# Low RBS WITHOUT catheter.



## falcon-18 (Jul 12, 2009)

hello, every body. today I listen this information if you are in diabitic pt . ans his RBS is LOW. and you can not open IV line. no catheter or another. you can give D5W by rectal. of course pt unconscious.  My Q . Is it true ?


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## emtjack02 (Jul 12, 2009)

There was a similar post not to long ago.  I believe it had a lot of replies.  You could probably search for it.


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## usafmedic45 (Jul 12, 2009)

falcon-18 said:


> hello, every body. today I listen this information if you are in diabitic pt . ans his RBS is LOW. and you can not open IV line. no catheter or another. you can give D5W by rectal. of course pt unconscious.  My Q . Is it true ?



I would not give D5W, but have given oral glucose this way.  BTW, there is a very interesting case report in the literature of fluid resuscitation in a remote area by rectal administration of crystalloid.


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## MSDeltaFlt (Jul 12, 2009)

falcon-18 said:


> hello, every body. today I listen this information if you are in diabitic pt . ans his RBS is LOW. and you can not open IV line. no catheter or another. you can give D5W by rectal. of course pt unconscious. My Q . Is it true ?


 
The search icon works pretty good.

http://www.emtlife.com/showthread.php?t=10693&highlight=Rectal


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## falcon-18 (Jul 12, 2009)

emtjack02 said:


> There was a similar post not to long ago.  I believe it had a lot of replies.  You could probably search for it.



thanks . I do not know about  this. anyway thanks about this .


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## falcon-18 (Jul 12, 2009)

usafmedic45 said:


> I would not give D5W, but have given oral glucose this way.  BTW, there is a very interesting case report in the literature of fluid resuscitation in a remote area by rectal administration of crystalloid.



If you do not have only D5W . what you will do . I think you will give him that. I will see link from MSDeltaFlt


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## falcon-18 (Jul 12, 2009)

MSDeltaFlt said:


> The search icon works pretty good.
> 
> http://www.emtlife.com/showthread.php?t=10693&highlight=Rectal



thanks . yeah it is pretty  . thanks


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## rescue99 (Jul 13, 2009)

Try a honey bear. A tube of oral glucose followed by a small bolus does work. I've shortened a french cath and done it one time many moons ago.


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## medic3416 (Jul 13, 2009)

Before you go putting things in someones rectum, what about GLUCAGON IM!!!!


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## falcon-18 (Jul 13, 2009)

rescue99 said:


> Try a honey bear. A tube of oral glucose followed by a small bolus does work. I've shortened a french cath and done it one time many moons ago.




you can not give  . pt unconscious . oral glucose lead to aspiration in unconscious :sad:




medic3416 said:


> Before you go putting things in someones rectum, what about GLUCAGON IM!!!!




but, If not available :sad: . what you will do? I mean last choice you will go to this.


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## rescue99 (Jul 13, 2009)

A honey bear is not administered per (cough) oral :>) I figured you meant you didn't have Glucagon as an option.


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## usafmedic45 (Jul 13, 2009)

I was assuming we were talking at the BLS level, so glucagon and D5W would not be available.  Also, I am not aware of a state that does not require oral glucose on all ambulances at the BLS level.  In my case, I carried a tube of it in my pocket while on duty (the person who was my partner for the longest time was prone to hypoglycemic events) and still keep two in the first aid bag in my car.

Also, you really can't raise someone's glucose level all that effectively with D5W due to the low glucose content.  It just takes too long to push the volume of fluid necessary, compared to the effect you'll get from oral or rectal glucose  As someone else said, you can always use non-medicinal sources of glucose.  I've personally seen cases or seen the documentation on cases where oral glucose (guess it would be rectal glucose in this setting), maple syrup and honey were all administered rectally. 



> oral glucose lead to aspiration in unconscious



Not always, but that is one of the reasons why I would favor the rectal route in that setting to avoid the possibility.


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## gicts (Jul 13, 2009)

What about an IO?


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## usafmedic45 (Jul 14, 2009)

As an ALS provider, I would hesitate to jump to doing an IO for something that can be effectively treated with a procedure with far lower risk of complications and a lot less pain involved (even after insertion IOs are not supposed to be the most comfortable device).  This is a major issue in EMS: the push for advanced procedure when something less aggressive will function just fine.  The best example of this is intubation in the setting where the patient can be adequately managed with a BVM and perhaps an OPA.  In the case of the scenario presented here, contrary to popular belief a failed IV is not an instant indication for an IO (pretty much the only exception to this is cardiac arrest or the unequivocal need to IMMEDIATELY give medications that have no alternate route). 

For the service I worked for, I can guarantee you would have been hauled before our medical director and your peers at audit and review to explain the decision to use an IO in this setting.  The first questions would have been: " Why not glucagon? Why not give the glucose rectally?".   

As the saying goes, if it's stupid and it works, it's not stupid; if it's ugly and it works, it's thing of beauty.  It might not be the most high speed practice out there- I don't know many people who look forward to sticking a tube of glucose up someone's backside- but if it fixes the problems and "saves" the patient without inflicting excessive pain or exposing them to undue risk, that is something that should be the bigger ego boost.  We are here for our patients- first, foremost and without question- and sometimes (most of the time?) EMS providers tend to get ahead of themselves in the rush for new skills or to apply the ones they already have.


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## emtjack02 (Jul 14, 2009)

I am confused as to why glucagon "is not available" as some post seem to get at.  If I had an unconscious person d/t hypoglycemia you better bet I would go IO if unable to get a PIV.  Why not go rectally? Because it's not in my protocols.


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## Ridryder911 (Jul 14, 2009)

emtjack02 said:


> I am confused as to why glucagon "is not available" as some post seem to get at.  If I had an unconscious person d/t hypoglycemia you better bet I would go IO if unable to get a PIV.  Why not go rectally? Because it's not in my protocols.



Ever heard of deviation from protocols? Call in and just ask just like you do for any other order that was not clear or a more simpler effective way of doing it. I treat patients not protocols. 


R/r 911


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## emtjack02 (Jul 14, 2009)

Sure I could call in.  My experience w/ our Med control is they dont like to stray from the protocols. We also have trouble reaching them sometimes because our truck s**ks. But thank you ry.


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## falcon-18 (Jul 14, 2009)

usafmedic45 said:


> I was assuming we were talking at the BLS level, so glucagon and D5W would not be available.  Also, I am not aware of a state that does not require oral glucose on all ambulances at the BLS level.  In my case, I carried a tube of it in my pocket while on duty (the person who was my partner for the longest time was prone to hypoglycemic events) and still keep two in the first aid bag in my car.
> 
> Also, you really can't raise someone's glucose level all that effectively with D5W due to the low glucose content.  It just takes too long to push the volume of fluid necessary, compared to the effect you'll get from oral or rectal glucose  As someone else said, you can always use non-medicinal sources of glucose.  I've personally seen cases or seen the documentation on cases where oral glucose (guess it would be rectal glucose in this setting), maple syrup and honey were all administered rectally.
> 
> ...





gicts said:


> What about an IO?






IO. not available. 

But if IO available I will use it or rectal ? I will give rectaly.


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## falcon-18 (Jul 14, 2009)

Ridryder911 said:


> Ever heard of deviation from protocols? Call in and just ask just like you do for any other order that was not clear or a more simpler effective way of doing it. I treat patients not protocols.
> 
> 
> R/r 911
> ...





emtjack02 said:


> Sure I could call in.  My experience w/ our Med control is they dont like to stray from the protocols. We also have trouble reaching them sometimes because our truck s**ks. But thank you ry.





If I will safe pt. I will not look protocol.


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## Ridryder911 (Jul 14, 2009)

The same as in a seizing patient. Would you rather I/O a seizing patient or give Diastat Gel rectally? Which is the best and most appropriate for the patient?

R/r 911


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## falcon-18 (Jul 14, 2009)

Ridryder911 said:


> The same as in a seizing patient. Would you rather I/O a seizing patient or give Diastat Gel rectally? Which is the best and most appropriate for the patient?
> 
> R/r 911





I think Diastat gel rectally. :unsure::unsure:


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## emtjack02 (Jul 14, 2009)

I would give valium or versed using a MAD then I would go valium PR.


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## falcon-18 (Aug 9, 2009)

rectal administration may be cause vagal stimulation, lead to arrest . :sad::sad:


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## Ridryder911 (Aug 9, 2009)

falcon-18 said:


> rectal administration may be cause vagal stimulation, lead to arrest . :sad::sad:



Actually it takes  more than just administration of the medication as in stimulation of the rectal and anus area causing the stimulation of the vagus nerve. Many medications are given rectally everyday (suppository form) without problems. 

R/r 911


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## falcon-18 (Aug 9, 2009)

Ridryder911 said:


> Actually it takes  more than just administration of the medication as in stimulation of the rectal and anus area causing the stimulation of the vagus nerve. Many medications are given rectally everyday (suppository form) without problems.
> 
> R/r 911




I am not sure about this becuase that I am asking :rolleyes . my  doctor 

 tell me that .


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## Shishkabob (Aug 9, 2009)

You'd have to do a awful lot of vagal stimulation to cause a cardiac arrest... more then is caused by anything going in/out of the rectum.


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## Ridryder911 (Aug 9, 2009)

falcon-18 said:


> I am not sure about this becuase that I am asking :rolleyes . my  doctor
> 
> tell me that .





Linuss said:


> You'd have to do a awful lot of vagal stimulation to cause a cardiac arrest... more then is caused by anything going in/out of the rectum.



I would say something but surely; one is NOT that naive! 

R/r 911


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## Shishkabob (Aug 9, 2009)

Err... directed at me or him?


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## falcon-18 (Aug 9, 2009)

Ridryder911 said:


> I would say something but surely; one is NOT that naive!
> 
> R/r 911



I do not know whay you say that . but anyway . no proplem . thanks


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## ResTech (Aug 9, 2009)

> rectal administration may be cause vagal stimulation, lead to arrest



I could not see rectal (or PR) admin causing vagal stimulation from the insertion alone. The only way I could see vagal stimulation being an issue is from the patient bearing down for some reason during the med insertion into the rectum. This of course would be vagal stimulation from the increase in pressure sensed by the baroreceptors and not so much from anal stimulation as it sounds was insinuated.



> I do not know whay you say that . but anyway . no proplem . thanks



What Rid was trying to get across to illustrate I think is this.... people have anal intercourse everyday and people enjoy (usually  ) it without any syncope or going into cardiac arrest.... so with that in mind, a tiny suppository isn't going to cause vagal stimulation.

Falcon... just curious... are you from another Country?


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## falcon-18 (Aug 9, 2009)

ResTech said:


> I could not see rectal (or PR) admin causing vagal stimulation from the insertion alone. The only way I could see vagal stimulation being an issue is from the patient bearing down for some reason during the med insertion into the rectum. This of course would be vagal stimulation from the increase in pressure sensed by the baroreceptors and not so much from anal stimulation as it sounds was insinuated.



When I say it can cause vagaus stimulation, that is not means in every one . but may be *1 *in every *10000* .  

that is what I mean . anyway this information coming to me and I tell you  to confirm is it true or no.

thanks


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## Aliakey (Aug 11, 2009)

My pathetic brain kinda leans to the thought: if you are initiating a significant vagal response simply by inserting a suppository intended for rectal administration, then he probably has a few more pending medical problems than originally called for.   Hate to be around the next time he visits the ol' outhouse with the latest USA Today newspaper in hand or makes his appointment for the next prostate check.

:blush:

I do have a (probably naive) question for those who know the ways of duck tape and baling wire:  When your EMS protocols do not have Diastat indicated on the pharmaceutical list, what's the best way to administer diazepam rectally if approved by your medical control?  

We do have some good protocols here (even IM glucagon for EMT-Basics); paramedics do have diazepam (Valium), Versed, and Ativan at their disposal among others.  EJs and IOs are also permitted in the standing orders.  However, I am also of the opinion that less invasive is better, if another alternative can be used.  We do have some pretty sick patients in my "beat", where gaining peripheral access would be a miracle in itself... and harder still when someone is actively seizing.

Can a Diastat-equivalent gel be formed with a water-based gel (KY, for example) and administered with the same effectiveness and time of onset as Diastat itself?  Or, is a liquid bolus the way to go?  If so, any helpful techniques on keeping the stuff inside the rectum?  One topic that was never covered in my EMS classes...

Thanks in advanced!


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## Ridryder911 (Aug 11, 2009)

Personally, I always just took the catheter of a 20g IV and placed it on a syringe and inserted it into the rectum. This allows the medication to be placed passes the sphincter and hold the cheeks so it could be absorbed as much as possible. 

R/r 911


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## falcon-18 (Aug 11, 2009)

Ridryder911 said:


> Personally, I always just took the catheter of a 20g IV and placed it on a syringe and inserted it into the rectum. This allows the medication to be placed passes the sphincter and hold the cheeks so it could be absorbed as much as possible.
> 
> R/r 911




you can also cut IV sit tube and place it into the rectum I think it is better than catheter . because catheter you can not control it in this rote and you need big size like flate anema.


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## Ridryder911 (Aug 11, 2009)

falcon-18 said:


> you can also cut IV sit tube and place it into the rectum I think it is better than catheter . because catheter you can not control it in this rote and you need big size like flate anema.



Actually, you don't. One has to be careful due to the seizure activity and you are only administering < 3ml of medication. 

R/r 911


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## ResTech (Aug 11, 2009)

I've always wondered too what the best method of administering a med rectally in the field. Fortunately, PR admin is a thing of the past for MD... replaced with IM Versed. But I would still like to know what works best for rectal delivery.


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