# Diabetic Emergency Question



## thowle (Jan 1, 2008)

Okay, today we were dispatched to a female patient with known diabetic related problems; the complaint was that the patient was eating breakfast, became disoriented and finally became unresponsive to verbal stimuli.

Prior to the patient becoming unresponsive, a family member gave a some orange juice to the patient, which rendered apparantly rendered very little positive results (because the pt later was unresponsive).


This seems like ( for an EMT-B ), a good time to administer Oral Glucose, I was thinking -- atleast until ALS arrived, and then they could do their own thing.

But my question is this, we were "taught" that if a patient is unresponsive, and/or cannot swallow that it is to be forseen as a CONTRAINDICATION, and seeing as how this patient is unresponsive -- what would the correct intervention be?

Of course, we would need to ensure ABC's, and monitor closely -- but would there be anything wrong with placing glucose on a tongue-depressor and inserting it by their gums so that it may absorb?

How would you handle this sitation?  Waiting for ALS without giving any intervention seems quiet risky to me.

Thanks


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## Jolt (Jan 1, 2008)

I think you can technically give glucose PR so you don't have to worry about aspiration, but that's all you...


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## thowle (Jan 1, 2008)

Jolt said:


> You can technically give glucose PR, but that's all you...



Yeah, I don't think I would want to be the one administering it that way  lol


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## ffemt8978 (Jan 1, 2008)

thowle said:


> Okay, today we were dispatched to a female patient with known diabetic related problems; the complaint was that the patient was eating breakfast, became disoriented and finally became unresponsive to verbal stimuli.
> 
> Prior to the patient becoming unresponsive, a family member gave a some orange juice to the patient, which rendered apparantly rendered very little positive results (because the pt later was unresponsive).
> 
> ...



Remember the first rule of medicine: DO NO HARM

It's even riskier for you to give an improper intervention than to do the basics or nothing at all.  Even giving oral glucose on a tongue depressor is contraindicated if the patient does not have a gag reflex.  You could do more harm by letting the patient aspirate the glucose because they can't protect their own airway.

As a BLS crew, there's not much you can or should do until ALS arrives.  ABC's, oxygen, vitals, and wait for ALS or transport to ALS intercept.


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## thowle (Jan 1, 2008)

ffemt8978 said:


> As a BLS crew, there's not much you can or should do until ALS arrives.  ABC's, oxygen, vitals, and wait for ALS or transport to ALS intercept.



Okay, good deal.  That's what I was needing to know.


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## Katie (Jan 1, 2008)

It may depend as well on your state protocol. We're to consider glucose here for 1) "altered mental status with known diabetic history" and 2) "unconscious for an unknown reason." Absence of a gag reflex being listed as a precaution, not a contraindication. I had that question as well during class as to giving oral glucose to someone who is unresponsive. My instructor said to consider glucose placed between the cheek and gum (as indicated in our protocol). In this case the pt does not have to swallow; rather the glucose is absorbed via the gums. So to minimise the risk of aspiration we administer "10-15 grams of glucose paste between the gum and cheek" both for adults and kids, and have suction ready, etc.


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## seanm028 (Jan 1, 2008)

I was taught the same as you said you were, "don't give oral glucose to a Pt who is ALOC".  I would call ALS and maintain ABCs while they were en route.


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## emtbuff (Jan 1, 2008)

we were also taught and teach no glucose if unresonsive.  However like others have said we have also done and seen it work by giving a small amount of glucose paste in the cheeck/gum area.  Little bit at a time.  With High flow O2 on and suction near by.  If you suspect problems don't do so...and if all else fails and you dont' wanna do this maintain an airway transport and if ALS is availble either wait if they are close or meet up.


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## MMiz (Jan 1, 2008)

Our protocols don't allow oral glucose for pts with an altered LOC or without a gag reflex.  I understand that you could place it between gums and cheek, but I sure wouldn't want to risk messing with a pt's airway.

I'd monitor and ensure the ABCs while ALS was en route.


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## paccookie (Jan 1, 2008)

If I were you, I would monitor vitals and provide oxygen while waiting for ALS to arrive.  I wouldn't give oral glucose to an unconscious patient.  

This would be an excellent situation for glucagon, but I know that's out of your scope of practice.  It's even out of my scope of practice as an intermediate.  I know protocols say to use D50 first, but I've seen glucagon have amazing results almost as fast as D50, plus you don't have to get an IV first and there's no risk of necrosis if your IV infiltrates.  

If your patient is conscious and you don't have oral glucose for whatever reason (like you're in the first responder role), you can use cake icing or cotton candy.  Although with cotton candy, blood glucose goes up quickly but drops quickly too.  We used that at the fair a few times last fall with good results.  lol

Christina


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## Ridryder911 (Jan 1, 2008)

A small amount of oral glucose can be safely administered orally, if the patient is placed in the coma position (on lateral side/recumbent) and placed between the cheek and gum (bucossa) or under the tongue (sublingual). Have suction on hand to suction as necessary. Again a small amount, not to induce or increase the risk of aspiration. 

Careful monitoring of the airway is essential. 

R/r 911


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## Aileana (Jan 1, 2008)

I believe our protocols allow us to give a small amount of glucose paste buccally. As long as you place the patient so that they don't aspirate it (which, if they are unconscious, you're probably doing anyways). Having suction handy is always a good idea for that, as well as constant monitoring and ensuring ABC's.


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## Momokahn (Jan 1, 2008)

I think this is a very interesting conversation topic.  The comment I would like to have on it is this.  Admin of glucose to an unresponsive pt. is a contraindication.  I know you mean well thowle but the problem is two fold.  Number 1.  If you decide to "bend" this rule (contraindication) for the benefit of the patient you might find yourself being able to justify to yourself "bending" other contraindications in the future and it could turn around and bite you.

Number 2.  I have to respectfully disagree with Ridryder911 about this being done safefully.  At his level he might be able to do this safer than a "B" but the pt is still unresponsive.  A line is the only way to avoid the airway possibly becoming compromised.  Saliva will be produced once that glucose hits the mouth and there is no way we to stop it.  Where goes sugar so goes water.

The bottom line problem thowle is this.  Lets say you administer the glucose and have no problem then the pt codes on you for something totally unrelated.  I would hate to be in the courtroom with the ambulance chasing attorneys when they try to shred you alive on something that had nothing to do with your teatment.  It's the dam ugly world we live in.

Take care and keep up the good work.


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## Ridryder911 (Jan 1, 2008)

One must remember why the glucose is administered. Even in first aid, rescuers are taught to make a sugar paste to administer for those with decreased LOC. 

As an EMT, one should be able to monitor an airway for aspiration, and decrease it again by placing the patient on the side and again with suction. Since oral glucose is not a liquid rather is a gooey paste like consistency. 

Having decreased glucose to produce unresponsiveness is dangerous enough to possibly warrant the risk of closely monitoring the airway to prevent aspiration to occur. Again, remembering the reason for unresponsiveness and the reason for administering it. Cells deprived of glucose (hence: insulin shock) can even cause more problems other than aspiration of small amount of oral glucose. 

The EMT curriculum advises to perform it with special attention and precautions as I described. If your protocols state differently, then I would contact medical control for advice... I would not be surprised that one would not be ordered to administer small amounts & again monitor airway.

R/r 911


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## iamjeff171 (Jan 1, 2008)

would you consider actually finding out what the pts blood glucose was to ensure this is in fact a diabetic emergency?  it sounds like the pt was already getting plenty of glucose (food and orange juice) before they became unresponsive.  

-Jeff


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## Ridryder911 (Jan 1, 2008)

Of course a FSBS should had been performed prior to differentiate between CVA and hypoglycemia, however; Hx if DM would be a precursor of the s/s ...

R/r 911


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## Flight-LP (Jan 1, 2008)

Ridryder911 said:


> Of course a FSBS should had been performed prior to differentiate between CVA and hypoglycemia, however; Hx if DM would be a precursor of the s/s ...
> 
> R/r 911



Darn, 
        Two pages of posts and I was about to call that one out. Beat me to it as usual. Key point here, before we start thinking about treatment, why not establish a possible diagnosis or at least cause of the altered LOC. Most diabetics do not get hypoglycemic while eating breakfast or fail to respond somewhat to OJ. If I was told that a pt. was eating and maintaining their medication regime and then became unconscious, I would start thinking outside of the "oh he/she is hypoglycemic box". A blood glucose level will confirm or disprove the hypoglycemic condition. Not too much of an issue with Oral Glucose, but if there is a continued interest in maintaining an EMS certification, I certainly wouldn't give Glucagon or D50 without getting one....


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## chaplainwmdavwarneremt (Jan 2, 2008)

I'd monitor and ensure the ABCs, administer Oxygen while ALS was en route.


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## oldschoolmedic (Jan 2, 2008)

Just something to consider, what happens if you put instaglucose in the unresponsive patient's mouth and my stupid paramedic self comes along and has to intubate the patient? Does anyone believe the possibility of introducing a sugar rich solution to a dark, moist, warm enviroment poses no problem?

Put nothing in their mouth (might not be hypoglycemia). Give them oxygen, get a baseline set of vitals, a blood glucose level, and keep them safe and comfortable until ALS arrives and can give them IV D50%, if indicated. Or better yet, load them into your unit, and meet ALS in route. Give them a report prior to arrival so they can have the appropriate gear with them when they get on your truck.


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## skyemt (Jan 2, 2008)

we do not give oral glucose to someone without a gag reflex... 

however, flight-lp, you beat me to my post?

presumably, ALS has already been called... but why so sure it is a diabetic emergency? it struck me as immediately odd to have that kind of emergency during breakfast, with no response to OJ...

as a basic i can say this... i see too many times where just because someone has a diabetic history, the mindset of the basic is to treat that condition.
diabetics, perhaps more than others, are prone to a great many OTHER afflictions that could cause these s/s...

if the s/s or events leading up to the episode are not really making sense vs what you might expect to see, it is time to take a step back and make sure you have a good assessment and history. ALS responding means you don't have to be hasty and administer a treatment you are not sure about...

and, MOST IMPORTANTLY, if that little voice in your head is saying "i'm not sure here", and you don't have ALS as a resource, CALL MEDICAL CONTROL FOR HELP.  that is one of their many important functions.


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## bonedog (Jan 2, 2008)

Here in BC only the first responders (usually FD) don't have IV's. Most basics can start IV's and tx hypoglycemia, if unable to establish IV they revert to glucagon. First line tx is sl/buccosal glucogoo... in recovery postion. ALS isn't usually dispatched on these calls, although we do appreciate pink hair...

If the patient has a pre-existing lesion, the hypoglycemia may mimick a CVA due to the decreased perfusion. Twice I have tx this presentation in care homes, the nursing staff were ecstatic that we were able to cure the "stroke".


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## TransportJockey (Jan 2, 2008)

If this were me, I'd keep watch on ABC's and either do an ALS intercept or wait for them to show. Here in NM it's a contraindication to use oral glucose on ALOC pts. Although if I was partnered with an EMT-I, they could start IV


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## enjoynz (Jan 2, 2008)

Interesting that this post should come up, when I was talking to another Ambulance officer just yesterday, about hypoglycaemia (how we spell it in NZ).
Here AO level (EMT - b) are allow to give IM Glucagon, but it does take a while to mix the powder to the liquid.
I saw something interesting on Christmas day, that I've never seen before.
My daugther got a lolly in the form of a spray (something like a breath freshener), the latest fad!
I was talking to my friend about it, and said that it would be good to have something like that to carry on the ambulance. You could just spray it under the pt's tongue, even if they had a lowered LOC.
Your thoughts?

Cheers Enjoynz


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## John E (Jan 2, 2008)

*Given the conditions stated...*

it seems to me that the proper course of TX for an EMT-B would be to monitor ABC's and call for ALS. Others have pointed out that it could very well not be a diabetic situation at all, why would you administer any sort of glucose if the patient is suffering from something unrelated?

I wish the poll that's being used had an option that included monitoring and calling for ALS instead of "do nothing but monitor".

John E.


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## triemal04 (Jan 2, 2008)

Risk vs Reward, just like most medicine.  If you know that hypoglyemia is the issue and ALS is not and will not be available, AND the transport time to the nearest ER is extended, then your options are limited.  Use small amounts of glucose and monitor the airway closely.

But, if ALS is nearby, then why?  Hypoglycemia is a problem that is easily corrected with the right equipment/knowledge, so why potentially make things worse if you don't have to.


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## bonedog (Jan 2, 2008)

As diabetic's are easily diagnosed and tx, I would think having basic's give IV dextrose/thiamine would be preferable, although I suppose that is the way our system is set up. I suppose state side ALS must be readily available in most areas, so that is why diabetics are tx by them only?


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## skyemt (Jan 2, 2008)

i rather think that diabetics often have complicated medical histories, due to the numerous system failures that are secondary to the diabetes...

it is precisely why most protocols allow basics to treat diabetics under a narrow set of circumstances, where the treatment or oral glucose is not likely to do much harm...


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## certguy (Jan 3, 2008)

*diabetic problem*

Given the fact the pt. was given OJ prior to becoming unresponsive ,  if the problem was hypoglycemia , this should've kept her from going uresponsive . At this point I'd be looking for a different problem . Many people have a tendency to tunnel vision on one possibility rather than consider all . I'd be considering the following ; 

What are pt's vitals ? 
How's her resperatory effort ? 
What's the rest of her hx ?
What's my transport time to the nearest facility vs. ALS ETA ?

Oral glucose is contraidicted due to unresponsiveness . I would consider inserting a NPA , 15 LPM by non - rebreather , suction if needed , if her respirations aren't effective , assist ventilations . Look for other clues to her condition ( accidental OD , CVA , cardiac , etc. ) . If I can get her to ER before ALS arrives , or can arrange an intercept , load and scoot . Watch the vitals closely the whole time  , note any change in condition , and be ready in case she crashes or comes around and becomes combative . An extra set of hands in the back never hurts . 

We need more options in that poll .


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## BossyCow (Jan 5, 2008)

Vitals certainly!  Before administering insta-glucose I would want to know what the pts blood sugar was.  I don't see much of an issue with the breakfast thing.  The pt was at the breakfast table as I see it and early morning is a prime time for low blood sugar.  The OJ may or may not have been sweet enough or in time to make a visible difference.  Also I would be looking for a possible meds mixup.  Very common for diabetics to take the wrong med if they are sleepy or not paying attention.  

If a glucometer reading showed low blood sugar, if the pt had a gag reflex, if there was suction available and the pt was placed in the position Rid described, I would most likely give them the oral glucose, just a pinch between cheek and gum.  If the saliva was an issue, it would be addressed by the positioning, the saliva would run down and out of the mouth.  Placed toward the front of the mouth rather than back in the throat, it can be absorbed by the tissue and be where it can be removed by suction if the pts LOC drops futher.


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## futureemt (Jan 6, 2008)

Okay, I know I didn't start school yet and I understand the gag reflex with the tablet, but they make a Oral glucose gel, we have it at work.  Wouldn't that be safer and absorb faster???


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## certguy (Jan 7, 2008)

*diabetic problem*



Flight-LP said:


> Darn,
> Two pages of posts and I was about to call that one out. Beat me to it as usual. Key point here, before we start thinking about treatment, why not establish a possible diagnosis or at least cause of the altered LOC. Most diabetics do not get hypoglycemic while eating breakfast or fail to respond somewhat to OJ. If I was told that a pt. was eating and maintaining their medication regime and then became unconscious, I would start thinking outside of the "oh he/she is hypoglycemic box". A blood glucose level will confirm or disprove the hypoglycemic condition. Not too much of an issue with Oral Glucose, but if there is a continued interest in maintaining an EMS certification, I certainly wouldn't give Glucagon or D50 without getting one....



BINGO ! I was beginning to wonder if anyone else would pick up on it till you guys did . Can we say " tunnel vision " boys and girls ? The food intake and OJ with meds shouldn't indicate a hypoglycemic problem . We're dealing with something else here , accidental OD or CVA perhaps . Not knowing exactly what we're dealing with , it'd be prudent to be prepared for the worst case scenerio and anything else is cake .


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## basic (Jan 7, 2008)

I was taught not to administer oral gluclose if they had no ability to swallow or an ALOC.  So, I would monitor ABC's while ALS was en route, as well as continue my assessment.


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## futureemt (Jan 7, 2008)

certguy said:


> BINGO ! I was beginning to wonder if anyone else would pick up on it till you guys did . Can we say " tunnel vision " boys and girls ? The food intake and OJ with meds shouldn't indicate a hypoglycemic problem . We're dealing with something else here , accidental OD or CVA perhaps . Not knowing exactly what we're dealing with , it'd be prudent to be prepared for the worst case scenerio and anything else is cake .



Okay, I just heard this.  I know  with low blood sugar you can drink OJ...but someone told me you can give milk too...anyone hear about this one?


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## emtwacker710 (Jan 17, 2008)

personally, because of the area I'm in als is 5 minutes away max, if that, so i would moniter abc's and gather history and all that fun stuff and wait for als to do an iv and all their special stuff


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## TKO (Jan 17, 2008)

Bringing threads back from the dead, are we? Ok, I'll go along....

After an assessment and Hx with BGT to determine that this is a sugar issue, I would follow my Hypoglycemia protocol (BGT > D10W bolus > Thymine > transport).  HOWEVER, if this pt was geriatric, IDDM with paper skin and spidery rolling veins, I would probably reconsider the I.V. to prevent causing an infection.  I could go with Glucagon SQ instead....but I would need something from the fridge to go.  So I might use glucogel, especially if I have a 20 minute transport time and no carbs to go with us.

As it stands with glucogel, it is pretty common practice (around BC, Canada anyway) for BLS and ALS to roll pts into a semi-prone position and apply glucogel to the buccal pouch as gravity will keep the gel from mucking with the airway.  Again, this is a common practice, but the Canadian Diabetic Association states that glucogel is a macromolecule that can not be absorbed through the buccal membrane and must be swallowed to be effective.

Although, many of us seem to have experiences to the contrary.


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## TKO (Jan 17, 2008)

Hey Bonedog, good to see another BCAS employee around (if you still are around here) !!

You must not get out much past Alpha territory these days.   There are a lot of EMRs still working in the system, and they can't start IVs or admin any drugs, except entonox  and can assist with pt prescriptions and give Nitro w/existing prescription.


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## TKO (Jan 17, 2008)

futureemt said:


> Okay, I just heard this.  I know  with low blood sugar you can drink OJ...but someone told me you can give milk too...anyone hear about this one?



Sure if that's all you have to work with.  Milk contains Lactose, which is a more complicated form of glucose.  However, if the pt is lactose intolerant you won't be doing them any favors.  Breads and high-carb products work very well because they are readily converted into fuel for the body and is the bods first choice.  Refined sugars are not necessarily the best choice.

A cheese sandwich is a great definitive treatment once the pt's LOC improves.


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## Meursault (Jan 17, 2008)

TKO said:


> Again, this is a common practice, but the Canadian Diabetic Association states that glucogel is a macromolecule that can not be absorbed through the buccal membrane and must be swallowed to be effective.
> 
> Although, many of us seem to have experiences to the contrary.



I have a feeling your experience is accurate. I've always been taught that glucose can be absorbed through mucous membranes, hence oral or rectal (thank God, not in my protocols) administration. From my limited experience with cell bio, glucose is not a macromolecule. I have no idea where they're coming from.


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## TKO (Jan 17, 2008)

Glucogel itself is a compound that is a macromolecule, not the glucose component.  I can't now find the reference to this finding, and I am not a biochemist, but I can provide it when I finish my tour in a few days.

Or perhaps someone knowledgeable will be able to corroborate what I have started here.


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## Meursault (Jan 17, 2008)

I thought  that might be the case, but I checked and the manufacturer of GlucoGel states that it's just a 40% dextrose gel, and several other manufacturers describe their products as containing pure glucose.

I couldn't find anything relevant about oral glucose on the Canadian Diabetes Association's site. If you can find that paper, post it, because I'm curious now.


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## TKO (Jan 18, 2008)

MrConspiracy said:


> I couldn't find anything relevant about oral glucose on the Canadian Diabetes Association's site. If you can find that paper, post it, because I'm curious now.



Will do!

Google isn't nearly as effective as it used to be....this was all I could find from here and it's not descriptive enough.  It's the same question.

http://www.diabetes.ca/cpg2003/downloads/hypoglycemia.pdf and then scroll to the bottom of the first page, under the paragraph "Treatment of Hypoglycemia" where it states that Glucogel must be swallowed to be significantly effective.


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## Meursault (Jan 18, 2008)

That handout cites four papers for the ineffectiveness of oral glucose. I wasn't, unfortunately, able to get the full text because they were all published some time ago. Two were published in JAMA ~30 years ago and indicate that oral glucose doesn't change serum glucose much unless swallowed, which is exactly what the handout said. 

Interestingly, one of them specifically tested absorption through the buccal mucosa by radiolabeling and found almost nothing reaches the bloodstream. 

I'm still looking for newer research, but it seems that glucose is effective, but it has to be swallowed, and it's a little slow for prehospital care (blood glucose rise of 3.1 mg/dL/minute in another study).


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## TKO (Jan 18, 2008)

and yet, most of us have personal experiences with glucogel that suggests the opposite is true.


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## griz1974 (Mar 4, 2008)

*oral glucose*

you can not give oral glucose if pt is unresponsive it cause an air way abstructsion do abcs and call als and transport asap


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## mikie (Mar 5, 2008)

BLS here: glucagon, IM


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## Ops Paramedic (Mar 5, 2008)

So who wrote the protocol?? (our BLS protocol here is along the same lines) It is most likely that by the time the ambo service is called for a hypoglyceamic pt, the pt will have a dercreased LOC??  So they want you to go and service the call, but in the same breath they are "contra indicating" you...

The answer to your poll is not on the list of choices.  Call your back-up and get going to hospital.  Monitor your ABCs & vitals etc. and transport lateral.  Your Back-up could meet you en route.


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## paramedix (Mar 18, 2008)

If the patient is unresponsive and lateral... why can't you put small amounts of glucogel on the outside of the gums?


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## fma08 (Mar 23, 2008)

officially dont do anything to compromise the pt's airway, i.e. giving oral glucose to an unresponsive pt. unofficially, we were taught in basic that, if carefully done, some oral glucose can be given through the buccal rout. So its up to you to decide. Get ALS coming for sure because there's nothing like some D-50 for hypoglycemia.


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## Jayxbird521 (Mar 23, 2008)

it could be do to other things as well not just diabetic


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## Firesurfer75 (Mar 26, 2008)

Administering glucose could kill 'em from the sounds of the scenerio.. check BGL. Don't admin anything oral when pt is unconcious, regardless of how small the object is. I'd say maintain airway, check BGL and seek ALS via on-scene or hospital.


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## TKO (Mar 30, 2008)

Ok, not to contradict myself, but rolling a pt into the lateral recumbent position and applying some glucogel into the buccal space is a good idea.  The pt will just drool the excess out anyway and the airway will be fine.  If even a small amount gets in there, that's a good thing.

Remember that diabetics have microvascular issues and are very prone to infections, so don't rely on Dextrose in water to save their butt, as for one thing, they're burning brain cells on your clock.  And if the medic pooches the line (because those veins are tricky) and D50 goes interstitial, then the pt could lose the extremity.  We absolutely have to be aware of the pts quality of life as a result of our actions.  

So a little intervention isn't going to hurt the pt whether it works or not.  Just so long as they aren't supine, they're ok for glucogel.  Don't withhold that little amount because someone says it's contraindicated in UnCx; get verification on that from your rule makers, because done properly it is a harmless attempt to use the only tool some BLS providers have.

And remember, high-flow 02 too!  Eliminate that acidosis.


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## skyemt (Mar 30, 2008)

TKO said:


> Ok, not to contradict myself, but rolling a pt into the lateral recumbent position and applying some glucogel into the buccal space is a good idea.  The pt will just drool the excess out anyway and the airway will be fine.  If even a small amount gets in there, that's a good thing.
> 
> Remember that diabetics have microvascular issues and are very prone to infections, so don't rely on Dextrose in water to save their butt, as for one thing, they're burning brain cells on your clock.  And if the medic pooches the line (because those veins are tricky) and D50 goes interstitial, then the pt could lose the extremity.  We absolutely have to be aware of the pts quality of life as a result of our actions.
> 
> ...



sure, sounds great... would you like to rewrite many of the protocols that say we can not give oral glucose to a pt that is unresponsive?


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## TKO (Mar 30, 2008)

Sure would!!!  LOL!

Sorry, but as I said in the above, find out from the powers that be for this specific method of glucogel delivery before attempting.  More times than not, there's nothing against it specifically.

Where I live (BC) we are beginning Treatment Guidelines; the concept is thinking outside the box with respect to pt treatments.  If it isn't going to make the pt worse, then there's no harm not to try it.  So AED for small children, for example, if it's not blunt trauma, electrical or cardiac hx then we couldn't shock.  But with Treatment Guidelines, if you've done everything else and CPR alone isn't working, then we can use the AED.  It isn't going to do any worse.

That's just the official changes, pretty well every EMS practicioner everywhere has been adapting to a bad situation within tolerance levels since EMS started interventions and treatments.

Back to the point, seriously, roll your UnCx pt onto their side and admin some glucogel (5-10 g) into the buccal pouch.  Have suction standing by.  This just isn't a harmful treatment.  It's like new ways of applying dressings.

PENDING APPROVAL, of course!


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## BossyCow (Mar 31, 2008)

We can act outside of our protcols with a simple phone call to medical control explaining the situation and the precautions we will take. If I called and told the doc that I wanted permission to do what TKO described and let them know that I had no ALS available, and gave the estimated time until I could meet with ALS, I would most likely be given permission.

Protocols are not Must Do's in every instance. They are guidelines and most systems have another protocol regarding those gray areas.


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