# Low Blood sugar



## fishyfish (Jul 12, 2016)

Pt. middle aged female blood sugar 20, o2 94% pulse 140 weak bp 88/80.  Arrive to find Fire has put on AED CPR is advised. GO!


----------



## luke_31 (Jul 12, 2016)

Umm. Maybe start with having fire step out and don't shock this patient. Based on what you are describing it would be IV, D50W, and reassess after a couple minutes once the glucose has had a chance to do its thing. I would put the patient on the monitor but unless a history of other than being a diabetic is present wouldn't expect to see anything funky.


----------



## DesertMedic66 (Jul 12, 2016)

Kick fire out. With that kind of a hand over I am going to start from the top. Recheck vitals, recheck GCS/AO status. Check sugar. If it is low then as ALS I'm going to get a line established and give 25G of D10%. Reasses for a change in mental status. 

Once patient wakes up see if she has any complaints. Recheck vitals. See if she would like to go to the hospital. If yes then transport if no then advise her of the usual AMA stuff. 

If she has a Hx of DM then I am comfortable with letting her AMA. If she doesn't have Hx then I would be a little more hesitant.


----------



## Akulahawk (Jul 12, 2016)

Agreed. Start with the simple stuff. I'm going to assume that the FSBG is at least somewhat correct and that the patient isn't mentating normally. This would drive me to start an IV, begin fluids, and institute either 25g of D50 or 25g of D10 as soon as I can get my hands on either. While starting that line, I'll also confirm the low FSBG on my own glucometer using a venous sample if possible. I figure that around the time the dextrose bolus is about 80% complete, the patient's "lights" will turn on... 

I'm not too worried about a pulse of 140 with a BP of 88-ish _and_ the AED proclaiming "shock advised" because it's only seeing a relatively high heart rate and not the other parts of the clinical puzzle. What the patient also possibly needs (at this point anyway) is fluid replacement. Given the HR and BP, I'm also going to look for possible reasons _why_ the patent's blood sugar is low with a tachycardia/mild hypotension. If it's hot out, the patient has been outside for a bit and little/no PO intake, that could spell another reason why the patient isn't doing well.

Now, any known history? Dialysis shunts or ports?


----------



## fishyfish (Jul 12, 2016)

History of heart trouble, diabetic,  takes medication for both. Fire has began CPR in accordance with AED. Fire states PT was found in home AC on last oral intake was lunch according to husband


----------



## CALEMT (Jul 12, 2016)

Wait a second. Pulse of 140 and CPR advised? Did I miss something? Why is fire doing CPR on a patient with a pulse? Kick em out for starters. Pretty much what everyone else is saying. D10 and reassess. The patient has a HX of diabetes then its a no brainer. Sugar, reassess, and get the AMA form ready.


----------



## DesertMedic66 (Jul 13, 2016)

jacollins95 said:


> History of heart trouble, diabetic,  takes medication for both. Fire has began CPR in accordance with AED. Fire states PT was found in home AC on last oral intake was lunch according to husband


Has this ever happened before? DM well under control? Does she take insulin? Did she possibly take to much? Great she ate lunch today, but we have no idea what time it is currently, is it midnight or is it 1600? Has she been vomiting or sick at all recently?

What kind of "heart problems"? What are the medications she is on? When was the patient last seen normal? 

Let's say we kicked fire out and started our own assessment, what are her vitals, AO status, and BGL?


----------



## fishyfish (Jul 13, 2016)

CALEMT said:


> Wait a second. Pulse of 140 and CPR advised? Did I miss something? Why is fire doing CPR on a patient with a pulse? Kick em out for starters. Pretty much what everyone else is saying. D10 and reassess. The patient has a HX of diabetes then its a no brainer. Sugar, reassess, and get the AMA form ready.



Fire arrived checked vitals learned of the history of Heart problems and for whatever reason attached the AED. The AED said no shocked advised start CPR, Fire did as the AED said.


----------



## fishyfish (Jul 13, 2016)

DesertMedic66 said:


> Has this ever happened before? DM well under control? Does she take insulin? Did she possibly take to much? Great she ate lunch today, but we have no idea what time it is currently, is it midnight or is it 1600? Has she been vomiting or sick at all recently?
> 
> What kind of "heart problems"? What are the medications she is on? When was the patient last seen normal?
> 
> Let's say we kicked fire out and started our own assessment, what are her vitals, AO status, and BGL?



Pt. is on an insulin pump,  lunch was around noon it is now 1410,  last seen normal 1345. History of heart attacks.  Removing fire from the question we get same vitals 20, o2 94% pulse 140 weak bp 88/80.


----------



## DesertMedic66 (Jul 13, 2016)

What are her actual vitals? Turn the pump off or disconnect it.


----------



## fishyfish (Jul 13, 2016)

DesertMedic66 said:


> What are her actual vitals? Turn the pump off or disconnect it.





DesertMedic66 said:


> What are her actual vitals? Turn the pump off or disconnect it.



Assume vitals given are 100 accurate, side question can CPR done and not needed cause any real harm other then the broken ribs?


----------



## DesertMedic66 (Jul 13, 2016)

Not going to assume a BP of 88/80 is anywhere near accurate. 

Breaking ribs that can in theory puncture other vital organs (heart, lungs, liver). Since you are literally squeezing the heart between the sternum and spine there is a good chance of damage to the heart. 

Since the heart is already pumping blood thru a normal rhythm squeezing the blood out of it when you compress is probably going to cause some issues.


----------



## medichopeful (Jul 13, 2016)

jacollins95 said:


> side question can CPR done and not needed cause any real harm other then the broken ribs?



Broken ribs by themselves is definitely some real harm.  Other than those, yes CPR can absolutely cause other injuries or condition.  Cardiac bruising, arrhythmia, you name it.  It's basically blunt-force trauma done in a medically controlled way.


----------



## medichopeful (Jul 13, 2016)

jacollins95 said:


> Fire has began CPR in accordance with AED.



This is a theoretical scenario right?  Not one that really happened?  Please tell me this didn't actually happen.


----------



## TransportJockey (Jul 13, 2016)

Report the fire crew to the state for negligence


----------



## fishyfish (Jul 13, 2016)

medichopeful said:


> This is a theoretical scenario right?  Not one that really happened?  Please tell me this didn't actually happen.



No this is a


medichopeful said:


> This is a theoretical scenario right?  Not one that really happened?  Please tell me this didn't actually happen.



The scene depicted is fictional, I'm actually looking for what would happen. If an AED was miss used.


----------



## NomadicMedic (Jul 13, 2016)

AED's have failsafes to prevent this from happening.


----------



## CALEMT (Jul 13, 2016)

jacollins95 said:


> Fire arrived checked vitals learned of the history of Heart problems and for whatever reason attached the AED. The AED said no shocked advised start CPR, Fire did as the AED said.



Then report fire to the county EMS office cause that's negligence. Who starts CPR without checking a pulse first? Also yes unnecessary CPR can cause damage to the heart.


----------



## OnceAnEMT (Jul 13, 2016)

DEmedic said:


> AED's have failsafes to prevent this from happening.



How so? Think there was a topic on this a while back, but can an AED tell the difference between vtach and pulseless vtach?

Not at all saying fire wasn't in the wrong, interested in the failsafe comment.


----------



## Akulahawk (Jul 13, 2016)

Grimes said:


> How so? Think there was a topic on this a while back, but can an AED tell the difference between vtach and pulseless vtach?
> 
> Not at all saying fire wasn't in the wrong, interested in the failsafe comment.


An AED cannot tell the difference in VT and pulseless VT. It assumes pulseless because it was applied and turned on. An AED is only supposed to recommend a shock for VF and VT situations. If it sees anything else, it's supposed to basically say "no shock advised" and "check pulse" and otherwise do nothing. So if you apply it to a patient that's got a HR in the 180's but has a narrow QRS (think SVT not VT), the AED will not advise a shock. People are the first fail-safe. You only apply the AED to someone that's pulseless. After that, the programming knows to look only for VF or VT.


----------



## NomadicMedic (Jul 13, 2016)

Akulahawk said:


> An AED cannot tell the difference in VT and pulseless VT. It assumes pulseless because it was applied and turned on. An AED is only supposed to recommend a shock for VF and VT situations. If it sees anything else, it's supposed to basically say "no shock advised" and "check pulse" and otherwise do nothing. So if you apply it to a patient that's got a HR in the 180's but has a narrow QRS (think SVT not VT), the AED will not advise a shock. People are the first fail-safe. You only apply the AED to someone that's pulseless. After that, the programming knows to look only for VF or VT.



As an aside, AED manufacturers are aware that misuse will occur, "Public access AEDs will be used by minimally trained personnel. The potential for misuse is high: use of AEDs is inappropriate in persons who are conscious and breathing or persons who are in true cardiac arrest but are receiving artifact-generating cardiopulmonary resuscitation during analysis of the rhythm." (http://circ.ahajournals.org/content/95/6/1677.full)

They build high specificity requirements in the the shockable rhythm algorithm and all AEDs will dump the charge if a non shockable rhythm is detected. An unconscious person in NSR or sinus brady won't get shocked and a patient with a rate of 140 wouldn't get shocked either. 

While it's an interesting hypothetical, how would a patient who presents with: 





> o2 94% pulse 140 weak bp 88/80


 ever receive CPR? It's really a non issue.


----------



## Tigger (Jul 13, 2016)

Akulahawk said:


> An AED cannot tell the difference in VT and pulseless VT. It assumes pulseless because it was applied and turned on. An AED is only supposed to recommend a shock for VF and VT situations. If it sees anything else, it's supposed to basically say "no shock advised" and "check pulse" and otherwise do nothing. So if you apply it to a patient that's got a HR in the 180's but has a narrow QRS (think SVT not VT), the AED will not advise a shock. People are the first fail-safe. You only apply the AED to someone that's pulseless. After that, the programming knows to look only for VF or VT.


http://www.jems.com/articles/print/...ads-nurse-to-shock-concious-boy-with-aed.html

Of note, though it's not the clearest article.


----------

