# What is the absorption rate of dextrose 50% if injected subcutaneously?



## ervin (Jun 26, 2008)

What is the absorption rate of dextrose 50% if injected subcutaneously?


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## Ridryder911 (Jun 26, 2008)

Very little to none; it usually causes tissue extravasation at the site causing necrosis and severe tissue damage (rotting it out). That is why it is essential that IV are very patent. 

Now, Glucagon can be administered I.M., Sub-q , IV, etc.. but sub-q is the slowest route >1 hr. 

R/r 911


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## mikeylikesit (Jun 26, 2008)

I usually do Glucagon IM and it takes areound 5 minutes to start working.


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## Hastings (Jun 26, 2008)

Lol, never give Dextrose any other route than IV. As said, massive tissue damage and other nasty complications.


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## mikeylikesit (Jun 26, 2008)

Hastings said:


> Lol, never give Dextrose any other route than IV. As said, massive tissue damage and other nasty complications.


Nah...just let them take a few drinks off it and they will be fine.


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## mikie (Jun 26, 2008)

Maybe a foolish question......what is the point of a subcutaneous injection?  The only time I've ever seen one was for my TB test


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## Hastings (Jun 26, 2008)

mikie333 said:


> Maybe a foolish question......what is the point of a subcutaneous injection?  The only time I've ever seen one was for my TB test



That's actually intradermal. SubQ is a little deeper.

For instance, epinephrine in a severe anaphylactic reaction.


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## mikie (Jun 26, 2008)

Hastings said:


> That's actually intradermal. SubQ is a little deeper.
> 
> For instance, epinephrine in a severe anaphylactic reaction.



Ah, my mistake, thanks!

So would an Epi-Pen be an example?


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## Hastings (Jun 26, 2008)

mikie333 said:


> Ah, my mistake, thanks!
> 
> So would an Epi-Pen be an example?



I could be wrong, but I believe most Epi-pens are meant to be used intra-muscularly; into the muscle. SubQ is just the preferred method of most paramedics in the situation.


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## Jon (Jun 26, 2008)

mikie333 said:


> Ah, my mistake, thanks!
> 
> So would an Epi-Pen be an example?


Nope... that is IM... because that is what auto injectors can do.


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## Flight-LP (Jun 26, 2008)

Hastings said:


> That's actually intradermal. SubQ is a little deeper.
> 
> For instance, epinephrine in a severe anaphylactic reaction.




Don't you mean IV vs. subQ????

SubQ Epi in a true anaphylactic reaction is ineffective. 

I agree with some, why even consider a subQ injection? Other than the opinion of Epi, what others do we really HAVE to give that way?

O.K. maybe Brethine..............


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## Hastings (Jun 26, 2008)

Flight-LP said:


> Don't you mean IV vs. subQ????
> 
> SubQ Epi in a true anaphylactic reaction is ineffective.
> 
> ...



SubQ Epi is in almost everyone's Anaphylaxis protocol because it's an emergency that needs immediately intervention, and taking the time to get an IV probably isn't the wisest idea. While the onset for most SubQ injections is long, the Epi works very fast when administered this way.

What other drugs do you inject SubQ? Insulin, for instance.


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## Jon (Jun 26, 2008)

Hastings said:


> SubQ Epi is in almost everyone's Anaphylaxis protocol because it's an emergency that needs immediately intervention, and taking the time to get an IV probably isn't the wisest idea. While the onset for most SubQ injections is long, the Epi works very fast when administered this way.
> 
> What other drugs do you inject SubQ? Insulin, for instance.


But paramedics don't administer Insulin.


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## Hastings (Jun 26, 2008)

Jon said:


> But paramedics don't administer Insulin.



Some do, actually.

But no, the two drugs listed above are usually the only pre-hospital ones to be given SubQ.


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## mikeylikesit (Jun 26, 2008)

Jon said:


> But paramedics don't administer Insulin.


I can administer insulin...to myself. Actually in my area we have the option of administering R insulin for regular insulin. the only thing with R is that it is out of your system in about an hour so crashing your patient could take place. plus as a diabetic i know that there are tons of factors that change change the dosing of insulin to give i.e exercise, baseline insulin levels, dehydration, sleep deprivation and urination to name a few.


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## mikie (Jun 26, 2008)

So if someone doesn't mind...what is the pros/cons, risks/benefits of SubQ vs IM?

thanks!


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## Hastings (Jun 26, 2008)

mikie333 said:


> So if someone doesn't mind...what is the pros/cons, risks/benefits of SubQ vs IM?
> 
> thanks!



Absolutely same thing, to be honest. SubQ just takes longer, on average, than IM.


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## Ridryder911 (Jun 26, 2008)

Personally many fail to recognize Sub-Q is the slowest as well must have a good perfusion to circulate the medication.. reasons why I don't understand most wanting to give Epi sub-q.. Especially in a shocky state. When if one can start and IV and administer the Epi per IV (of course different strength and dosage) but immediately works... 

Sure, if all if fails Epi Sub-Q.. 

Other med.'s I give Sub-Q routinely is Morphine Sulfate.. lasts longer, Terbutaline, Loveknox, Heparin  and so forth....

Benefits: slow absorption rate (good or bad dependent on the need) so larger dosages (strength) can be administered, less nerve damage, more systemically distributed.. in other words can throughout the body.. not as concentrated

Risks: Some medications are too toxic to the skin and subcutaneous fat, very slow absorption rate (less blood supply), smaller dosages may need to be given in two dosages, where IM is higher blood supply, muscle (larger such gluteal) can absorb larger dosages.. etc..

R/r 911


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## KEVD18 (Jun 26, 2008)

brady paramedic care vol. 1, ch.10, p.399 "Subcutaneous Injection"

"Like intradermal injections, no more than 1.0ml of medication is administered subcutaneously"

so for a moment, lets disregard the extravasation and tissue necrosis for a moment and pretend a subQ injection of d50 would be perfectly healthy. how many subq's would you have to do at 1ml per to reach an effective dose? there arent even enough spots on the body to do it...


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## Ridryder911 (Jun 26, 2008)

KEVD18 said:


> brady paramedic care vol. 1, ch.10, p.399 "Subcutaneous Injection"
> 
> "Like intradermal injections, no more than 1.0ml of medication is administered subcutaneously"
> 
> so for a moment, lets disregard the extravasation and tissue necrosis for a moment and pretend a subQ injection of d50 would be perfectly healthy. how many subq's would you have to do at 1ml per to reach an effective dose? there arent even enough spots on the body to do it...



Actually not true.. remember, anywhere there is fat... there is sub-q. Now, there is preferred sites.. as well, one would not want to have 50 (1 ml) injections...


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## akflightmedic (Jun 27, 2008)

Jon said:


> But paramedics don't administer Insulin.




We carried and administered insulin in Alaska...as Paramedics.


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## mycrofft (Jun 27, 2008)

*Epi pens...try one sometime*

Take an old one and shoot it into an orange or such. Needle is relatively small gauge and only about 3/4 inches long, maybe an inch. This isn't your 2-PAM Cl or Atropen from Chem-warfare class, shorter needle. If you tip it, or the subject's really obese, you can make that a sub-q, or bore down (no pun intended) and get IM. SQ with epi, as with insulin, helps avoid dumping it all on board immediately, unlike intracardiac, where you are depending upon  it shocking the system to a degree...if it can make Uma Thurman look fully awake, it'll do you, too.
We had a pt resist a Bristoject of D50 into the antcubital vein and spent about $50,000 in plastic surgery, hospitalization, and therapy to rehab his wiped out bicep. Saved his life, though.

Other drugs subQ...heroin, speedballs, etc.

Oh, you might want to throw that orange away before somone tries to eat it.:wacko:


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## Flight-LP (Jun 27, 2008)

Hastings said:


> SubQ Epi is in almost everyone's Anaphylaxis protocol because it's an emergency that needs immediately intervention, and taking the time to get an IV probably isn't the wisest idea. While the onset for most SubQ injections is long, the Epi works very fast when administered this way.
> 
> What other drugs do you inject SubQ? Insulin, for instance.



Duh on the Insulin, I should have thought about that one...............

But, I have never had a guidline or protocol that called for Epi SQ in an anaphylactic patient, its always been IV........................

Different strokes for different folks I guess...........


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## Hastings (Jun 27, 2008)

Flight-LP said:


> Duh on the Insulin, I should have thought about that one...............
> 
> But, I have never had a guidline or protocol that called for Epi SQ in an anaphylactic patient, its always been IV........................
> 
> Different strokes for different folks I guess...........



Well, since you're a CCP/FPM, you probably have the luxury of always having an IV established. However, for the first responding Paramedic, most protocols call for SubQ Epi before IV Epi because:

1. It's quick.
2. It doesn't require an IV.
3. It works.

If the SubQ Epi doesn't work, or tissue perfusion is obviously not adequate, you can jump right to IV Epi.


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## MedicPrincess (Jun 27, 2008)

mycrofft said:


> We had a pt resist a Bristoject of D50 into the antcubital vein and spent about $50,000 in plastic surgery, hospitalization, and therapy to rehab his wiped out bicep. Saved his life, though.


 
Can you explain this?  Did you loose the IV and a small amount of the D50 infiltrated? Was administration of the D50 continued even after the IV site was no longer patent, at the knowledge of the person administering?  Wasn't the line checked throughout administration to ensure there was no infiltration? Was it intentionally given IM?  How much "resisting" was going on?  I can say I have had multiple people restrain a pt who was "resisting" in order ot administer the D50, and managed to give it.Just because you "saved his life" doesn't make it right.

What about Glucagon?


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## mikie (Jun 27, 2008)

Not to steal the question from above but this is very intersting and new to me (still only a basic :glare

So what is the depth (a few MM difference probably), angle of injection & location difference between SubQ and intradermal?  


Thanks everyone for your great responses!


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## Hastings (Jun 27, 2008)

mikie333 said:


> Not to steal the question from above but this is very intersting and new to me (still only a basic :glare
> 
> So what is the depth (a few MM difference probably), angle of injection & location difference between SubQ and intradermal?
> 
> ...



Well, for an intradermal injection, you're going almost parallel to the skin, and only until the tip of the needle is under the skin. It's so superficial that a bubble is created on top of the skin when something is injected underneath the skin that way. Typically only done in the forearm.

A subcutaneous injection is into the fat, which means you have to bypass that layer of skin. You pinch the skin up, and go at a 45 degree angle. A subQ injection can be given anywhere there is fat. Popular site is the arm.


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## fma08 (Jun 27, 2008)

our protocol just changed for anaphlyaxis, its now (for adults) 0.3mg of 1:1000 IM, used to be Sub-q.


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## Hastings (Jun 27, 2008)

fma08 said:


> our protocol just changed for anaphlyaxis, its now (for adults) 0.3mg of 1:1000 IM, used to be Sub-q.



Pretty much same idea as the SubQ one. It was those claiming that the protocol called for IV Epi that I found hard to believe.


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## Flight-LP (Jun 27, 2008)

Hastings said:


> Well, since you're a CCP/FPM, you probably have the luxury of always having an IV established. However, for the first responding Paramedic, most protocols call for SubQ Epi before IV Epi because:
> 
> 1. It's quick.
> 2. It doesn't require an IV.
> ...




Again, regardless of being in the air or on the ground, I have NEVER had a written guidline calling for Epi SQ before IV in true anaphylaxis. Severe allergic reaction maybe, but not full blown anaphylaxis. Also FYI, I do not currently fly as a medic......................


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## Flight-LP (Jun 27, 2008)

Hastings said:


> Pretty much same idea as the SubQ one. It was those claiming that the protocol called for IV Epi that I found hard to believe.



Find it as hard to believe as you want, but the reality is that patients suffering circulatory compromise will not metabolize Epi when administered SQ. IM maybe, but it is still too slow. If you have a pt. with circulatory collapse, i.e. immediate life threatening symptoms, IV Epi is the recommended course of treatment..........

http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-143

http://emj.bmj.com/cgi/content/abst...63c7f018aecc535e7bac47e2&keytype2=tf_ipsecsha

http://www.mchd-tx.org/clinical/documents/MCHDSDOApril2008.pdf   (Page 178)

http://www.atcomd.org/downloads/PATIENT CARE GUIDELINES ONLY v06.01.08 ALL PROVIDER LEVELS.pdf   (Page 2)


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## Hastings (Jun 27, 2008)

Flight-LP said:


> Find it as hard to believe as you want, but the reality is that patients suffering circulatory compromise will not metabolize Epi when administered SQ. IM maybe, but it is still too slow. If you have a pt. with circulatory collapse, i.e. immediate life threatening symptoms, IV Epi is the recommended course of treatment..........
> 
> http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-143
> 
> ...



I don't think you're getting what I'm saying.

First of all, I made it clear in my previous post that while SubQ Epi is the primary protocol, if there is inadequate tissue perfusion, then you need to do IV Epi. However, SubQ Epi is the primary protocol because it can be administered immediately without the establishment of an IV, thus avoiding the situation getting bad enough where tissue perfusion is an issue and IV Epi IS necessary.

Someone can require immediate intervention while not being in such a dire state where their tissues aren't being perfused. SubQ Epi is the choice in such a case. The majority of cases. I'm sorry, but it's true.


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## mycrofft (Jun 28, 2008)

*MedicPrincess, I needed to answer you here. Sorry to interrupt the flow.*


2. The patient was attempting to thwart treatment because he was aggitated and disoriented from hypoglycemia which he purposefully induced (ate suger before he got his insulin so he would get a large sliding scale dose of Regular, then vomited up supper in his cell) to avoid being extradited to a Federal penitentiary. He wanted to go to a hospital. He got it.
3. The practitioner who did it had done it once before (Bristoject mainline without IV line patent) with good result, but the second attempt ended in this fiasco. Excellent example and it answers your questions: yes, it was boneheaded and wrong.
4. No it wasn't me, it was someone who was not experienced and not level-headed in an "emergency", thereby compounding it.
5. We did not have Glucagon available to us then. Sure do now!


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## Flight-LP (Jun 28, 2008)

Hastings said:


> I don't think you're getting what I'm saying.
> 
> First of all, I made it clear in my previous post that while SubQ Epi is the primary protocol, if there is inadequate tissue perfusion, then you need to do IV Epi. However, SubQ Epi is the primary protocol because it can be administered immediately without the establishment of an IV, thus avoiding the situation getting bad enough where tissue perfusion is an issue and IV Epi IS necessary.
> 
> Someone can require immediate intervention while not being in such a dire state where their tissues aren't being perfused. SubQ Epi is the choice in such a case. The majority of cases. I'm sorry, but it's true.



Yeah, its called an allergic reaction, not anaphylaxis.....................

Obviously you failed to actually read the links. They directly contradict that very statement. My original posting was to state a personal experience, not get into a pissing match with you. Think what you wish, treat as you wish. You apparently allow zero flexibility to considering any other thought process than your own. So why you continue posting multiple pages in these threads I guess will continue to perplex me.................


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## Hastings (Jun 28, 2008)

Flight-LP said:


> Yeah, its called an allergic reaction, not anaphylaxis.....................
> 
> Obviously you failed to actually read the links. They directly contradict that very statement. My original posting was to state a personal experience, not get into a pissing match with you. Think what you wish, treat as you wish. You apparently allow zero flexibility to considering any other thought process than your own. So why you continue posting multiple pages in these threads I guess will continue to perplex me.................



Anaphylaxis IS an allergic reaction. What you need to do when you get on scene is assess how severe the reaction is, and whether or not SubQ Epi would even be effective. But in many cases, it will be. And if I arrive early enough before they're in a state of shock, then I'm going to go for the SubQ Epi. Why? Because it's easier. It all depends on the patient's state.


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## mikeylikesit (Jun 29, 2008)

Ridryder911 said:


> Actually not true.. remember, anywhere there is fat... there is sub-q. Now, there is preferred sites.. as well, one would not want to have 50 (1 ml) injections...


 My preferred site is on the cheek it they let me since i tell them that it won't hurt as bad. plus you know every patient almost has adipose tissue on their cheeks.B)


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## zacdav89 (Jul 1, 2008)

after reading the posts i haven't seen the science behind not using the subq epi in a anaphalaxis reaction so i thought i would put my two cents in, in mild to moderate subq epi is the most effective because the blood has yet to been shunted from the skin, in anaphalaxis the blood is shunted back to the core and the skin looses its vascular flow so limiting the absorption of the subq epi, indicating rapid iv epi. that was how i was told to hand a  mild allergic vs anaphalatic reaction.h34r:


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