes in the future: In-vehicle medical monitoring. J Diabetes Sci Technol 2010;4:464-9.
Clarke WL, Cox DJ, Gonder-Frederick LA, Kovatchev B. Hypoglycemia and the decision to drive a motor vehicle by persons with diabetes. JAMA 1999;282:750-4.
Cox DJ, Ford D, Gonder-Frederick L, Clarke W, Mazze R, Weinger K, et al.
Driving mishaps among individuals with type 1 diabetes: A prospective study. Diabetes Care 2009;32:2177-80.
Weinger K, Kinsley BT, Levy CJ, Bajaj M, Simonson DC, Cox DJ, et al.
The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus. Am J Med 1999;107:246-53.
Cox DJ, Gonder-Frederick LA, Kovatchev BP, Clarke WL. Self-treatment of hypoglycemia while driving. Diabetes Res Clin Pract 2001;54:17-26.
Inkster B, Frier BM. Diabetes and driving. Diabetes Obes Metab 2013;15:775-83.
Rojas LB, Gomes MB. Metformin: An old but still the best treatment for type 2 diabetes. Diabetol Metab Syndr 2013;5:6.
Harsch IA, Stocker S, Radespiel-Tröger M, Hahn EG, Konturek PC, Ficker JH, et al.
Traffic hypoglycaemias and accidents in patients with diabetes mellitus treated with different antidiabetic regimens. J Intern Med 2002;252:352-60.
Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes: Pathophysiology, frequency, and effects of different treatment modalities. Diabetes Care 2005;28:2948-61.
Watson WA, Currie T, Lemon JS, Gold AE. Driving and insulin-treated diabetes: Who knows the rules and recommendations? Pract Diabetes Int 2004;24:201-6.
Eadington DW, Frier BM. Type 1 diabetes and driving experience: An eight-year cohort study. Diabet Med 1989;6:137-41.
American Diabetes Association, Lorber D, Anderson J, Arent S, Cox DJ, Frier BM, Greene MA, et al
. Diabetes Care 2013;36 Suppl 1:S80-5.
Ian Hindmarch: Drugs, driving and traffic safety. Hum Psychopharmacol Clin Exp 2010;25:191. (Book review). DOI: 10.1002/hup.1092.
Stevens AB, Roberts M, McKane R, Atkinson AB, Bell PM, Hayes JR. Motor vehicle driving among diabetics taking insulin and non-diabetics. BMJ 1989;299:591-5.
American Diabetes Association. Standards of medical care in diabetes-2012 (Position Statement). Diabetes Care 2012;35:S11-63.
El-Menyar A, El-Hennawy H, Al-Thani H, Asim M, Abdelrahman H, Zarour A, et al.
Traumatic injury among females: Does gender matter? J Trauma Manag Outcomes 2014;8:8.
Tuma MA, Acerra JR, El-Menyar A, Al-Thani H, Al-Hassani A, Recicar JF, et al.
Epidemiology of workplace-related fall from height and cost of trauma care in Qatar. Int J Crit Illn Inj Sci 2013;3:3-7.
Al-Thani H, El-Menyar A, Abdelrahman H, Zarour A, Consunji R, Peralta R, et al.
Workplace-related traumatic injuries: Insights from a rapidly developing Middle Eastern country. J Environ Public Health 2014;2014:430832.
Kennedy RL, Grant PT, Blackwell D. Low-impact falls: Demands on a system of trauma management, prediction of outcome, and influence of comorbidities. J Trauma 2001;51:717-24.
Dede AD, Tournis S, Dontas I, Trovas G. Type 2 diabetes mellitus and fracture risk. Metabolism 2014;63:1480-90.
Berlie HD, Garwood CL. Diabetes medications related to an increased risk of falls and fall-related morbidity in the elderly. Ann Pharmacother 2010;44:712-7.
Volpato S, Leveille SG, Blaum C, Fried LP, Guralnik JM. Risk factors for falls in older disabled women with diabetes: The women's health and aging study. J Gerontol A Biol Sci Med Sci 2005;60:1539-45.
Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, et al.
Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): Prospective observational study. BMJ 2000;321:412-9.
Dominguez LJ, Paolisso G, Barbagallo M. Glucose control in the older patient: From intensive, to effective and safe. Aging Clin Exp Res 2010;22:274-80.
Hope SV, Strain WD. Hypoglycemia in the elderly. Diabet Hypoglycemia 2013;6:3-10.
Gregg EW, Beckles GL, Williamson DF, Leveille SG, Langlois JA, Engelgau MM, et al.
Diabetes and physical disability among older U.S. adults. Diabetes Care 2000;23:1272-7.
Maurer MS, Burcham J, Cheng H. Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility. J Gerontol A Biol Sci Med Sci 2005;60:1157-62.
El-Menyar A, Al-Thani H, Mekkodathil A, Mohammed S, Singh R, AlBinAli H, et al.
Diabetes mellitus in patients presenting with cardiovascular events: Descriptive analysis from a tertiary heart hospital over a 22-year period. Curr Vasc Pharmacol 2015;13:624-36.
El-Menyar A, Al Thani H, Hussein A, Sadek A, Sharaf A, Al Suwaidi J. Diabetic retinopathy: A new predictor in patients on regular hemodialysis. Curr Med Res Opin 2012;28:999-1055.
Al Suwaidi J, Zubaid M, El-Menyar AA, Singh R, Rashed W, Ridha M, et al.
Prevalence of the metabolic syndrome in patients with acute coronary syndrome in six middle eastern countries. J Clin Hypertens (Greenwich) 2010;12:890-9.
Department of Clinical Medicine, Weill Cornell Medical College; Department of Surgery, Trauma Surgery Section, Clinical Research, Hamad General Hospital, Doha; Department of Internal Medicine, Ahmed Maher Teaching Hospital, Cairo, Egypt
Source of Support: None, Conflict of Interest: None
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