# Lifeline Activation



## Swimfinn (Aug 27, 2012)

You are called on scene to a lifeline activation. after about 10 mins of ****ing around outside looking for a key, PD arrives and kicks in the door. 

After searching the house, you find a woman 85 years old in the TV room on the floor. She is altered and thrashing around on the floor trying to get up. No matter how hard you try you cannot get her to stay still.


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## STXmedic (Aug 27, 2012)




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## Medic Tim (Aug 27, 2012)

why did you wait for the police? did you feel the old lady was a safety threat?


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## usalsfyre (Aug 27, 2012)

Gonna need a little more to go on...

General condition of the residence? Impression of the patient? Vitals? History?


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## DPM (Aug 27, 2012)

Break dancing. 

Next scenario please.


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## Meursault (Aug 27, 2012)

Medic Tim said:


> why did you wait for the police? did you feel the old lady was a safety threat?



In my experience, because people expect police to kick in doors and because police departments, unlike EMS agencies, are willing to protect their employees from frivolous legal action. That, and I probably couldn't kick an exterior door without making a fool of myself.

Around here, fire does it more often, and do they ever get excited about it.


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## Swimfinn (Aug 27, 2012)

we waited for police because the engine was 30 min out...

bp was 100/60
hr of 78
responsive to painful stimuli
blood glucose of 31
spO2 of 93% on room air



sorry about that i thought i had added the vitals

Edit: unknown history


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## Aidey (Aug 27, 2012)

Give her glucose.


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## Doczilla (Aug 27, 2012)

Blood sugar of 31, eh? ......................


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## Doczilla (Aug 27, 2012)

Arrrrgh got beat to it again!


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## DesertMedic66 (Aug 27, 2012)

Aidey said:


> Give her glucose.



Same. Reassess after glucose and see how she is. AOx4 with no complaints, doesn't want to go to the hospital, have her eat something that will keep her sugar up, and then AMA.


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## Swimfinn (Aug 27, 2012)

blood sugar raises up to 91 after an amp of D-50. Got her packaged and into the rescue. Did another vitals.

bp: minimal change
hr: 77
blood sugar: 40
alert and orientedx2


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## DesertMedic66 (Aug 27, 2012)

Someone correct me if I'm wrong but does IM glucagon last longer (ie keeps blood sugar levels up longer) then dextrose?


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## Anjel (Aug 27, 2012)

Swimfinn said:


> blood sugar raises up to 91 after an amp of D-50. Got her packaged and into the rescue. Did another vitals.
> 
> bp: minimal change
> hr: 77
> ...



Her BGL went up 9 with an entire amp of D50? Strange. 

And I was told glucagon is great, but if she was to sign AMA, she would no longer have any back up glucose storage in her liver. I hope I am making sense with that. 

We don't have it. So I'm not sure.


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## Medic Tim (Aug 27, 2012)

MrConspiracy said:


> In my experience, because people expect police to kick in doors and because police departments, unlike EMS agencies, are willing to protect their employees from frivolous legal action. That, and I probably couldn't kick an exterior door without making a fool of myself.
> 
> Around here, fire does it more often, and do they ever get excited about it.



We only get fire if we are in a city. The volly rural departments here do fires and accidents( if we are lucky) Police will not come to kick a door in for us... they will come once we do kick it in to secure it. If we need in before a keyholder can be found. we get in.  Most times though we do not kick the door in. whatever is safest and makes the most logistical sense(cut screen, break window, kick in door, etc) We don't do this alot just when we know for sure someone is locked in and there is immediate need to get to them.

where I work in the US, we are to call for police and or fire but we can kick it in if we feel it is in the pts best interest. 

Both have SOPs/SOGs


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## Medic Tim (Aug 27, 2012)

Swimfinn said:


> ..... blood sugar raises up to 91.....
> 
> 
> 
> ...



so which is it......91 or 40?


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## Doczilla (Aug 27, 2012)

Glucagon dosent increase it as fast. It's only for unattainable I.V access to buy time. Plus, I'd their liver is tapped, it won't work.


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## STXmedic (Aug 27, 2012)

Giver her another amp an tell her to lay off the insulin when it's not needed :unsure:


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## Anjel (Aug 27, 2012)

Doczilla said:


> Glucagon dosent increase it as fast. It's only for unattainable I.V access to buy time. Plus, I'd their liver is tapped, it won't work.



Oh! Oh! I was kinda right!


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## NomadicMedic (Aug 27, 2012)

You can't use glucagon in kids or alcoholics, their glycogen stores have been reduced and you won't have anything to convert.

This this sounds like a call I just went on. Woman was only supposed to take a couple units of insulin and wound up giving herself 20. I'd give her D50 and her sugar would only go up a couple of points. So, we took her to the hospital and they put her on a drip and waited for the insulin to wear off.


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## abckidsmom (Aug 27, 2012)

Or possibly an overdose of metformin or some other oral hypoglycemic.


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## Swimfinn (Aug 27, 2012)

Anjel1030 said:


> Her BGL went up 9 with an entire amp of D50? Strange.
> 
> And I was told glucagon is great, but if she was to sign AMA, she would no longer have any back up glucose storage in her liver. I hope I am making sense with that.
> 
> We don't have it. So I'm not sure.



no her blood sugar went up 91. it fell back down after the ten mins it took to get her packaged and into the truck


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## Anjel (Aug 27, 2012)

Swimfinn said:


> no her blood sugar went up 91. it fell back down after the ten mins it took to get her packaged and into the truck



Ohhhh ok. Ya too much insulin.


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## Doczilla (Aug 27, 2012)

That's definately suspicious of some extrinsic factor tanking BGL. 

Although, as with anyone, as soon as it's humanly possible you try to get a more complex form of sugar in their system. In this case, if she didn't resume mentation, that's not possible. 

I've seen firefighters head into their kitchen, peruse through their fridge, and cook them a meal. Truly heartwarming. And firefighters are great cooks.


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## Doczilla (Aug 27, 2012)

Anjel1030 said:


> Ohhhh ok. Ya too much insulin.



AGAIN!!! That's like the third time today day I've stepped on a post.


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## abckidsmom (Aug 27, 2012)

Doczilla said:


> That's definately suspicious of some extrinsic factor tanking BGL.
> 
> Although, as with anyone, as soon as it's humanly possible you try to get a more complex form of sugar in their system. In this case, if she didn't resume mentation, that's not possible.
> 
> I've seen firefighters head into their kitchen, peruse through their fridge, and cook them a meal. Truly heartwarming. And firefighters are great cooks.



We have an hour transport time to the hospital.  I've cooked plenty of meals for people.  If they aren't sick, can point to a clear reason for the low, and are feeling better, it's worth it.


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## FLdoc2011 (Aug 27, 2012)

Sometimes these patients can be tricky and you really need to look at their meds and some other factors. 

What diabetic meds is she on?  Sulfonylurea, metformin, insulin (short or long acting), etc...
Has she missed meals?
Does she have renal insufficiency? 

Metformin has low incidence of hypoglycemia and probably would not be the culprit.  Certainly an overdose can cause other serious issues but in someone taking as directed it has low risk of hypoglycemic events.

Usually we see an elderly person on a sulfonylurea (Ex: glipizide) with maybe some underlying renal insufficiency who continues to take the med and stops eating, OR develops worsening renal failure and doesn't clear the drug.   Sulfonylureas are the ones that directly stimulate insulin release and are notorious for causing hypoglycemia.  Combine a long acting Sulfonylurea with some renal failure and you can have refractory hypoglycemia that can last a day or so necessitating putting them on a D5/D10 drip until the drug is cleared.   They'll improve after that amp of D50 you give but will continue to crash if not given some continued support.  Same goes with a long acting insulting such as levemir, they can get mixed up and give themselves 100units instead of 10 and the same applies.


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## Doczilla (Aug 27, 2012)

Have you ever seen torsades with this?


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## FLdoc2011 (Aug 27, 2012)

Doczilla said:


> Have you ever seen torsades with this?



Have not


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## Swimfinn (Aug 27, 2012)

well she claimed to have been on the floor for 3 days at one point. but im not so sure about that for many reasons. first of all she was altered. second if her bloodsugar was low cause she missed meals, why did her glucose drop again below 50 after an amp of D-50? it had to be an insulin overdose.


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## Swimfinn (Aug 27, 2012)

and again we really werent able to obtain much of any useful information from her. if we asked her how long she had been on the floor it would vary from 3 days to 6 hours. also, anytime we tried to ask her something all she would say is "im sorry im sorry"

her voice was hoarse like she was possibly a smoker?

if she was septic could that explain why her blood sugar was unstable after the first amp of d-50?


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## Aidey (Aug 27, 2012)

Swimfinn said:


> well she claimed to have been on the floor for 3 days at one point. but im not so sure about that for many reasons. first of all she was altered. second if her bloodsugar was low cause she missed meals, why did her glucose drop again below 50 after an amp of D-50? it had to be an insulin overdose.



Or liver failure.

Why no medications? Were you unable to search the obvious spots to see what she takes?


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## Handsome Robb (Aug 27, 2012)

n7lxi said:


> You can't use glucagon in kids or alcoholics, their glycogen stores have been reduced and you won't have anything to convert.



Time out. 

Since when can't we give glucagon to kids or alkys? I agree with your science but it is still approved for use in both situations. 

With that said, just because we can give it doesn't mean it's going to work. 

Food for thought, and please don't shoot me for quoting a protocol but

<20 kg and unable to obtain IV access glucagon 0.5 mg IM
>20 kg and unable to obtain IV access glucagon 1.0 mg IM

With a chronic ETOH patient they'd be getting 100 mg thiamine IM as well. 

I would love to be allowed to give it IN but who knows if that will ever happen.


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## abckidsmom (Aug 27, 2012)

NVRob said:


> Time out.
> 
> Since when can't we give glucagon to kids or alkys? I agree with your science but it is still approved for use in both situations.
> 
> ...



It's worth a try but it's not going to work. I try it when obtaining IV access is not happening with the quickness.


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## Aidey (Aug 27, 2012)

You can always use it, it just may not have much of an affect. It is also highly dependent on the patient and their overall health level. The banana yellow 90lb 5'10'' alcoholic is probably not going to respond. A pink 180lb 5'10'' alcoholic probably will.


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## FLdoc2011 (Aug 27, 2012)

Swimfinn said:


> why did her glucose drop again below 50 after an amp of D-50? it had to be an insulin overdose.



See my above post


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## Tigger (Aug 27, 2012)

MrConspiracy said:


> In my experience, because people expect police to kick in doors and because police departments, unlike EMS agencies, are willing to protect their employees from frivolous legal action. That, and I probably couldn't kick an exterior door without making a fool of myself.
> 
> Around here, fire does it more often, and do they ever get excited about it.



Just once I would like to use my OEMS required hammer and large flathead screwdriver!


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## Doczilla (Aug 27, 2012)

NVRob said:


> Time out.
> 
> Since when can't we give glucagon to kids or alkys? I agree with your science but it is still approved for use in both situations.
> 
> ...



Even with healthy individuals, don't let glucagon give you a false sense of security. Again, best case scenario is let them stop seizing from hypoglycemia so you can get a line. 

Part of the "insulin shock" response is catecholamine release. That's why it got that nickname, thus the symptoms that go with it. Part of that is the release of glucagon, and the conversion of non-carbohydrate substances into energy. [Gluconeogenesis]. 

How many hemhorragic shock patients are hypoglycemic? 

When someone reaches the point of obtundation, and usually by the time you get to them, those initial mechanisms have failed to some extent. So even in a healthy liver, you're pretty much scraping the bottom of the barrel, and giving it that last "umph" to buy literally minutes. 

The best I've seen is them going from U on AVPU to P.


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## Handsome Robb (Aug 27, 2012)

Doczilla said:


> Even with healthy individuals, don't let glucagon give you a false sense of security. Again, best case scenario is let them stop seizing from hypoglycemia so you can get a line.
> 
> Part of the "insulin shock" response is catecholamine release. That's why it got that nickname, thus the symptoms that go with it. Part of that is the release of glucagon, and the conversion of non-carbohydrate substances into energy. [Gluconeogenesis].
> 
> ...



And this is why I bring things up. Because ya'll teach me the stuff school never did.


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