# The ultimate what would you do



## bigdogems (Sep 6, 2011)

This is one of my favorite scenarios to discuss so I thought I'd put it in here.

Never had this. It is a complete hypothetical

Respond to a MVA. Find a middle aged male pt unresponsive with head trauma. Pt has blown pupil, is hypertensive. You provide all care that would normally be given ABCs ect. Upon taking a Blood sugar you get a reading of 20 mg/dL. 

Do you give D50???? Keep in mind what the side effects are when D50 gets out of the vascular system.

Even better. Does anyone have a protocol that covers use of D50 in a head injury pt?


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## abckidsmom (Sep 6, 2011)

I would give D25, slowly over several minutes.  A BGL of 20 never did anybody any good.  The only time I have heard that we DON'T give D50 to people is when we're guessing without a glucometer.


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## MrBrown (Sep 6, 2011)

We do not use D50 we use 10% glucose.

This bloke has bigger problems than hypoglycaemia to worry about.

For those in the "ZOMG he's hypoglycaemic we need to fix it!!!" camp why not try glucagon?


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## bigdogems (Sep 6, 2011)

My personal opinion is very slow push of D50 just to get Bld/Sgr within normal limits. There may be complications of giving it in a head bleed but without enough sugar you WILL die. I have asked multiple docs about this and its pretty much a 50/50 split on to give it or not.


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## JPINFV (Sep 6, 2011)

I wonder how much outrage there will be once D50 is finally replaced with D10.


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## ArcticKat (Sep 6, 2011)

I'd just hang a 500ml bag of D5 and let it flow, try to keep it around 30 mins for the infusion rate, but as has been mentioned, this guy has bigger problems, I'll fix this one and move on.  If I have time I'll check his BGL 10 minutes down the road.  

It's pretty rare that I even give D50, I'll typically bolus a D5 and have the patient wake in a more controlled fashion.


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## bigdogems (Sep 6, 2011)

One thing Ive quickly come to notice on here is the vast difference in treatment based on location.(on a world scale) Once to the paramedic level everything is pretty close from state to state inside the U.S. And I mean that in a good way. Its interesting to see the differences.


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## gw812 (Sep 6, 2011)

Still a -B so forgive any ignorance, but isn't intracranial bleed a contra to D50? I'm with Brown on this - bigger fish to fry than the hypoglycemia. I'm already preparing to have to manage ABC's for this guy. Maybe D5W once you get to establishing an IV? Would that be a compromise between getting sugar into the system and the risk of the D50?


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## jjesusfreak01 (Sep 6, 2011)

ArcticKat said:


> I'd just hang a 500ml bag of D5 and let it flow, try to keep it around 30 mins for the infusion rate, but as has been mentioned, this guy has bigger problems, I'll fix this one and move on.  If I have time I'll check his BGL 10 minutes down the road.
> 
> It's pretty rare that I even give D50, I'll typically bolus a D5 and have the patient wake in a more controlled fashion.



Would you hang a 500ml bag knowing that the patient is hypertensive? My un-educated opinion for this patient would be D25 bag or slow push, but I think I would hold off of Glucagon because it will reverse the effects of any beta blockers our patient might be taking (and if he's elderly with previous strokes or heart problems, he's probably taking something). I want to reverse the hypoglycemia, but I don't want to cause increased intracranial pressure.


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## thinkABC (Sep 6, 2011)

Medical control....


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## EMS Patient Care Advocate (Sep 6, 2011)

Well he doesnt have enough sugar to provide brain function. What good is saving a dead brain. Yes D50 is very bad if leaked into the brain. There is good evidence that D50 can easily be diluted down to help reduce the side effects. I agree to call medical control as diluting to D10 for an infusion may not be standing orders. I HAVE had this scenario! This was the docs recomendation. They need the glucose and there is NO documented study that he knew of where D50 caused signicant necrosis when given to a possible open head bleed.


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## ArcticKat (Sep 6, 2011)

jjesusfreak01 said:


> Would you hang a 500ml bag knowing that the patient is hypertensive?



Sorry, wasn't paying attention during my patient assessment.

Probably not, I'd go with D5NS instead.  It doesn't cause edema like D5W and 500ml over 30 min isn't going to complicate matters with volume expansion.  I'd prefer D5 1/2NS, but we don't carry it.


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## lightsandsirens5 (Sep 6, 2011)

JPINFV said:


> I wonder how much outrage there will be once D50 is finally replaced with D10.


I'll be happy. ^_^

To be honest, in this scenario, I would probably dilute my D50 down to below D25...closer to D10 and then give a few grams. If it brought it up any, then push a bit more. He is still alive at 20 mgdl, right? So keep him alive. He doesn't need a BGL of 1500 to run his central command center. All he needs is enough. Where that is, who can say. I think I would just admin to effect while I hoped and prayed another ILS/ALS unit was responding to help me.


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## bigdogems (Sep 6, 2011)

jjesusfreak01 said:


> Would you hang a 500ml bag knowing that the patient is hypertensive? My un-educated opinion for this patient would be D25 bag or slow push, but I think I would hold off of Glucagon because it will reverse the effects of any beta blockers our patient might be taking (and if he's elderly with previous strokes or heart problems, he's probably taking something). I want to reverse the hypoglycemia, but I don't want to cause increased intracranial pressure.



Different dose and route. 1mg IM for diabetic. Usually depending on protocol 3-5 mg IV for beta blocker OD


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## bigdogems (Sep 6, 2011)

EMS Patient Care Advocate said:


> Well he doesnt have enough sugar to provide brain function. What good is saving a dead brain. Yes D50 is very bad if leaked into the brain. There is good evidence that D50 can easily be diluted down to help reduce the side effects. I agree to call medical control as diluting to D10 for an infusion may not be standing orders. I HAVE had this scenario! This was the docs recomendation. They need the glucose and there is NO documented study that he knew of where D50 caused signicant necrosis when given to a possible open head bleed.



I figured someone had to have this issue at one time or another in the real world. Same scenario could be used with a stroke pt. The doc that you talked to thinks the same way as most of the medical directors I've asked have. People get scared off because of how much they stress tissue necrosis with pushing D50. But among MDs there is a large thought that by the time it reaches the brain it has been processed enough not to cause damage


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## EMS Patient Care Advocate (Sep 6, 2011)

bigdogems said:


> I figured someone had to have this issue at one time or another in the real world. Same scenario could be used with a stroke pt. The doc that you talked to thinks the same way as most of the medical directors I've asked have. People get scared off because of how much they stress tissue necrosis with pushing D50. But among MDs there is a large thought that by the time it reaches the brain it has been processed enough not to cause damage



Actually yes, one of mine was a patient with stroke like symptoms as well as a low blood sugar and altered mental. My CCEMTP QA/QI gave me heavy criticism for my decision to titrate the D50 so I got to asking as many ER MD opinions as I could. They are more concerned with the patient getting the sugar than the unlikely risk of D50 leaking into the brain tissue at a concentration enough to cause necrosis. 

The concentration debate is subject to a different topic all together- D50/D10/D5. (Slamming d50 pushing a blood sugar from 20mg/dL to 300mg/dL can never be good either.) One day I too think we will be diluting and titrating this medication as we do any medication- including oxygen.
Common sense tells me though that if you dilute the D50 down to say D10 and slow the infusion some, we could greatly if not completely eliminate the worry of IV sugar in the brain injured/CVA patient. This is still recommended as “unnecessary” by the physicians I posed the scenario to. I hope this helps. It did me. Great question!


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## EMS Patient Care Advocate (Sep 6, 2011)

*No RSI*

The Short of it.
Motor vehicle crash, pt unresponsive, teeth clenched. 
In ambulance unable to pass any oral airways, NPA placed. Assisted ventilations, patient respirations are 6 a minute without assistance. Opt not to attempt nasal intubation due to likely complications and increased ICP.
No chest or lung injuries
Pupils unequal
Pt has heavy scarring over veins from what is likely heavy long term IV drug use
This state does not carry RSI medication pre-hospital.
The state does not allow facilitated intubation if you want to keep your license.
You invited air medical with the RSI supplies and protocols. They are not on scene yet. 
Respirations difficult to deliver with clenched teeth.
Looking at the big picture, knowing the respirations may be depressed from head injury or drugs- I need the patient to help me help him. I pull out the Narcan and slowly titrate to my not so surprise- RR came up to about 20 a minute. SP02 improved to 100% just gentle BVM assistance.
Just prior to air medical paralyzing the patient he begins decorticate posturing.
What would you do?


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## DESERTDOC (Sep 6, 2011)

I would give the D-50% or whatever glucose concoction you have.  The brain needs oxygen and sugar.  You know they are low on one of the two needed to sustain life.  Crappy call, but they need the fuel.


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## Handsome Robb (Sep 6, 2011)

MrBrown said:


> For those in the "ZOMG he's hypoglycaemic we need to fix it!!!" camp why not try glucagon?



This was my thought.


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## truetiger (Sep 6, 2011)

The patient's brain is this scenario has already experienced one insult. The brain needs sugar and oxygen to live, leaving the patient in a hypoglycemic state is just going to exacerbate the situation. I'd give D50 in very small increments to get to 60 and then a D5 drip if need be for maintenance.


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## systemet (Sep 7, 2011)

Give a half amp D50W, reassess.  Give the other half if necessary.  I'm not sure if I ever had specific protocols for this, but that's the sort of situation where I was allowed to use judgment.

I don't know enough about the effects of glucagon in closed head injury to feel comfortable enough going with it if I have IV access.  If I can't get IV access, then, yes, absolutely I'd give the glucagon IM.

Hypoglycemia is going to absolutely increase the rate of neuronal death in this patient.  It needs to be treated.  There's no point in ensuring the cerebrum is perfused, if the perfusion isn't transporting glucose.

My understanding is that glucose and neurologic outcome in head injury are correlated, but that no one's established causation yet.  That is, sick head injury patients who end up more severely disabled have high blood glucose, but this may just be a consequence of the stress response.  While avoiding iatrogenic hyperglycemia makes sense, I'm not sure if anyone's shown that this translates into better outcomes.


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## AlphaButch (Sep 7, 2011)

The minimum it takes to get the BG to 60ish and a bolus of diesel.

We're looking at adding D10 to our inventory for incidents such as this and after reviewing studies on the use of D10 instead of 50. This would at least give us more options.


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