# Insulin



## xrsm002 (Aug 23, 2013)

Do any services out there carry Insulin? I'm just curious had a patient's family that thought our service carried it.


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## STXmedic (Aug 23, 2013)

I believe the system medic417 works for carries insulin (rural Texas system). Try shooting him a pm if you have specific questions.


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## xrsm002 (Aug 23, 2013)

Nope just curious since there are different types of it what versions carry it. Had a call where I could have benefitted the patient.


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## VFlutter (Aug 23, 2013)

xrsm002 said:


> Nope just curious since there are different types of it what versions carry it. Had a call where I could have benefitted the patient.



Just curious, how could it have benefited the patient? 

I can think of very few, if any, situations where prehospital insulin would be beneficial. 

Many people forget that insulin is considerd a high risk medication and accounts many adverse effects and medication errors.


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## Akulahawk (Aug 23, 2013)

Chase said:


> Just curious, how could it have benefited the patient?
> 
> I can think of very few situations where prehospital insulin would be beneficial.
> 
> Many people forget that insulin is considerd a high risk medication


My question as well...


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## Wheel (Aug 23, 2013)

Chase said:


> Just curious, how could it have benefited the patient?
> 
> I can think of very few situations where prehospital insulin would be beneficial.
> 
> Many people forget that insulin is considerd a high risk medication



Very high risk, and it often takes months to regulate for most diabetics, as it effects everyone differently in how they process it. I have talked to many ER docs that won't deal with it except in extreme circumstances, and they admit any patient that needs it to the ICU. I can't imagine a circumstance that I'd want it.

Edit: not to mention storing it would make it unreasonable for us to carry


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## VFlutter (Aug 23, 2013)

There is no good way generically dose insulin. Dosing is highly patient specific based on the patient's renal function, metabolic status, diet, etc. I do not see any decent way to dose it on a hyperglycemia patient in the prehospital environment.


Agreed, most ER Physicans will be very conservative if treating at all. They will defer to the ICU or Endocrinologist


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## JPINFV (Aug 23, 2013)

HyperK patients I guess. DKA patients simply aren't worth the trouble prehospitally and without labs.


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## xrsm002 (Aug 23, 2013)

Well bgl >500


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## xrsm002 (Aug 23, 2013)

Thanks all for your input, patient family assumed we as EMS providers carried insulin.


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## xrsm002 (Aug 23, 2013)

The patients glucometrr said 1000


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## xrsm002 (Aug 23, 2013)

Okay they might use benefited from it. But I doubt it would have worked that quick.


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## JPINFV (Aug 23, 2013)

xrsm002 said:


> Okay they might use benefited from it. But I doubt it would have worked that quick.



Why do you think they might have benefited from it? The negative effects of hyperglycemia specifically isn't acute. The effects of things like DKA are much better managed by things like fluids prehospitally. Insulin in the hospital is actually continued even after the BGL is decreased until the anion gap is normal ("closed") (sodium - chloride - bicarb = 12), even if that means providing dextrose.


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## Handsome Robb (Aug 23, 2013)

JPINFV said:


> HyperK patients I guess. DKA patients simply aren't worth the trouble prehospitally and without labs.



That'd be the only reason I could see for it. HyperK.

Even if the pt's CBG was 1000 mg/dL the last thing they need is to get slammed with insulin and have a rapid change in that CBG level. DKA and HHNK patients are generally brought down pretty slowly. They also get more than just insulin. Plus fixing their CBG doesn't fix the metabolic acidosis.


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## mycrofft (Aug 23, 2013)

xrsm002 said:


> Okay they might use benefited from it. But I doubt it would have worked that quick.



"Regular" insulin works quickly, especially IV (inject into a port of a running IV). Quick in, quick out.

HOWEVER:

1. DKA needs much more than insulin and its side effects can be forestalled  (not cured) through other means.

2. Other hyperglycemias by themselves are not emergent, although they can cause trauma through accidents.

3. Once you give insulin to any patient but especially an unstabilized one, you  are off to the races, trying to give just enough and not test too often, chase glucometry readings up and down with meds and sugar, etc., potentially causing :
4. Iatrogenic insulin-induced hypoglycemic seizures.

We had a family who twice called for an ambulance because they had run out of insulin and thought we'd provide it. Nope.


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## VFlutter (Aug 23, 2013)

xrsm002 said:


> The patients glucometrr said 1000



A blood sugar of 1000 should not be treated with SubQ Insulin. The patient needs to be in an ICU with an Insulin drip, aggressive hydration, and close electrolyte monitoring. It is not treated instantly, it will take hours to days. There is absolutely no reason to attemp this in the back of the ambulance. 



xrsm002 said:


> Okay they might use benefited from it. But I doubt it would have worked that quick.



What benefit? 

No, it will work that quickly. That is the problem. Quick enough to cause electrolyte shifts and potassium redistribution. 

If you drop the patients sugar from 1000 to 800 what have you accomplished? Have you fixed the problem? Or merely chasing a number




JPINFV said:


> until the anion gap is normal ("closed") (sodium - chloride - bicarb = 12),



Most providers have a very poor, if any, understanding of anion gap acidosis.


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## Akulahawk (Aug 23, 2013)

JPINFV said:


> HyperK patients I guess. DKA patients simply aren't worth the trouble prehospitally and without labs.


In the prehospital HyperK patient, I can see providing albuterol to that patient, but I just can't see insulin being given in the prehospital arena... not that it doesn't work differently, but rather because each patient's needs are so very different...


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## JPINFV (Aug 23, 2013)

Akulahawk said:


> In the prehospital HyperK patient, I can see providing albuterol to that patient, but I just can't see insulin being given in the prehospital arena... not that it doesn't work differently, but rather because each patient's needs are so very different...




At the hospital I'm at, 10 units insulin plus 25 mg D50 is what I've seen done every time for hyperK following calcium. I've yet to see any of the teams go with albuterol to internalize potassium.


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## Akulahawk (Aug 24, 2013)

JPINFV said:


> At the hospital I'm at, 10 units insulin plus 25 mg D50 is what I've seen done every time for hyperK following calcium. I've yet to see any of the teams go with albuterol to internalize potassium.


I'd rather use insulin + D50 than albuterol for internalizing K. Albuterol is what we do carry in the field and it does internalize K a bit, just not as well. My thought process is simply to begin the process of internalizing the K with the albuterol and let the hospital continue with calcium and then insulin + D50. That is, if the K is that bad... known prehospitally to be that bad. Usually we just don't suspect K being that bad unless we're looking at extricating a crush patient. Outside of that, I don't think our protocols even _touch_ using albuterol in that manner. 

Anyway, that doesn't deal with a hyperglycemic patient. The most I'm going to do in the field (short response time) is probably begin fluid replacement in the hyperglycemic patient. I know there's much more that needs to be done...


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## xrsm002 (Aug 24, 2013)

Thanks for all the input I've learned some new things tonight.


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## medichopeful (Aug 24, 2013)

xrsm002 said:


> The patients glucometrr said 1000



Just for your own knowledge, if someone has a high BGL one of the things that is going to be done before giving insulin is making sure they are hydrated (what are some of the symptoms related to hyperglycemia?).  Insulin will come later.

Starting IV fluids may be helpful in the pre-hospital environment for hyperglycemia, along with other indicated treatments to get the ball rolling towards bringing the BGL down, but insulin isn't the first step in this process once it gets to be too high.


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## VFlutter (Aug 24, 2013)

Akulahawk said:


> . Usually we just don't suspect K being that bad unless we're looking at extricating a crush patient. Outside of that, I don't think our protocols even _touch_ using albuterol in that manner.



Do you carry Calcium gluconate? Works wonders for hyperK induced arrhythmias


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## Akulahawk (Aug 24, 2013)

Chase said:


> Do you carry Calcium gluconate? Works wonders for hyperK induced arrhythmias


Last time I was around an ambulance, no. We didn't. I'd be surprised if they did these days. Probably had to do with the idea that patients could be brought to the ED before something bad happens... :blink:


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## JPINFV (Aug 24, 2013)

Chase said:


> Do you carry Calcium gluconate? Works wonders for hyperK induced arrhythmias





...but doesn't do anything for the serum potassium levels.


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## JPINFV (Aug 24, 2013)

Akulahawk said:


> Last time I was around an ambulance, no. We didn't. I'd be surprised if they did these days. Probably had to do with the idea that patients could be brought to the ED before something bad happens... :blink:




Please. That sine wave is just artifact.


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## VFlutter (Aug 24, 2013)

JPINFV said:


> ...but doesn't do anything for the serum potassium levels.



I know, but it can prevent cardiac arrest until the K can be treated appropriately.


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## Wheel (Aug 24, 2013)

Chase said:


> Most providers have a very poor, if any, understanding of anion gap acidosis.



Before I go chasing down stuff to read on my day off today, do you have any recommendations for a resource for this?


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## Clipper1 (Aug 24, 2013)

Wheel said:


> Before I go chasing down stuff to read on my day off today, do you have any recommendations for a resource for this?



Overview of acid-base disturbances with the calculation for anion gap.

http://www.thoracic.org/clinical/critical-care/clinical-education/abgs.php


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## Wheel (Aug 24, 2013)

Clipper1 said:


> Overview of acid-base disturbances with the calculation for anion gap.
> 
> http://www.thoracic.org/clinical/critical-care/clinical-education/abgs.php



Thank you very much.


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## fma08 (Aug 24, 2013)

xrsm002 said:


> Thanks for all the input I've learned some new things tonight.



Keep at it and keep learning.


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## Akulahawk (Aug 24, 2013)

JPINFV said:


> Please. That sine wave is just artifact.


It must be... Otherwise it could be a sign of, oh, I don't know, a really high K level? And since it's just artifact, it's nothing to worry about... right?


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## mycrofft (Aug 24, 2013)

Are we looking at _in vitro_ or _in vivo_ relevant materials?
I can run your brain on ketones but you'll die. Is this something like that?

:mellow:


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## Aidey (Aug 24, 2013)

xrsm002 said:


> The patients glucometrr said 1000



Say what? I'm not familiar with home glucometer brand that will read numbers that high.


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## VFlutter (Aug 25, 2013)

Aidey said:


> Say what? I'm not familiar with home glucometer brand that will read numbers that high.



Good catch, I didn't noticed the "home glucometer" at first. Most hospital meters do not even read that high. Anything over 500 needs a lab draw to confirm.


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## mycrofft (Aug 25, 2013)

Chase said:


> Good catch, I didn't noticed the "home glucometer" at first. Most hospital meters do not even read that high. Anything over 500 needs a lab draw to confirm.



I assumed it was figurative hyperbole.
Ours went from "500" immediately to "HI".

("HI" yourself! :angry: )


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## unleashedfury (Sep 22, 2013)

Chase said:


> Good catch, I didn't noticed the "home glucometer" at first. Most hospital meters do not even read that high. Anything over 500 needs a lab draw to confirm.



I was wondering the same. 

I am also curious how could a prehospital service carry insulin and store it successfully insulin last I remember must be refridgerated so unless the new buses come out with a reefer unit. I don't see it hitting the streets anytime soon 

On top of that theres still the clinical overview. why is the sugar high? is it DKA, or non compliance or new onset diabetes or head injury or recent steroid use? theres too many factors to go into play for me to think about giving a pt. insulin before knowing that it will benefit. 

Second part of it reading the thread almost seem liked the OP was chasing a number theres patients out there that have high blood sugars and just stay there hell my wife used to work in a old folks home and she had a woman who if her sugar went below 200mg/dl. she'd look like a normal person with a sugar of 30.


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## STXmedic (Sep 22, 2013)

Fury: Just to address your comment about the need for refrigeration (too tired to give any kind of thought out response on anything else  ).

On-board fridges are actually quite common now. Many units are finding use for them with things like cold fluids for induced hypothermia, medication storage for meds like Vec and diltiazem, and even just to have cool/cold water on board for whatever need.

That is all. Hoping to knock out another couple hours of sleep before shift change


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## Medic Tim (Sep 22, 2013)

A few of our clinics carry insulin. Some of them are fly in fly out camps and it can take a while to get to the hospital or to the pharmacy if a pt runs out.


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## VFlutter (Sep 22, 2013)

Regular Insulin should be refrigerated to extend shelf life however once opened it can be stored at room temperature for one month. So technically you could just keep a vial at room temp in the ambulance and replace it monthly. But you would have to look at the long term cost.


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## unleashedfury (Sep 22, 2013)

STXmedic said:


> Fury: Just to address your comment about the need for refrigeration (too tired to give any kind of thought out response on anything else  ).
> 
> On-board fridges are actually quite common now. Many units are finding use for them with things like cold fluids for induced hypothermia, medication storage for meds like Vec and diltiazem, and even just to have cool/cold water on board for whatever need.
> 
> That is all. Hoping to knock out another couple hours of sleep before shift change



Meh were still in the dark ages, fluid induced hypothermia is done by the whole cold pack trick. While I don't agree with it since its hard to control the temp vs. a chilled fluid via a fridge


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## medicsb (Sep 23, 2013)

A lot of MICUs in NJ used to carry insulin.  The purpose was for presumed hyperkalemia-induced cardiac arrest in dialysis patients, though considering that it could only given if orders received from a doc, it is possible that some docs could order it for other situations.  I think insulin is still part of NJ's optional meds, so there may still be some places carrying it.


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## chaz90 (Sep 23, 2013)

medicsb said:


> A lot of MICUs in NJ used to carry insulin.  The purpose was for presumed hyperkalemia-induced cardiac arrest in dialysis patients, though considering that it could only given if orders received from a doc, it is possible that some docs could order it for other situations.  I think insulin is still part of NJ's optional meds, so there may still be some places carrying it.



How critical is insulin for severe hyperkalemia in the early stages of treatment? I understand it's used as part of the hyperkalemia cocktail, but I'd presume calcium chloride is more effective in the short term.


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## medicsb (Sep 23, 2013)

chaz90 said:


> How critical is insulin for severe hyperkalemia in the early stages of treatment? I understand it's used as part of the hyperkalemia cocktail, but I'd presume calcium chloride is more effective in the short term.



CaCl is more rapid in its onset of action, but is temporary.  Ca is more of a stop-gap measure to give time for other treatments to take effect.   When you don't have any labs available, it is probably a lot safer to bolus someone with CaCl and fluids than to use D50 and insulin.  Without labs, using insulin is probably only acceptable in extreme case (cardiac arrest) or with ECG changes consistent with HyperK AND hemodynamic instability.


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