# Low Blood Sugar



## Swimfinn (Sep 3, 2012)

You are dispatched at 813 in the morning to a local rest area for a 12 year old girl with a low blood sugar.

You arrive on scene with a crew of 2 AEMTs 6 mins later to find the girl with a blood sugar of 39. You also obtain this set of vitals:

HR 91
BP 104/77
SpO2 100% on outside air

As you look back at the patient, you notice that she appears as though her head is turned left and slightly upward, eyes midline to left deviation, her tongue appears to be continously darting in and out of her mouth and licking the top lip. In slurred speech she states that she starts to feel "funny" and that her neck is stiff.

How do you proceed?


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## NomadicMedic (Sep 3, 2012)

You start an IV, administer dextrose and reevaluate once she is no longer hypoglycemic.

I know where you're going with this, but you have to fix what you can, first.


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## firecoins (Sep 3, 2012)

I will send her to Cincinnati for a test after giving dextrose.


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## Swimfinn (Sep 3, 2012)

n7lxi said:


> You start an IV, administer dextrose and reevaluate once she is no longer hypoglycemic.
> 
> I know where you're going with this, but you have to fix what you can, first.



oh do you? care to explain?


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## HMartinho (Sep 3, 2012)

What  is her medical history?

When was her last meal?

What is the neurological status?

And why is she hypoglicemic? Is she type-1 diabetic? Addison's syndrome? long time without eating? anorexia? high carb meal?


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## the_negro_puppy (Sep 3, 2012)

She has an insulin secreting tumor. Better cal House


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## Swimfinn (Sep 3, 2012)

she has an hx of type 1 diabetes and epilepsy. she was doing her pre-meal blood sugar check. last thing she ate was 14 hours ago. steak and asparagus with a glass of milk.

edit: she is A&O to person and place


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## HMartinho (Sep 3, 2012)

the_negro_puppy said:


> She has an insulin secreting tumor. Better cal House



I have seen many hypoglycaemic episodes in healthy adults but not in children. So, I think that is relevant take a good medical history. 

To properly treat a symptom, it is good to know the cause.

Just my 2 cents


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## HMartinho (Sep 3, 2012)

Swimfinn said:


> she has an hx of type 1 diabetes and epilepsy. she was doing her pre-meal blood sugar check. last thing she ate was 14 hours ago. steak and asparagus with a glass of milk.
> 
> edit: she is A&O to person and place



Then proceed as others have said:

IV, glucose, check bgl, and transport to hospital.


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## Swimfinn (Sep 3, 2012)

iv and glucose started. bgl up to 81. spiked a bag of fluids. patient keeps having what appear to be petit mal nonconvulsive seizures. nearest hospital is 30min away going code 3. what now?

Edit: also, after talking to the father, it sounds like her typical seizures are myoclonic, not petit mal seizures

Edit 2: do you think these seizures are a result of the chemical imbalance in the brain due to the hypoglycemia, or the epilepsy, or something else?


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## HMartinho (Sep 3, 2012)

Swimfinn said:


> iv and glucose started. bgl up to 81. spiked a bag of fluids. patient keeps having what appear to be petit mal nonconvulsive seizures. nearest hospital is 30min away going code 3. what now?
> 
> Edit: also, after talking to the father, it sounds like her typical seizures are myoclonic, not petit mal seizures
> 
> Edit 2: *do you think these seizures are a result of the chemical imbalance in the brain due to the hypoglycemia, or the epilepsy, or something else?*



Good question h34r::wacko:

Anyway, there is something strange:

She has type 1 diabetic, has a bgl of 39, and is alert and oriented? It is not common.

mydriasis? Anisocoria? Miosis? The pupils respond to light?


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## DesertMedic66 (Sep 3, 2012)

Swimfinn said:


> oh do you? care to explain?



You don't know what all is being caused by the low blood sugar or if it is something more. So you have to fix the low sugar to see if the patient is still having other issues. 

As you have already said the patients sugar was fixed and the patient appears to be having seizures. So then go from there. 

What are the patients vitals after the dextrose. What are her O2 sats? Did she just switch to a new medication? Has she been taking her meds as she should?


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## Swimfinn (Sep 3, 2012)

she is on 2mg of diazepam with each meal and 9 units of Lantus every morning. 

bp up to 118/94
hr up to 110

SPO2 99%

no new meds. father is pretty sure she has been doing her meds correctly
pupils were PEARL when she wasn't "absent"


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## Swimfinn (Sep 3, 2012)

call for ALS or no?


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## NomadicMedic (Sep 3, 2012)

Swimfinn said:


> call for ALS or no?



Continue with an easy, no lights or siren transport. IV at KVO. 

If the seizures continue unabated, I would consult with the doc about benzos. 

Draw bloods, serum lactate and just monitor. 

... And I am ALS.


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## Swimfinn (Sep 3, 2012)

we were a crew of 2 at intermediate level though..


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## NomadicMedic (Sep 3, 2012)

Swimfinn said:


> we were a crew of 2 at intermediate level though..



This is not a call that intermediates, with limited education and an incomplete "wanna be paramedic" drug box are equipped to handle. I apparently missed that this was an intermediate crew, so yes, the answer is have a fully equipped ALS crew manage the call.


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## leoemt (Sep 4, 2012)

I'm not sure I'd be calling for ALS yet (in my area we have a luxury of LOTS of hospitals close by). 

Initial call is for low blood sugar with a hx of DM. If she can maintain her own airway, do a check of the BGL and give her some oral glucose. She is talking so I am thinking that she can maintain her own airway. Reassess. 

The hx of seizures is concerning but nothing that I need to bother ALS for at this time. I am concerned with the licking lips as that may indicate an oncoming seizure. However, nothing I can do. 

In my area we only call ALS for seizures if pt is in Status Epilipticus. 

Reassess patient and if BGL rises does her other symptoms disappear? If BGL does not rise after oral glucose, ALS would be requested. 

If her other symptoms are an absence seizure (petit mal) they should disappear within 30 seconds. 

Does she have a fever? Neck stiffness without trauma makes the hospital worry about Meningitis. Since her type of seizure disorder is unlikely to cause neck stiffness Med Control might have us perform a Kernig's sign test and look for other signs of Meningitis.

Based on the info you provided she is going to be getting routine transport to local ER via BLS.


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## leoemt (Sep 4, 2012)

Disregard my above post, I couldn't edit it because the 15 minute limit was up. 

After doing some research (and re-reading the scenario) I would be calling ALS. 

Her other symptoms raise the possibility that she is in the aura stage of a seizure. As a result, she can't maintain her own airway so no oral glucose. ALS will be called to start an IV. 

Reassess and transport routine.


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## Doczilla (Sep 4, 2012)

Let's not get carried away. Let the hospital decide what's wrong with her. Children have much less glycogen stores than adults do, so one amp of d50 is not guaranteed to "fix" her neurologic symptoms, even if the BGL spiked from one dose. 

The process of cellular injury in the brain is complex, and the only true way to start ddxing is after a barrage ancillary studies. Even then, take all of your facts as they come; compartmentalize them, then make your educated guess after you have all of the information you can. 

Could it be meningitis? Who knows? Will it change your treatment? Nope.


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## NomadicMedic (Sep 4, 2012)

It's clear that the primary TREATABLE IN THE FIELD issue is hypoglycemia. Aside from that, the patient may have seizures related to her chronic condition, may have a new illness such as meningitis or a Medulloblastoma or may have sustained a head injury that bystanders are not aware of. 

In any case, the first issue is to attempt to correct the hypoglycemia. From what I understand, IV Dextrose is an intermediate skill. However, if the Patients mental status does not improve and the patient continues to experience seizures, a full ALS unit, with the ability to administer benzos and manage the airway, if needed, should be the response/transport unit. 

This is why I am not a fan of "advanced EMTs" taking the place of a full ALS unit. An intermediate/advanced EMT working with a paramedic would be fine, but sending two technicians with just enough education and drugs to be dangerous and expecting them to manage anything but "ALS light calls" is problematic.


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## mycrofft (Sep 4, 2012)

Roger the 2 preceding posts. Tx glucose and apply tincture of throttle cautiously. Guard airway.


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## Doczilla (Sep 4, 2012)

n7lxi said:


> It's clear that the primary TREATABLE IN THE FIELD issue is hypoglycemia. Aside from that, the patient may have seizures related to her chronic condition, may have a new illness such as meningitis or a Medulloblastoma or may have sustained a head injury that bystanders are not aware of.
> 
> In any case, the first issue is to attempt to correct the hypoglycemia. From what I understand, IV Dextrose is an intermediate skill. However, if the Patients mental status does not improve and the patient continues to experience seizures, a full ALS unit, with the ability to administer benzos and manage the airway, if needed, should be the response/transport unit.
> 
> This is why I am not a fan of "advanced EMTs" taking the place of a full ALS unit. An intermediate/advanced EMT working with a paramedic would be fine, but sending two technicians with just enough education and drugs to be dangerous and expecting them to manage anything but "ALS light calls" is problematic.



This. SO this. This soooo hard.


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## Remeber343 (Sep 4, 2012)

Swimfinn said:


> you notice that she appears as though her head is turned left and slightly upward, eyes midline to left deviation, her tongue appears to be continously darting in and out of her mouth and licking the top lip



I would call for a chaplain and start an exorcism. 


I have a question for you, OP.

If the D50 fixed the above issues, would you transport to the hospital?  If so, why, if not, why.  I am quite curious as to how you would proceed.

What if the "seizure" she was having had stopped on your arrival, you admined D50, and she was asymptomatic.  Would you still transport?


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## NomadicMedic (Sep 5, 2012)

FWIW, I believe the OP is a teen aged first responder. I think this scenario is presented as a "learning experience" rather than anything the OP has been involved in. 

Thus, this scenario should be used only as a teaching point, not to Monday Morning QB the care (or lack of it).


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