# D50 with Head Injury/CVA Patients..



## TsmithFF10 (Sep 1, 2008)

Yes, I searched before I posted.. but unfortunately I could not find anything already about this subject.  Sorry if it's already out there.

I have posed this question with a couple fellow co-workers recently, and wanted to hear your opinions.

Your patient is a possible acute stroke or isolated closed head injury patient, with a BSL of 30.  Do you make the hypoglycemia the priority and treat it, or do you withhold the D50 at the risk that it could cause further damage?

Now I know that D50 can possibly be necrotic to the brain tissue, I've also had someone tell me that D50 makes the blood 'thicker' and could possibly increase ICP's?  But is hypoglycemia a more acute emergency, granted with a BSL of 30 there are no simple sugars to the ischemic brain tissue, and also the possibility that it could be mimicking the signs of a CVA anyways?

I've got my own opinion on this but just wanted to hear some educated input, thanks to everyone for any response.


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## reaper (Sep 2, 2008)

I dilute down to D25 and give just enough to bring up the BGL and maintain it. In this situation, you have two different emergancies and they both need to be treated.


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## mdtaylor (Sep 2, 2008)

I don't think you will lose your patient to hypoglycemia during the trip to the hospital. Flight medics and long distance transports may have other protocols.

We would not treat the low BGL at all opting instead to let the ED do so, since our transport times are usually 5-10 minutes. If really necessary, Glucagon IM or SC may be considered.


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## Sasha (Sep 2, 2008)

Ignore it and let the hospital deal with it, they have CT, they can confirm stroke or not, and whether its ischemic or a brain bleed and deal with appropriately.


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## MSDeltaFlt (Sep 2, 2008)

What do your protocols say?  What does your medical control say?


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## JPINFV (Sep 2, 2008)

TsmithFF10 said:


> also the possibility that it could be mimicking the signs of a CVA anyways?



I think that's the biggest conundrum. So much so that hypoglycemia is even a rule out criteria for the Los Angeles Prehospital Stroke Scale. (scale. study.)


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## Emtgirl21 (Sep 2, 2008)

But is their AMS due to low blood sugar or do they have a head injury? Do you risk treating it as a head injury and it only being low blood sugar and you look stupid or do you treat it as a low blood sugar and necroses some more brain matter?


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## Ridryder911 (Sep 2, 2008)

Wow ! I am surprised by the answers. Ignore it, aww... don't worry about it? 


All I can recommend is this http://www.hpso.com/


Hypoglycemia may mimic CVA's; one of the reason that all suspected CVA's should get a FSBS to rule the hypoglycemia as the primary cause. Treat the hypoglycemia ! 

Unfortunately, it very obvious that most here do not have an understanding of how important glucose is in the body. As well most here have not studied the *Kreb's Cycle *. 

Glucose is essential for attaching the oxygen molecule to the cell for transport to the brain. In very simplified words, without it the brain will *starve* (hence the reason they lose loc). It won't matter .. poo poo if there is no glucose on board to carry the oxygen. 

Remember hypoglycemia = Insulin *Shock *! 

Do you treat shock first or a potential head injury? 

Yes, one should be very cautious upon administering large amounts of glucose. As alike was mentioned more and more are treating accordingly instead of a number of mg of glucose. D10w, D25w could be an alternative, as well remembering that D50w is only 25gms of glucose. 

Remember; not that long ago D5W was the fluid of choice for head injuries. Remember it is the concentration level glucose of the hypertonic solution that is causing the necrosis.

Again treat the life threatening injuries, and remarkable  hypoglycemia (<50) is a life threatning emergency and supersedes the head injury, potential head bleed. 

Call your medical control if you have any questions, it is much better than allowing someone to die because of lack of treatment that could had been prevented a needless death! 

R/r 911


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## BEorP (Sep 2, 2008)

Is it not standard to have glucagon available?


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## TsmithFF10 (Sep 2, 2008)

MSDeltaFlt said:


> What do your protocols say?  What does your medical control say?



My protocols say administer Dextrose 50% if BSL is below 60, whether it is to possible CVA or head injury patient.  But, even as important as protocols are, that is beside my question and what I'm truly curious of.  I'm asking what others do in the field, and what their opinion is on what's right and what's wrong.

My personal opinion is that you absolutely MUST treat the hypoglycemia, whether it's by a less concentrated dose using the pediatric D25w, or possibly glucagon IM.  In that situation I'd without a doubt make the call, paint my picture, and ask for that order.  It's an acute emergency and something we can treat in the pre-hospital setting.  Not only can it mimic the signs of a stroke, but the brain needs it's oxygen - before it becomes even more ischemic and eventually infarcts.

How about some of your local protocols?  What do they state?

Thanks again everyone.


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## Outbac1 (Sep 2, 2008)

You have to treat the hypoglycemia as Rid said. If you don't you might not have a pt to put in the ct scanner. But I wouldn't just slam in an amp of D50. Maybe 20cc to start and titrate to effect. You don't want any more D50 than necessary but you have to feed the brain and the rest of the body. When the pt glucose levels are between 4 - 7 mmol/l (70-120mg/dl), you know you have enough on board and you can treat the pt's other problems. Keep in mind you have to recheck the glucose as D50 doesn't last that long, especially when you don't give a full 50cc. If your pt is still unconscious you can't feed them like you would normally do. To ignore it is just bad medicine.


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## Ridryder911 (Sep 3, 2008)

I don't treat protocols; rather I treat patients. I don't have such protocols to administer or not administer D50w in that specific condition. In fact the total length of our Critical Care Paramedics Protocol is a total of 40 pages in length (including the so called BLS portion). 

My service and myself do not believe in cook-book medicine. If you have a shake & bake Paramedic, then you will have to have a cook book treatment. Fortunately, my Medical Director believes in knowing and treating general emergency medical care. Does one really have to have a written page to splint? 

Learn and know pathophysiology, it is the true basics of all medicine. If one really even understood the basic minimal level of science regarding glucose and the need of it as well  as not having enough or too much in the body, we would not even be having this discussion. 

It is not only surprising but also scary of some of the answers that was given. This border lines on dangerous care, not knowing such basics as glucose metabolism is just shameful. 

Statements as describing to delaying care, emphasis being placed upon of don't worry about it; really frightens me. Apparently diabetic care is still being poorly taught in EMS. This is apparently at all levels as well. One should know at least that hypoglycemia is one of the most time related emergencies in emergency medicine. That as the hypoglycemia lengthens permanent brain damage to brain cells can occur. That after a period of time that the body has to resort to fat cells to be used, that is why every second counts in treating hypoglycemic patients. 

Regardless of the reason for low blood sugar, insulin causes almost all remaining blood glucose to be taken up by cells. This is why there are alterations of level of consciousness. 
The mistaken identification of assuming one is intoxicated is often made...Why? Because the brain is unable to function properly due to poor brain metabolism.. WHICH IS ONE OF THE MOST IMPORTANT EMERGENCIES! 

Hypoglycemia is rarely seen outside Diabetes Mellitus, rather in traumatic injuries such as even head injuries; quite the opposite occurs and hyperglycemia is often seen. 

Again, appropriate triaging of systems and their injuries. Cerebral resuscitation supersedes all other efforts. Without glucose it is not if; but rather for a fact the brain cells will DIE! One cannot actually determine if there is a cerebral hemorrhage, occlusion or tear.  If the patient is in shock, it really doesn't matter. 

Alike Oxygen, glucose is one of the basic building blocks of life. Without it, there is no energy for the cell, no ability for the cell to transport nutrients, thus systems die. The patient goes into a rapid shock and yes may die. 

The reason some of us here attempt to differentiate care given by different levels is this BASIC science. This was and should had been taught in junior high/high school science.

When people discuss Basics before Advanced; let's start at the real basics. The building blocks of the body.. the cell and work our way upward. 

R/r 911


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## fma08 (Sep 3, 2008)

Outbac1 said:


> You have to treat the hypoglycemia as Rid said. If you don't you might not have a pt to put in the ct scanner. But I wouldn't just slam in an amp of D50. Maybe 20cc to start and *titrate to effect*. You don't want any more D50 than necessary but you have to feed the brain and the rest of the body. When the pt glucose levels are between 4 - 7 mmol/l (70-120mg/dl), you know you have enough on board and you can treat the pt's other problems. Keep in mind you have to recheck the glucose as D50 doesn't last that long, especially when you don't give a full 50cc. If your pt is still unconscious you can't feed them like you would normally do. To ignore it is just bad medicine.



thank you




Ridryder911 said:


> I don't treat protocols; rather *I treat patients*. I don't have such protocols to administer or not administer D50w in that specific condition. In fact the total length of our Critical Care Paramedics Protocol is a total of 40 pages in length (including the so called BLS portion).
> 
> My service and myself do not believe in cook-book medicine. If you have a shake & bake Paramedic, then you will have to have a cook book treatment. Fortunately, my Medical Director believes in knowing and treating general emergency medical care. Does one really have to have a written page to splint?
> 
> ...



and thank you ^_^


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## EMT-P633 (Sep 3, 2008)

Just my opinion and standard of my service is if we start an IV we always do a glucose check, If we have a patient with a decreased LOC, be it head injury from trauma or a suspected CVA, a glucose check is one of my top priorities.  And to fully answer your question, yes I treat low glucose below 60


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## Emtgirl21 (Sep 4, 2008)

Rid and I actually agree upon a subject....its a break through.


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## zyadfares (Dec 4, 2017)

we discuss with same paramedic about that question i till them must cases i treat i give D50 first  but most guys till me wrong because d50 make ICP HOW IS WRONG & HOW IS WRIGHT


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## TXmed (Dec 4, 2017)

I dont beleive a stroke assessment can be accurate if the bgl is that low. Give the D50 amd reassess. Yall are over thinking things.


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## akflightmedic (Dec 4, 2017)

A CCEMT P who cannot neither spell nor use proper English...

And a second CCEMT P who cannot date check!


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## CALEMT (Dec 4, 2017)

Rights and DICE bro... this thread has been expired since 08.


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## luke_31 (Dec 4, 2017)

akflightmedic said:


> A CCEMT P who cannot neither spell nor use proper English...
> 
> And a second CCEMT P who cannot date check!


You did notice that he is in Saudi Arabia. It's possible English isn't his first language.


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## akflightmedic (Dec 4, 2017)

luke_31 said:


> You did notice that he is in Saudi Arabia. It's possible English isn't his first language.



You mean where a lot of American paramedics work, Brits, Aussies, etc???


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## luke_31 (Dec 4, 2017)

akflightmedic said:


> You mean where a lot of American paramedics work, Brits, Aussies, etc???


Yes, but it doesn't mean that this is one of them. It's possible it's a local.


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## Chimpie (Dec 5, 2017)

*Stay on topic, even if the topic is nine years old.*


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## akflightmedic (Dec 5, 2017)

Someone does not appreciate sarcasm...love when I get lectured on "locals"....even in a 9 year old topic. Unwad your panties Luke.

And you do realize most foreigners speak better English than us, right?  
Except the Aussies....LOL


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