# D50 and Head Bleed



## JPB (Mar 19, 2012)

We had a discussion this morning at my base.

I was severly outnumbered, soooo here was the situation.

Unresponsive hypoglycemic pt with possible head trauma/CVA.

Protocal says to jump straight to D50, and that was the general concinsis of the group at the base.

my arguement was :
However, due to head trauma/CVA why would I jump to D50 instead of administering 1.0mg of glucagon first to try and get glycogen released.  If it does not work, used the D50 kind of as a last resort and titrate the administration.  I try to make it a common practice to treat pt not protocal.  Protocal is a guideline not a treatment IMHO.

I understand that the brain needs its glucose needs to be treated ASAP and am not against giving the D50, but why not try all other aspects first.

Their argument was:
I could not prove that their was a head bleed......OK? So why do I need to prove it, if I have signs and symptoms indicitive of a "head bleed."  And there was no garentee that the glucagon was going to do the trick.

I was a bit concerned when other medics were saying stuff like, "I could care less about signs and symptoms of ICP or of head trauma when giving D50."


Sooo, I guess I did that rant to ask this.  

What is the deal, am I wrong bucking my FTP/Auditor (he was involved in the debate and could make life a bit hard for me if he wanted) over this issue?

I am a bit interesed to hear you responses  

TKS in advance,
JPB


----------



## Shishkabob (Mar 19, 2012)

D50 is hypertonic, yes, but the main issue with the possible necrosis fears from a hemorrhagic CVA is the sheer amount of glucose, 25g, in the solution.  See if you can't dilute before giving, such as D5, D10, or D25.  Most diabetics really don't need the full D50, however, they DO need sugar, now, as it is a life threatening ordeal.



I've done some quick searches for Glucagon in CVA and have not found a single study or other piece of evidence on the uitilization of glucagon in a possible stroke, however, knowing the profile of glucagon there's a few things to think about:

1) Not all patients have the glycogen stores required by glucagon to work.  Think about a lot of your stroke pateints... a lot of emaciated geriatric patients.

2)  Glucagons effect on the heart rate.  If it IS hemorrhagic, you've just increased the HR.  No bueno.    Obviously, neither is D50, but alas.

3)  We go back to thing above about D50 having 25g of sugar.... with glucagon, the amount of subtance released by the carbohydrate is unknown.

4)  Slow onset, it takes 15ish minutes for Glucagon to really start working.  You've just wasted 15 minutes sitting on scene seeing if glucagon would have any effect, which is 15 minutes they could have been awake from D50, or 15 minutes you could have been closer to a stroke center.





However, if anyone finds evidence on it, I'd be interested to know.  However, I venture to guess everyones stroke guidelines are about the same:  "If hypoglycemic, follow hypoglycemia guidelines", which has you do D50 first, instead of stroke having it's own exception saying do Glucagon first.

I'm going to email my medical director and get his insight.


----------



## CCNRMedic1982 (Apr 11, 2012)

I agree and disagree with both sides of the debate. What I think it comes down to is the life threatening emergency. Other than signs and symptoms there is no definitive evidence to support a hemorrhagic stroke vs. Ischemic stroke. However, there is evidence to support hypoglycemia and no absolute contraindications for the administration of a drug that could potentially alleviate the "life threat" of hypoglycemia.  The onset of D50 alone in comparison with glucagon makes it the better choice for the patient. Along with other considerations listed in the previous post. There are some things protocol or not that we just have to accept and not treating a life threat with no definitive testing is one them. I had the same type of pt and they got 3 doses of D50 en route to facility. Definitive care was the same we just need to get them there as stable as we can. I used to think glucagon as well but haven't found any evidence or services that will support it. Nice post!


----------



## MSDeltaFlt (Apr 11, 2012)

Hypoglycemia will show signs of CVA.  Treat the pt.  Give 1/2.  Get the sugar above 60... 70... whatever your protocol says you must treat hypoglycemia, get it above that much. THEN worry about head bleed.

Bare in mind that it might take several minutes for the sugar to cross the blood-brain barrier. I've had a hypoglycemic OB take 30 minutes to come fully lucid. 

Remember we don't fix anything in the prehospital field. We only get it started.


----------

