Challenges and
Defenses II
Claims
and Responses to Common Challenges and Defenses in Driving While Impaired Cases
The National Traffic Law Center is a
program of the National District Attorneys Association. This document was
prepared under Cooperative Agreement Number DTNH22-05-H-05166 from the U.S.
Department of Transportation, National Highway Traffic Safety Administration.
Points of view or opinions in this document are those of the authors and do not
necessarily represent the official position or policies of the Department of
Transportation, NHTSA, or the National District Attorneys Association. i
TABLE OF
CONTENTS Acknowledgements ...........................................................................................................iii
Introduction
.......................................................................................................................
v Confronting Defense Issues in Prescription and Over-the-Counter Drug DUIs
......... 1 The defendant is not guilty because he was
using an over-the- counter or lawfully prescribed
drug...............................................................................
1 The defendant was mistakenly or involuntarily intoxicated.
......................................... 2 The quantitative levels of the drug
are below the therapeutic dose and therefore not capable of causing impairment.
............................................................... 3 The defendant
was unconscious or cannot remember what happened due to the effects of Ambien
and therefore not legally responsible for his actions. ...................... 4
Jurors may empathize with the defendant about the use of a legal drug.
...................... 6 Breath Testing Results: Defense Alternative
Explanations .......................................... 8 Diabetes
.........................................................................................................................
8 Defendant has diabetes
..........................................................................................
11 GERD (Gastroesophageal Reflux Disease)
................................................................. 13 Defendant
has GERD, which created an artificially high reading or inaccurate result on
the breath-testing instrument. ................................................
13 Challenges to Blood Draws and Test Results
................................................................ 17 The
swab used to cleanse the skin prior to the blood draw contained alcohol and
contaminated the sample. ........................................................
17 The presence of clots in the blood sample artificially increased the
reported alcohol concentration.
...................................................................................
18 ii Challenges to Blood Draws and Test Results (cont.) Improper
package and storage of the blood caused the development of yeast (Candida
albican,) artificially increasing the reported alcohol concentration
(fermentation).
..........................................................................19
The State has not demonstrated that the gray top blood tubes used to draw the
blood contained the proper chemicals to ensure a valid analysis.
...............................20 Serum and plasma have higher alcohol contents
than whole blood. Because BAC is measured in terms of whole blood, the serum
and plasma results are misleading.
.....................................................................................20
The blood testing instrument measured and reported something other than ethyl alcohol
and this artificially increased the reported BAC.
............................................21 The tubes used to collect the
blood were expired, so the results cannot be trusted.
.........................................................................................................22
Arterial blood is a much better indicator of actual BAC levels when compared to
venous blood.
..........................................................................................22
The gray top tubes used to collect the blood samples were not FDA-approved.
Therefore, the jury and/or judge should not trust the results.
......................................23 Measurement Uncertainty
...............................................................................................24
The chemical test results without an accompanying uncertainty measurement
value are not scientifically reliable.
.............................................................................25
The bare chemical test result without a confidence interval misleads the jury.
...........26 Challenges to the Source Code of Breath Testing Instruments
...................................28 The defense needs the source code in
order to be assured of the accuracy of the breath test instrument and its
results. .................................................28 The defendant has
a right to discovery of the source code and the prosecution must produce it.
........................................................................................30
Resources and References
...............................................................................................32
iii
ACKNOWLEDGMENTS
This guide was created by the National Traffic Law Center of
the National District Attorneys Association and is the result of a
collaborative effort of the following traffic safety professionals:
L. Beth Barnes, Arizona Traffic Safety Resource Prosecutor,
Assistant City Prosecutor, Phoenix, Arizona
Edward A. Berkovich, Utah Traffic Safety/Domestic Violence
Resource Prosecutor
Brian Chodrow, Program Analyst, Impaired Driving Division,
National Highway Traffic Safety Administration
Daniel M. Fox, California Traffic Safety Resource Prosecutor
Moses Garcia, Washington Traffic Safety Resource Prosecutor
William Lemons, Minnesota Traffic Safety Resource Prosecutor
Mark M. Neil, Senior Attorney, National Traffic Law Center of
the National District Attorneys Association
Jared Olson, Idaho Traffic Safety Resource Prosecutor
R. Alexander Robinson, former Staff Attorney, National
Traffic Law Center of the
National District Attorneys Association
Joanne E. Thomka, Program Director, National Traffic Law
Center of the National
District Attorneys Association iv v
INTRODUCTION
DUI cases have become some of the most complex in the
criminal justice system. As a result, defense challenges are being raised more
frequently and are more procedural and scientific in nature. These challenges
range from the initial law enforcement stop of the vehicle to the testing
procedures used to determine alcohol concentration in blood, breath, and urine
samples to possible alternative explanations for those results. This monograph
was developed to assist prosecutors and law enforcement in understanding the
nature of these challenges. It will assist prosecutors in formulating effective
responses to these newer challenges and defenses and include drugged driving,
alternative explanations to breath test results, blood draws and testing,
scientific uncertainty, and computer source code discovery requests.
The National Traffic Law Center previously published Overcoming
Impaired Driving Defenses, thanks to a contribution from a charitable
foundation, discussing such defense challenges as invalid traffic stops,
arrests and Miranda issues, as well as common trial tactics of attacking the
investigation, such as driving observations, personal contact, field sobriety
tests and breath testing. That monograph may be downloaded from the National
District Attorneys Association Web site at www.ndaa.org.
The
terms DUI (driving under the influence), DWI (driving while intoxicated or
impaired) and OUI (operating under the influence) are considered
interchangeable for the purposes of this publication. vi 1
Confronting
Defense Issues in Prescription or Over-the-Counter Drug DUIs
When the topic of “drugged driving” comes up, most people
think almost exclusively of the use of illicit or controlled substances by
someone operating a motor vehicle. However, prescription or over-the-counter
(OTC) drugs also impair a person’s ability to operate a motor vehicle in a safe
and prudent manner. Both prescription and OTC drugs are known to cause mental
and physical impairment, especially when multiple drugs are used in combination
or drugs are mixed with alcohol.
CLAIM: The defendant is not guilty because he was
using an over-the-counter or lawfully prescribed drug.
RESPONSE: Entitlement is not a
legally recognized defense.
An entitlement defense encompasses the mens rea of “I
didn’t do anything wrong, or at least I didn’t know that I was doing anything
wrong.” It amounts to the defendant offering a seemingly valid excuse for his
behavior. An entitlement defense occurs when the defendant presents a valid prescription
or OTC purchase to the jury as justification for the medications found in his
system. In doing so, the defendant asserts to the jury that he has done nothing
unlawful by consuming the medicine and driving. Dissected: the defendant
focuses the jury’s attention on the reason for the impairment and not on his decision
to drive. He can justify the impairment but the prosecutor needs to point out
that the defendant still can’t justify the decision to drive while impaired.
How a defendant came to be impaired is not an element of
proof in a DUI case. However, the prosecutor should make strategic and tactical
efforts to satisfy a jury’s curiosity of how impairment occurred. The
prosecutor must also educate the jury that they must decide whether the defendant
was impaired at the time of driving and not how he be-came impaired. It matters
not that the defendant had a prescription or bought the medication over the
counter. By so doing, this will negate the entitlement defense.
If the defendant alleges he possessed a prescription for the
drug found in his sys- tem, the prosecutor may be able to request the
defendant’s prescription records as part of pretrial discovery. If this type of
discovery is allowed in the jurisdiction, the prosecutor should request the
names and contact information of all doctors writing prescriptions for the
defendant and a record of all the filled prescriptions at the time of the
crime. The prosecution should actively counter any claim of doctor-patient
confidentiality and HIPAA privacy by pointing out the appropriate HIPAA
exception statutes (see 45CFR164.512) and the fact that the defendant’s intent
to present such a defense creates an implied waiver of medical confidentiality.
This information may help the prosecutor in answering the following questions:
• What was the length and depth of the defendant’s experience
with the drugs found in his system at the time of arrest?
• Was the medicine being used in conjunction with other
medicines? 2
• Did the
defendant follow the directives of his doctor in taking the medication (dosage,
timing, accompaniment, etc.)?
• Did the quantity of the medicine and its metabolites in the
defendant’s system correlate to a proper dosage of the medicine in agreement
with the defendant’s prescription(s)?
• Did the medicine come with explicit warning labels?
• Did the defendant receive any warnings from the doctor(s)
or the pharmacist?
• Was the defendant’s long-term consumption pattern
consistent, and did it keep pace with the doctor’s directives and prescription
quantities?
• Did the defendant receive prescriptions from more than one
health care provider? If so, were the providers aware of each other?
CLAIM: The defendant was mistakenly or
involuntarily intoxicated.
RESPONSE: The defendant drove
impaired.
The entitlement defense borrows from and mixes elements of
the defenses of mistake and involuntary intoxication. By asserting a privilege
to take the medicine, the defendant implies that the impairment occurred
unintentionally - that it was a mistake. It also implies a lack of knowledge as
to the impairing nature of the substance - that the intoxication was
involuntary: “I didn’t mean to do it” and “I didn’t know it would do that to
me.”
To prevail on a mistake defense, the defendant must convince
the jury that his belief that he was not impaired was reasonable. The defendant’s
mistaken belief that a prescription entitled him to drive while under the
influence is not the fact in question. Nor is the defendant’s mistaken belief
that he wasn’t violating the law. He must be mistaken as to the fact of his
impaired state and his belief has to be both actual and reasonable. True,
impaired people often believe that they are okay to drive. However, most
jurors, when presented with the facts and observed behavior of the defendant by
law enforcement officers, often find such beliefs to be unreasonable. One need
only analogize this to an alcohol DUI to see how rigorous a burden the
defendant faces in this type of defense.
Similarly, in drugged driving cases, the defense of
involuntary intoxication contains two key flaws: (1) the crime of DUI does not
require proof that the defendant in- tended to become intoxicated, and (2)
involuntary refers to the act of consuming the in- toxicant, not the outcome of
the consumption.
A person voluntarily consuming a substance with knowledge
that it can impair does not give rise to the defense of involuntary
intoxication. Involuntary intoxication arises when a person unknowingly
consumes an intoxicant, usually as a result of fraud, trickery, or deceit.
Defendants may be hard pressed to present credible evidence that the drug
pro-cured over the counter or as a result of visiting a healthcare practitioner
and then a pharmacy was subsequently consumed involuntarily. 3
Some defendants
seek to preserve the viability of the involuntary intoxication defense by
asserting ignorance as to the intoxicating properties of the drug. This type of
defense is often presented in argument without any testimony from the defendant.
Unless the defendant testifies personally as to their subjective belief, the
defense attorney should not be permitted to argue this defense at any point in
the case.
If the defendant does testify, the prosecutor should be
prepared to confront the reasonableness of the defendant’s ignorance. The prosecutor
should gather as much evidence as possible pertaining to the medical reason for
the prescription (pain relief, muscle relaxation, insomnia, etc.) or OTC
medicine, any warnings that accompany the medicine (packaging, inserts,
doctor’s statements, pharmacist advisements, etc.) as well as the defendant’s
past experience with the medicine.
CLAIM: The quantitative levels of the drug are
below the therapeutic dose and therefore not capable of causing impairment.
RESPONSE: Therapeutic doses of
medication may equate to impairment.
Typically, this defense arises when the defendant introduces
evidence that the amount of the drug found in their system would not produce
impairment. The defense is raised almost exclusively where the quantitative
level of the drug measures near or below the minimum therapeutic dosage level.
Many jurors may be under the misconception that taking a prescription or OTC
drug as part of a medical regime will make a person “all better” or normal. The
concept that these drugs might cause impairment may be out- side their daily
understanding of drugs and how they work.
To effectively combat this defense and jurors’ lack of
understanding, a prosecutor needs a working knowledge of the drug and its
effects. A drug handbook, the Physician Desk Reference (PDR) or a similar
publication can be a good source for this information. Likewise, procure any
available pharmacy literature, inserts and packaging that come with a
prescription or OTC drugs.
If available, speak with a toxicologist about the effects of
the drug, what the quantitative amount means and what the lab protocols were
for testing. Review with the toxicologist whether the therapeutic or even lower
dosage of the drug could have an impairing effect and what those effects may
be. Then review the test results specific to the defendant and what, if any,
impairing effect that amount may have. Some drugs, by their very nature and
even when taken properly, can cause impairment for driving. For ex- ample,
sleep aids taken at a therapeutic level cause sleep.
If possible, involve a drug recognition expert (DRE) in the
case. A DRE’s ability to describe drug impairment and driving behavior may
significantly assist in the presentation of the prosecutor’s case. The
information obtained from the toxicologist can be tied together with the DRE
assessment and signs of impairment observed by the law enforcement officers and
others. 4
CLAIM: The
defendant was unconscious or cannot remember what happened due to the effects
of Ambien and therefore not legally responsible for his actions.
RESPONSE: Amnesia by the
defendant is not unconsciousness and is not a legal defense.
Ambien is zolpidem tartrate,1 which is marketed as both
Ambien and Ambien CR. Both promote the rapid onset of sleep (usually within 20
to 30 minutes of consumption). Ambien CR (controlled release) is designed to
assist a person to fall asleep and stay asleep. Ambien CR is designed to wear
off within six or seven hours and thereby permit the person to awaken normally.
Understanding the Ambien Defense
The crux of the Ambien defense is that the defendant was
unconscious, and thus unable to make a conscious decision, at the time he chose
to drive. Unconsciousness ne-gates the mens rea element required in
almost all crimes.
The manufacturer’s prescription inserts for Ambien CR states:
Complex behaviors such as "sleep-driving" (i.e.,
driving while not fully awake after ingestion of a sedative-hypnotic, with
amnesia for the event) have been reported with sedative-hypnotics, including [zolpidem.
These events can occur in sedative-hypnotic- naive as well as in
sedative-hypnotic-experienced persons. Although behaviors such as
"sleep-driving" may occur with Ambien alone at therapeutic doses, the
use of alcohol and other CNS depressants with Ambien appears to increase the
risk of such behaviors, as does the use of Ambien at doses exceeding the
maximum recommended dose.
As noted in the insert, complex behaviors may occur when
Ambien is used appropriately; however, such behaviors increase when it is used
improperly. Therefore, the prosecutor needs to watch for evidence indicating
the improper use of Ambien whenever the defense is raised. Any improper use
negates an otherwise legitimate defense; that the person took the drug as
prescribed and did not consume any alcohol or other CNS depressants.
1 Ambien and Ambien CR are registered trademarks of
Sanofi-Aventis U.S. LLC. 5
The defense may
claim that a defendant’s lack of memory is a result of unconsciousness. The
defense, however, often overlooks the distinction between unconscious- ness and
amnesia. According to Black’s Law Dictionary, unconsciousness is defined
as “being without awareness; not conscious. A person who commits a criminal act
while unconscious may be relieved from liability for the act.”2 In other words,
the person is unaware that he is performing an action. Amnesia, on the other
hand, is defined in the Merriam-Webster’s Medical Dictionary as “a loss
of memory sometimes including the memory of personal identity due to brain
injury, shock, fatigue, repression, or illness or sometimes induced by
anesthesia. It may also be a gap in one’s memory.”3 Unconscious-ness may be a
legal defense; amnesia may not.
The prosecution bears the burden of proving consciousness.
Fortunately conscious-ness can be proven rather easily. The arresting officer
should be able to give the follow-ing information as it pertains to the
defendant’s actions and responses:
• Was the defendant aware of his surroundings?
• Was he capable of answering questions in a cogent and
logical manner or was he confused and unresponsive?
• Was the defendant able to identify himself and provide
pertinent and accurate personal information?
• Was the defendant able to follow directions?
Upon a showing of consciousness by the prosecution, the
defense bears the burden of producing evidence suggesting unconsciousness.
Often, the defense offers little more than the self-serving declarations of the
defendant claiming to have taken Ambien and be-ing unable to recall anything
else afterwards. The defendant’s claim of no recollection is amnesia, not
unconsciousness. If the defense fails to put forth sufficient proof of
un-consciousness, then no unconsciousness defense should be presented to the
jury for consideration.
Should the defense succeed in making a showing of
unconsciousness, most States would require the defendant’s unconsciousness be
the result of involuntary intoxication. Recall that involuntary relates to the
consumption of the intoxicant, not to the consequences-es that result from the
consumption. The prosecutor should point out that the defendant went to a
doctor, received a prescription, had it filled at a pharmacy, may have had the
op-opportunity to speak directly with a pharmacist, and then consumed the drug
for the ex-pressed purpose of sleeping. That information could negate a defense
claim that he did not know that it could make him perform acts while asleep.
The law generally does not recognize voluntarily intoxication
to the point of un- conscious as a defense. If it did, then every instance in
which a person consumed alcohol to the point of blacking out and then got
behind the wheel would be perfectly defensible.
2 Black’s Law Dictionary, 8th Edition.
3 See, Merriam-Webster’s Medical Dictionary, 2012 6
Additional
information that the prosecutor should examine if an Ambien defense is raised
includes the following:
• Did the defendant take the Ambien in combination with other
drugs or with alcohol?
• When did the defendant take the Ambien in relation to the
time of operation of the vehicle?
• Has the defendant had prior episodes of somnambulism
(sleepwalking) while on Ambien?
• Has the defendant consumed Ambien in excess of the
designated dosage?
ISSUE: Jurors may empathize with the defendant
about the use of a legal drug.
RESPONSE: Address the issue of
“Identification Bias” during voir dire.
Cases involving drivers impaired by “legal” or licit drugs
present some of the most difficult jury and proof issues a prosecutor may ever
face. The multitude of factors found in many licit drugged driving cases
provide the defense with ample opportunity to conduct an appeal to the jurors’
hearts and minds and to derogate the prosecution’s evidence. Addressing the
identification bias commonly found in licit drug DUI cases exposes any
entitlement defense and eliminates any technical defenses. The prosecutor has
the op-opportunity to enlighten and empower the finder of fact to recognize and
reject the defense’s strategies in an objective, rational, and principled
manner.
Driving and legal drug use are near universal in our society.
As such, jurors have an instant commonality with the defendant that brings with
it both conscious and subconscious self-identification influences. Jurors who
empathize with a defendant may go to great lengths to acquit. When a juror can
envision himself ending up in the defendant’s chair or thinks “there but for
the grace of God go I,” the prosecutor has an identification bias issue that
must be confronted.
The defense does not need to explicitly raise the
identification bias in favor of the defendant. While most jurors cannot
identify with other criminal behavior, they may have little difficulty
identifying and empathizing with an otherwise law-abiding citizen who finds
himself accused of driving under the influence. However, few potential jurors
may feel a kinship with people accused of driving under the influence of
illicit drugs like heroin, cocaine or methamphetamine. But, in cases involving OTC
and commonly pre- scribed drugs, the biases can be particularly strong and
easily exploited by the defense. The presence of a doctor’s prescription often
weights the balance heavily in favor of the defense.
Long-running campaigns to create and increase public
awareness of the dangers of drunk driving have been successful. These campaigns
have created a mindset in most 7
people that
reflexively equates drinking and driving with “bad behavior.” As a result, many
jurors may consciously or subconsciously separate themselves from the accused
sit- ting before them when the accusation is drunk driving. Few public
awareness campaigns currently exist to educate the public about the dangers of
drugged driving. There is no readily recognizable licit drugged driving message
that a prosecutor can invoke to men- tally distance the jurors from the
defendant. As a result the prosecutor must attempt to show these behavioral
differences between the jurors and the defendant.
Prosecutors use voir dire ostensibly to eliminate from the
jury panel those individuals who are unable, for whatever reason, to serve as
fair and impartial jurors. In licit drug DUIs, the prosecutor must use voir
dire to uncover conscious and subconscious biases for the defendant. For
example, the prosecutor might ask potential jurors if they take prescription
and OTC medicines, and if they operate motor vehicles after taking such medications.
This line of questioning identifies those jurors who may have possible
conscious and subconscious biases.
Subsequently, the prosecutor may inquire if the jurors are
aware that DUI is a crime of personal responsibility. For example, it is legal
to drink and drive and a person of legal age does not need a prescription to
drink alcohol. What is illegal is driving while impaired. It does not matter if
the impairment is caused by alcohol, legal drugs, or illegal drugs. What
matters is the decision on the part of the person to get behind the wheel of an
automobile while impaired. That decision is fundamental to all DUIs.
Impaired drivers often contend that they thought that they
were okay to drive. This mindset forms the core of the entitlement defense. The
law does not recognize “I thought I was okay to drive” as a legitimate defense.
Yet, it gets put before the jury in a great many drug DUI cases. Whether the
defendant thought he was okay to drive or was even aware of the true magnitude
of his impairment is not one of the facts that the jury is asked to decide.
Often jurors will reject the notion of whether a person thinks he or she is
okay to drive as a deciding factor in a DUI case. Many jurors will respond with
statements such as “he should have known better” and “he was just fooling
himself.” Those expressions of thought and belief play up the personal responsibility
theme and aid in neutralizing the identification bias inherent in drug DUIs. 8
Breath Testing
Results: Defense Alternative Explanations
Diabetes
A classic defense in impaired driving cases is to claim the
officer mistakenly attributed signs of alcohol impairment to that of a diabetic
reaction. Although a common medical condition, diabetes is often misunderstood
and misrepresented by the defense. Understanding the disease and its effects on
the body will allow prosecutors to dispel the notion diabetics are being
wrongfully convicted in DUI cases.
Type 1 Diabetes versus Type 2 Diabetes
Diabetes is a disease in which the body does not produce or
properly use insulin. Insulin is a hormone made by the pancreas and its
function is to convert the food a person eats into energy needed to sustain
daily life. There are two main types of diabetes: Type 1 and Type 2.
Type 1 diabetes, previously known as juvenile diabetes, is
usually diagnosed in children and young adults. In Type 1 diabetes, the body does
not produce the hormone insulin that is needed to convert sugar (glucose),
starches, and other food into energy. Only 5- to 10% of people with diabetes
have this form of the disease. This fact is important to remember when we later
talk about the substance “acetone.”
Type 2 diabetes, previously known as adult onset diabetes, is
the most common form of diabetes and accounts for 90- to 95% of all cases. In
Type 2 diabetes, the body either does not produce enough insulin or the cells
simply ignore the insulin. When glucose builds up in the blood instead of
entering the cells, it immediately starves the cells of energy and over time
may damage the person’s eyes, kidneys, nerves, or heart.
Hypoglycemia versus Hyperglycemia
When the diabetes defense is raised, the most important
distinction for the prosecutor to recognize is the difference between
hypoglycemia and hyperglycemia. Either condition can happen to diabetics from
time to time. However, the effects of hypoglycemia (low blood glucose) are much
different than the effects of hyperglycemia (high blood glucose). The defense
will try to intermingle the two conditions to create a story most advantageous
to their client.
Hypoglycemia occurs when blood
glucose (or blood sugar) concentrations fall be-low a level necessary to
properly support the body’s need for energy throughout its cells. It is often
referred to as an insulin reaction because the body either has too much
insulin, meals and snacks are missed, or there is an increase of physical
activity or exercise. Furthermore, hypoglycemia can occur if a diabetic injects
too much insulin, resulting in insulin shock. 9
Some of the
symptoms of hypoglycemia and alcohol impairment can be similar – slurred
speech, dizziness, and disorientation. The onset of hypoglycemia is rapid. Left
untreated, it can result in loss of consciousness and/or seizure activity. Unlike
signs of alcohol impairment, the symptoms of hypoglycemia will not dissipate
over time. Treatment is required for the person to get better. It should also
be noted hypoglycemia does not pro-duce a fruity smell to the breath and will
not cause a false positive and/or elevate a breath alcohol test result.
Hyperglycemia occurs when blood
glucose concentrations are high. This happens when the body has too little
insulin or when the body cannot use insulin properly. The on-set of
hyperglycemia is slow. The signs of hyperglycemia include feeling thirsty,
constant urination, and a dry mouth. Hyperglycemia will not cause impaired
behavior that mimics intoxication in the same manner that hypoglycemia will.
If left untreated, hyperglycemia can lead to a condition
called ketoacidosis. This is a serious condition that can lead to a diabetic
coma or even death. Ketoacidosis develops when your body does not have enough
insulin. Without insulin, the body is not able to use glucose and will begin to
burn fat for energy, which produces ketones. Ketones are acids that build up in
the blood and appear in the urine. This is a warning that the diabetes is out
of control or the person is otherwise getting sick.
Ketoacidosis can produce a fruity acetone-like smell to the
person’s breath. It is a smell much different than the smell of beer, bourbon
or other alcoholic drinks. It is claimed this fruity smell can be mistaken for
alcohol, but most officers should be able to tell the difference. In fact, if
the officer detects a fruity smell on the person’s breath at roadside, it would
be expected the person would appear to be very ill. The person could be
vomiting and exhibiting signs of fatigue, difficulty breathing (shallow), and
confusion. Ketoacidosis is a very serious condition.
Note: Ketosis may exist for conditions other
than diabetes. Ketoacidosis is rare in people with Type 2 diabetes. It is most
common in people with Type 1 diabetes who have taken too little insulin.
Remember, only 5 to 10% of people with diabetes have Type 1 diabetes. 10
|
Characteristic
|
Hypoglycemia
|
Hyperglycemia
|
|
Onset
|
Rapid
(minutes)
|
Gradual
(days)
|
|
Mood
|
Labile,
irritable, nervous, weepy, combative
|
Lethargic
|
|
Mental
status
|
Difficulty
concentrating, speak-ing, focusing, coordinating
|
Dulled
sensorium, confused
|
|
Inward
feeling
|
Shaking
feeling, hunger, headache, dizziness
|
Thirst,
weakness, nausea/
vomiting,
abdominal pain
|
|
Skin
|
Pallor,
sweating
|
Flushed,
signs of dehydration
|
|
Mucus
membranes
|
Normal
|
Dry,
crusty
|
|
Respiration
|
Shallow
|
Deep,
rapid (Kussmaul)
|
|
Pulse
|
Tachycardia
|
Less
rapid, weak
|
|
Breath
odor
|
Normal
|
Fruity,
acetone
|
|
Neurologic
|
Tremors
late: hyperreflexia, dilated pupils, convulsion
|
Paresthesia
|
|
Ominous
signs
|
Shock,
coma
|
Acidosis,
coma
|
|
Blood
Glucose
Ketones
Osmolarity pH Hema-tocrit HCO3
|
Low:
below 70 mg/dl Negative/trace Nor-mal
Normal
Normal Normal
|
High:
240 mg/dl or more High/large (only if DKA) High
Low
(7.25 or less) High
Less
than 15eEq/L
|
|
Urine:
Output
Sugar
Acetone
|
Normal
Negative Negative/trace
|
Polyuria
to oliguria
High
High
|
