# Diabetic Run!



## divinewind_007 (Jul 14, 2007)

Heres a run i had earlier today. Look over...tell me anything you would have done different. Critique away!! 


Dispatced to elderly male unresponsive with liver cancer.

Arrived on scene to find:

74 elderly male
Family reports liver cancer and diabetes
Pt. had oxycodones for cancer but no extra pills had been taken.
Pupile equal and reactive
Pt. awake but will not follow commands and only making grunting noises.
Initial impression low blood sugar.
Glucose 39
B/P 136/78
Pulse 66
02 sat 94%
Respirations 16
Normal Sinus on monitor
Started nasal cannula at 2 LPM
Pt. has porta cath but our medics are not trained to access them
The veins we do hit blow....Cancer treatments had eat them up we suspect
Even EJ unsusseful
Pt. not with it enough for oral glucose
Gave Glucagon....was hoping to get him around enough to adminster oral glucose

Transported emergency just in case. 
Glucagon brought pt. up to 45 then 5 mins later he was at 30.
He never came around enough to give the oral.

Arrived at hospital.
They accessed porta cath and gave D50. Pt. came out of it and was fine when we left. Blood sugar at arrival at hospital was 22. Anything different you would have done? Any of yuns able to access porta-caths?


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## Bongy (Jul 14, 2007)

Well... PortA-Cath is quite tricky device and good for you that you didn't start to play with...  Glucagon possibly can not be useful due to damage to glucogen storages due to liver cancer... But what about centraline? Or even one-shot injection directly to femoral?


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## Flight-LP (Jul 14, 2007)

We carry the Huber needles and do access the P-a-C's. You did what you could do and got him to definitive care. Job well done.......

Bongy - You won't find too many EMS services here in the states that allow central access. My service can (subclavian and femoral), but it is very rare that we do anymore, especially since we have the P-a-C access capabilities and the EZ I/O for both adult and peds (tibial and humerous access). I have yet to have a patient recently that actually needed one in the field with these advances...


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## Bongy (Jul 14, 2007)

I'm not sure,that giving D50 IO is a goog idea... Connective tissue necrosis..e.t.c...


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## Flight-LP (Jul 14, 2007)

Its been shown to not be an issue and is not contraindicated, however I wouldn't give it I/O as we have too many pts. that refuse transport after administering it. Not going to start an I/O and then have someone decide to not go. If the I/O is put in, it stays in until the hospital removes it..............

I had the same concern though we first started carrying them a couple of years ago..............


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## divinewind_007 (Jul 14, 2007)

Bongy said:


> Well... PortA-Cath is quite tricky device and good for you that you didn't start to play with...  Glucagon possibly can not be useful due to damage to glucogen storages due to liver cancer... But what about centraline? Or even one-shot injection directly to femoral?



i knew that there was a sitiuation where glucagon was ineffective i just could not remember the specifics. Everytime i had used it before it worked great so it still caught me off guard when it did not pull him out of it. Of course thats why we ran emergency just in case it didnt help. Still, it sucks to have only one option and then it doesnt work either. Thanks for the info. all!


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## RedZone (Jul 15, 2007)

Bongy said:


> Well... PortA-Cath is quite tricky device and good for you that you didn't start to play with...  Glucagon possibly can not be useful due to damage to glucogen storages due to liver cancer... But what about centraline? Or even one-shot injection directly to femoral?



Yeah, that's the first thing that came to mind to me too.  If the liver's too damaged, I would assume the glucagon would be ineffective.  Sounds like you did the right thing.  This reminded me a LOT of the scenario I posted, but since he wasn't at all hypoxic, I give you a nice shiny gold star for not giving him narcan.

As far as the oral glucose... if he was awake and had a gag reflex... what's the contraindication?  Not trying to say you did anything wrong as I wasn't there... just curious why you felt he wasn't with it enough to give oral glucose.  Good job, you did what you had to do.

And Bongy or Flight-lp (or anyone really).... can you give me some more info about port-a-caths... I've been running into them a lot lately.


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## Goose (Jul 16, 2007)

What about administering D50 PR?  It is not anyones favorite means for administration, but when all else fails, it is a great route to give D50.  Just a thought.  I have administered it PR before with positive results.


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## RedZone (Jul 16, 2007)

Goose said:


> What about administering D50 PR?  It is not anyones favorite means for administration, but when all else fails, it is a great route to give D50.  Just a thought.  I have administered it PR before with positive results.



Huh.  Either I learned something today or that's one sick joke.  Good thing I'm not authorized for PR except for valium in peds stat-ep.

Seriously though, that's an on-label administration route?


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## VentMedic (Jul 16, 2007)

RedZone said:


> And Bongy or Flight-lp (or anyone really).... can you give me some more info about port-a-caths... I've been running into them a lot lately.



Popular port for chemo patients especially breast cancer.

We've got a good policy but I'll have to copy and paste it later off our intranet. In the meantime:

http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/P-81.pdf

http://www.smiths-medical.com/catalog/implantable-ports/port-cath-implantable-venous.html


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## RedZone (Jul 16, 2007)

VentMedic said:


> Popular port for chemo patients especially breast cancer.
> 
> We've got a good policy but I'll have to copy and paste it later off our intranet. In the meantime:
> 
> ...



Thanks... I've accessed them before, but only when there has been a nurse present to first confirm the device is venous access and that whatever med/fluid I'm giving is ok to use (did this just last night).  Either that, or I'll draw up the medication and hand it to the nurse to push.

I realize that having a nurse around has been a luxury in these particular instances.  Thanks for the info, if you can get me that other info, I appreciate it.  I might speak with my medical director about considering a policy for this.


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## VentMedic (Jul 16, 2007)

For a policy, you may not have to reinvent the wheel. Many Flight, CCT and specialty transport teams have included these in their policies and they are written "multi-disipline" for paramedics, nurses and RTs.


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## Goose (Jul 16, 2007)

RedZone said:


> Huh.  Either I learned something today or that's one sick joke.  Good thing I'm not authorized for PR except for valium in peds stat-ep.
> 
> Seriously though, that's an on-label administration route?



No joke, it is an approved route for D50.


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## divinewind_007 (Jul 16, 2007)

RedZone said:


> As far as the oral glucose... if he was awake and had a gag reflex... what's the contraindication?


 
He was awake but he was definetely not with it. He could not follow any commands. He would sometimes go out of conciousness for short periods. We would get him to come back around with painful stimuli only. We did not give it too him because we did not think he would be able to swallow it and we did not want to have a airway obstruction.


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## Bongy (Jul 16, 2007)

Goose said:


> No joke, it is an approved route for D50.


Wow... Glucose enema... Just Great!! I'm impressed!!:wacko:
By the way... In my case,I don't need nurse presence when operating with port-a-cath... I'm a nurse ether...:blush:


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## RedZone (Jul 17, 2007)

Bongy said:


> Wow... Glucose enema... Just Great!! I'm impressed!!:wacko:
> By the way... In my case,I don't need nurse presence when operating with port-a-cath... I'm a nurse ether...:blush:



So what are the complications you advised before about not acessing the port prehospitally?


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## Bongy (Jul 18, 2007)

RedZone said:


> So what are the complications you advised before about not acessing the port prehospitally?



In general - most common is contamination.... Very hard to ensure good aceptic conditons on prehospital... 
Second - air aspiration - Yes...It can happen even on venous site..
Last one,and not less important - nessesary to wash a port-a cath with heparine before use... PE avoiding procedure..


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## Ridryder911 (Jul 18, 2007)

Accessing ports are considered a Critical Care skill and should be written as such, above the normal Paramedic level skills and training. 

I *never* wash a port with heparin..nor do I suggest such. Some patients do not need additional heparin dose. 

Personally, aseptic technique is found adequate enough, if done * properly*. Everyday, millions of ports are accessed for chemo without "sterile" procedures. Yes, as much sterility if possible, since it is a central line, so many consider it a sterile technique, again it all depends upon the institution.

Most policies suggest you withdraw or aspirate 10 ml of blood for waste, then flush with saline. One should always obtain the history of use of ports and inquire when last time port was used or maintained. When aspirating, many are positional and having the patient lean forward or even taking a deep breath can actually cause the device to work and flush easily. 

Many facilities have leaned away from using Heparin flush, and now seal off with Saline. If used routinely, I see no problem with that; it is those that are not may have troubles. 

We will see more and more ports and PICC lines as out patient treatments increase. EMS personal should be familiar with each device and the reason for such. 

R/r 911


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## Bongy (Jul 18, 2007)

Ridryder911 said:


> I *never* wash a port with heparin..nor do I suggest such. Some patients do not need additional heparin dose.


With all respect(and I mean a LOT OF!)...I thing that heparin (about 100 units in 20 cc saline) is nessesary,aspecial in single lumen LONG catheters... Not one and not twice I saw a lot of embolies "shot off" from a catheter... This ammout of heparine will not have ANY systemic influence but only a local one... And I advise not to be "light minded" about aceptic tecnics... Remeber!! YOUR contamination will go DIRECTLY to heart,without "first pass"(I know...it's pharmacological term) and without perepheral immune response... Be careful!


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## Flight-LP (Jul 18, 2007)

All of our placements are performed under sterile conditions (of course in the most un-sterile environment!). We still Heparinize our caths with 500 units, but it is evaluated on an individual basis weighing all of the issues at hand. I have yet to see a significant hemolytic reaction from the Heparin bolus, but Rid does have valid points..............as always!

BTW Rid, where have you been? Haven't seen you around on either forum lately....


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## VentMedic (Jul 18, 2007)

Ridryder911 said:


> Accessing ports are considered a Critical Care skill and should be written as such, above the normal Paramedic level skills and training.
> 
> R/r 911



Actually it's considered a Med-Surg nursing skill in many hospitals since that is where most of these patients are.  But you are right it is above the normal Paramedic skills and training.  Since these patients with Port-A-Caths are fairly common and are transported via a variety of different ALS teams, some do have pretty good policies and have been trained for access. Although, many of these teams do include an RN.  However, not all teams are created equal in skills or training, no matter the credentials. 

Unless you were referring to the CCT paramedic and not Critical Care Unit, then my apologies Rid, you are correct.


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## Ridryder911 (Jul 18, 2007)

I do believe that Heparin and flushes etc.. is a personal or rather institutional choice. Like Bongy describes it is a minute amount, however; when one already has a bad PTT or skewed INR, every little bit should be considered, especially repeat draws and meds. 

Yes, it is routine med-surg.. but like you described Vent most of the tume it is considered an advanced CCT procedure. 

P.S. ... just returned from Disney World.. great trip.. too short! 

R/r 911


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