# When to not use glucose



## golf (Mar 27, 2012)

In wilderness first aid, we have been taught to give oral glucose for diabetic problems (hypo or hyper) when not sure which the patient has.  Idea being, it will take awhile before it really matters and better to err on the side it was hypoglycemia.  Yet, in an article I read, it stated that if the person has not had insulin for a few days in the back country, and you know they usually take insulin, then do not give oral glucose.  So the question is:  if a person is insulin dependent, and you give them oral glucose (lets say a tube worth), what happens and how long does it take?  tnx....


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## MS Medic (Mar 27, 2012)

What I was told in basic class, and this may not hold water so please let me know if the idea is bunk, is that oral glucose raises levels insignificantly compared to the levels already. But if they are hypoglycemic, then the consequences of withholding outway the dangers of administeration to a hyperglycemic pt.


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## Aidey (Mar 27, 2012)

Telling apart hypo and hyper patients is not rocket science and it should be pretty easy to tell if your patient is hypo and needs glucose.


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## Anjel (Mar 27, 2012)

There are ways to tell if its hypo or hyper. It shouldn't be a completely blind guess.

If someone is insulin depended and haven't had insulin in a few.days. Chances are they will have high sugar.

Do you not have a glucometer? If not then remember this.

Cold and clammy give them candy.

Hot and dry sugar high.

Chances are is a diabetic is unconscious and it is a diabetic problem, then its most likely gonna be hypoglycemia. 

It takes the sugar being pretty damn high for someone to go unconscious. So if an insulin depended diabetic hasnt had.insulin, they will be high as it is. And you might push them over the edge with more sugar. 

Use what you gather in your SAMPLE, OPQRST, and initial exam to make your decision. And make sure you know the signs and symptoms of both.


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## Pavehawk (Mar 27, 2012)

golf said:


> In wilderness first aid, we have been taught to give oral glucose for diabetic problems (hypo or hyper) when not sure which the patient has.  Idea being, it will take awhile before it really matters and better to err on the side it was hypoglycemia.  Yet, in an article I read, it stated that if the person has not had insulin for a few days in the back country, and you know they usually take insulin, then do not give oral glucose.  So the question is:  if a person is insulin dependent, and you give them oral glucose (lets say a tube worth), what happens and how long does it take?  tnx....



If they are insulin dependent (type 1) and have NOT had insulin for several days in the "outback" they will not be HYPOglycemic even if they have not been eating. Type 1 diabetics do not make insulin.

A type 2 out in the woods could be in either state depending on what mediciations they have with them, and if they take them or not and what they have to eat. 

Just popping a tube of glucose to a diabetic is not a good idea unless they are showing symptoms of HYPOglycemia. If they are HYPERglycemic glucose would not be indicated. this is pretty easy to figure out as the symptomology is different even without a BGL. BUT if for some reason you did you're not going to make them significantly worse.

If the patient is nonresponsive with a history of diabetic disease of some type and you are unsure of what to do then this part is even easier... you're not going to be giving them ORAL glucose (or anything else).

As for IV glucose most (but not all) agencies now a days do not blindly give D50 (or D25/D10) without getting a BGL, but in a nonresponsive patient in a SAR situation, without evidence or suspicion of head injury or CVA D50 could be life saving. We have some SAR medic's on the forum perhaps some of them will chime in with more practical SAR protocol. I'm afraid my field SAR medic days are long behind me... back in my day if you were down you got D50 and narcan just for playing the game!!!

Hope this helps and Im sure one of the SAR guys will hop in anytime!

Cheers,

Pave


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## Anjel (Mar 27, 2012)

My bad I forgot about type 1 diabetes.


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## NYMedic828 (Mar 27, 2012)

As already stated, there are usually prominent ways to tell them apart.

If someone is hypoglycemic, the signs and symtpoms are pretty obvious. Either the patient will know they need sugar and will tell you how they feel, or they will be in an obviously altered mental state/unconscious. Many of these patients also come with pretty profuse diaphoresis + cool skin.(sweating)

If the patient is with a group, ask them for some background info. Hypoglycemia doesn't just hit you like a brick and you collapse. It is a gradual burning up of the fuel for your brain.

If a patient presents with an altered mental state, odds are they are NOT hyperglycemic. People with high sugar lack the ability a normal person does to either
A: Produce insulin
B: Utilize insulin properly.
C: Combination of A and B

This is where either a pill to aid in the facilitation of insulin/glucose use comes in. Or actual insulin injections.

A patients medications can tell you an awful lot about them if you know what to look for. 

To name a few:
Insulin - Humalog, Novalog, Humulin, Lantus
Pills - (Sitagliptin) Januvia, Glucophage (metformin)

A type one diabetic will always take insulin because there pancreas does not produce it.

A type two diabetic will usually take a pill, sometimes insulin as well because their body cannot produce sufficient amounts of insulin at the same time as having problems utilizing it.

Anyway, a person with hyperglycemia will rarely present with an altered mental state unless they have been hyperglycemic for a while. And by a while, I mean days, sometimes even longer. It is very rare someone be symptomatic with hypergylcemia in an acute setting. 

That said, the damage from hyperglycemia does not come from having too much sugar in your system. The damage comes from what your body does in place of the sugar. Since the glucose in your blood cannot get into the cells without insulin, it simply stays there and your blood sugar will just continue to rise no matter how much you eat. Your body now needs to find an alternative source of fuel that it can use without insulin. The body turns to fat. It burns fatty acids in effort to keep the engine running. The problem with fatty acids, is that burning them produces ketone bodies which are acidic. After a long enough timeframe the buildup of ketone bodies will cause the pH of the body (your body is similar to a pool) to become too acidic for normal physiologic function to continue. The body needs to maintain a nearly neutral pH. (its actually very slightly basic) So with this low pH (acidic) the body tends to try and bring balance every way it can. This usually causes the patient increased urination in an effort of the kidneys to remove acids from the body. With that excess loss of fluid from urination (polyuria), dehydration sets in, which results in increased thirst.(polydipsia) (which will reflect via the skin and mucus membranes as well) 

Little side note, the brain continues to function relatively normally during hyperglycemia because the brain can work off of "serum" glucose. This means that for primary functions it really doesn't NEED insulin. And without the rest of the body using the sugar up, the brain has plenty to enjoy.

So, in short, giving sugar to a hyperglycemic patient, in such low doses, is not going to have any harmful effects. Worst case it just raises their blood glucose a little more, but that isn't what is causing the real damage to their body. Also if someone is in a severely dehydrated state with hyperglycemia, giving them something by mouth can sometimes cause nausea.

Don't quote me to the letter on any of this, It sounds right in my head but im sure some of the forum brain surgeons will chime in at some point


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## MS Medic (Mar 27, 2012)

After reading the other posts, I went back and reread the OP and realized I misread it in the first place. So my first post in this thread looks pretty dumb.:blush:


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## NYMedic828 (Mar 27, 2012)

Also, in regards to how long it takes oral sugars to have an effect you can go more in-depth and look at something called the "glycemic index." The GI is a measure of how efficiently the body uses carbohydrates, or sugars. Pure Glucose has a glycemic index of 100. This means it is the most rapidly absorbed form of carbohydrate/sugar you can take orally. A tube of glucose is not pure glucose, but its as close as you are gonna get to it. It is usually 40% glucose which means it has 400mg of glucose per ml. I say its not pure because it is mixed with some preservatives, flavoring and water. Quite shockingly, orange juice or similar substances actually have a glycemic index of nearly half a tube of oral glucose. (Hence why we add sugar to those if we use it as an alternative)

A tube of oral glucose can take up to 15 minutes to have an effect.

Everybody is different it all depends how quickly their body absorbs the sugar.


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## Hockey (Mar 27, 2012)

A tube of oral glucose won't hurt anyone.

If they are hot, dry, and breathing really deep, I would hold off on it.  But beyond that, one tube won't hurt anyone


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## DesertMedic66 (Mar 27, 2012)

Hockey said:


> A tube of oral glucose won't hurt anyone.
> 
> If they are hot, dry, and breathing really deep, I would hold off on it.  But beyond that, one tube won't hurt anyone



Well if you throw it really hard it might..


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## Anjel (Mar 27, 2012)

firefite said:


> Well if you throw it really hard it might..



Especially some of the expired crap we have lol


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## golf (Mar 27, 2012)

*Good Take Aways*

Thanks for all the commentary.  Several new memory aids and ways to see the issue in a different way.


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## the_negro_puppy (Mar 27, 2012)

If the are conscious enough to swallow properly and obey your instructions to consume glucose, then they *should* hopefully be  able to give you their medical hx


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## Anjel (Mar 27, 2012)

the_negro_puppy said:


> If the are conscious enough to swallow properly and obey your instructions to consume glucose, then they *should* hopefully be  able to give you their medical hx



Ok so what if they are unconscious and you need to give glucose?


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## MS Medic (Mar 27, 2012)

Give it bucally by rubbing it on the inside of the cheek with a bite stick, tounge depresser, ect


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## NYMedic828 (Mar 27, 2012)

MS Medic said:


> Give it bucally by rubbing it on the inside of the cheek with a bite stick, tounge depresser, ect



I had a firefighter try and do this.

My patient was <20 mg/dl unconcious and the firefighter was kind enough to put an entire tube of glucose in her mouth before we got there. She told us she gave it bucally.


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## Anjel (Mar 27, 2012)

MS Medic said:


> Give it bucally by rubbing it on the inside of the cheek with a bite stick, tounge depresser, ect



Yes I know how to lol but they wouldn't be awake to tell you their history. So its not so easy and black and white.


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## MS Medic (Mar 27, 2012)

Anjel1030 said:


> Yes I know how to lol but they wouldn't be awake to tell you their history. So its not so easy and black and white.



It never is. We are only taught black and white in order to shade our greys.


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## Anjel (Mar 27, 2012)

MS Medic said:


> It never is. We are only taught black and white in order to shade our greys.



Ha I like that.


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## NYMedic828 (Mar 27, 2012)

Moral of the story - its pretty hard to hurt somebody with the equivalent of a few jolly ranchers.


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## ITBITB13 (Mar 27, 2012)

Anjel1030 said:


> It takes the sugar being pretty damn high for someone to go unconscious.



I've had patients with a sugar level in the low 600's, and they were totally alert, as if nothing was wrong. :wacko:


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## Anjel (Mar 27, 2012)

Our glucometers go till 600 and then read high. We had a "high" reading and the lady was just complaining of a headache lol


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## NYMedic828 (Mar 28, 2012)

Read my long post...

I explained it...


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## TraprMike (Mar 31, 2012)

Anjel1030 said:


> Ok so what if they are unconscious and you need to give glucose?



glucagon for the win!!


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## mycrofft (Mar 31, 2012)

*Wilderness   first    aid*

1. The amount of sugar you can give in a Glutose tube is like 15 grams? If hyperglycemic, this will not be enough to worsen it, and can help if hypo.
But..."wilderness"....this like glucagon will hit and then run (if the pt is hypoglycemic). If a hypo pt rouses, get some real live food into them.
2. How much sugar is the oral mucosa adapted to absorb into the bloodstream? One study shows that dextro sugar is absorbed better than levo ones  http://onlinelibrary.wiley.com/doi/10.1211/0022357021778402/abstract

but their study is in vitro...they didn't just put sugar in a pt mouth then measure serum glucose, they used instruments and a petrie dish so to speak. Doesn't indicate if the transport is significant.

If you put sugar in the mouth your salivate. If you salivate you swallow (get it orally) or drool it out (don't get it in at all). If you drool and don't drool it out, you can aspirate. The "don't dose obtunded pts" rule still makes sense, especially in the wilderness.


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## Chris07 (Mar 31, 2012)

In a backcountry setting, if you are unsure about whether or not a person has hypoglycemia or hyperglycemia, it is best to give them sugar. Hypoglycemia kills much faster than hyperglycemia, and hypoglycemia is really the only thing we can treat in the backcountry. Hyperglycemia, cannot and should not be treated in the backcountry.

Will giving sugar to a hyperglycemia make their sugar higher? Yes, but not by much. Will withholding sugar from a hypoglycemic hurt them? Yes, it can even kill them. In general, unless you KNOW the person is suffering from Hyperglycemia, sugar should be given. 

...oh and for the love of God, don't give a hyperglycemic insulin "to lower their sugar". It's risky and can crash their sugar levels. Hyperglycemics are best given controlled doses of insulin in a clinical setting, not a half-syringe full under a tree in the Appalachian mountains.


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## mycrofft (Apr 1, 2012)

Chris, having create unstable diabetics for six years I say RIGHT ON. Start seesawing insulin and glucose and a positive feedback cycle quickly develops, then huge swings, or apparent periods of stability which rapidly dissolve.
1. Give sugar if pt can manage airway and swallow.
2. Get them out to help.

Oh, and entertain the thought that maybe there is something else wrong instead of/as well as glucose imbalance. Keep evaluating, don't get all target fixated.


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