# Hypoglycemic scenerio question



## dalmain (Jan 12, 2014)

This maybe a silly questions for you Paramedics out there. Maybe I missed something in school but when you have a hypoglycemic patient BS: 29 unresponsive. You have I.V. access and begin to push D50 slowly. About halfway thru the D50 you see the patient responding, eyes are opening and the patient is moving....would you at this point check the BS or continue and push the rest of the D50 and than check the BS? Halfway the BS is 249. A big spike. Would you stop there or just finish pushing the rest of the D50? A 500 cc NS is open after D50 IVP. 
It was my partners decision to stop mid way and check the BS. He didn't want to give anymore D50 once he got the 249 BS. If I were the one administrating the drug I would probably have pushed the whole D50. The way I learned in school and I read in the protocols. If a patient shows improvement during drug administration should you just stop at that point? Just wondering.


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## chaz90 (Jan 12, 2014)

I would absolutely stop and routinely do midway through Dextrose administration. I often use a 100 mL NS bag to dilute my Dextrose, and I'll stop as soon as the patient is conscious enough to eat something. I leave the IV in until I clear the call in case I give more. A full 25G of IV Dextrose is incredibly harsh for a diabetic and can throw their A1C and BGLs off for a long time. The more gentle you are waking them, the better it is for the patient.


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## Tigger (Jan 12, 2014)

dalmain said:


> This maybe a silly questions for you Paramedics out there. Maybe I missed something in school but when you have a hypoglycemic patient BS: 29 unresponsive. You have I.V. access and begin to push D50 slowly. About halfway thru the D50 you see the patient responding, eyes are opening and the patient is moving....would you at this point check the BS or continue and push the rest of the D50 and than check the BS? Halfway the BS is 249. A big spike. Would you stop there or just finish pushing the rest of the D50? A 500 cc NS is open after D50 IVP.
> It was my partners decision to stop mid way and check the BS. He didn't want to give anymore D50 once he got the 249 BS. If I were the one administrating the drug I would probably have pushed the whole D50. The way I learned in school and I read in the protocols. If a patient shows improvement during drug administration should you just stop at that point? Just wondering.



I'd bet that your protocol also says something about using good clinical judgement too. It doesn't make sense to just keep blindly giving a medication in the face of obvious improvement, what will giving more dextrose to a patient with a BGL of 249 do to help the patient?


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## NomadicMedic (Jan 12, 2014)

Yeah. It's like Narcan. Titrate to effect.


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## Angel (Jan 12, 2014)

if this were my call/my pt I don't normally check blood sugar until a couple mins after giving it (the entire 25gm). Ive yet to have a pt come alert whilst pushing d50 (granted ive only been doing this for 5 minutes).

I guess if this DID happen then the dextrose did its job, document how much I gave, their BS and if they can eat/drink something fine. although you say 249 is "high" it could be their norm or on that pts lower end. my dad would consider this a good BS to have.

its all provider judgment like the others have said.


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## Carlos Danger (Jan 12, 2014)

Angel said:


> if this were my call/my pt *I don't normally check blood sugar until a couple mins after giving it (the entire 25gm). Ive yet to have a pt come alert whilst pushing d50* (granted ive only been doing this for 5 minutes).
> 
> I guess if this DID happen then the dextrose did its job, document how much I gave, their BS and if they can eat/drink something fine. although you say 249 is "high" it could be their norm or on that pts lower end. my dad would consider this a good BS to have.
> 
> its all provider judgment like the others have said.



This.


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## mycrofft (Jan 12, 2014)

I'd be charry about directly pushing D50 into a vein. How about, if you have the means, a piggyback with the D50 in some saline, and a shutoff between it and the TKO line? You can titrate more finely, and the likelihood of hyperosmotic damage to the vein and or neighboring tissues is reduced.

#1 question: latest insulin dose, what time and what was it? How sure?

 That fast a climb in serum glucose suggests initial mis-measurement and/or mis-measurement in the followup. 

I'm betting the initial measurement was off, or the pt's internal mechanisms are coming on line. (Is the pt also a drinker?). If this was "fingerstick glucometry", was the finger _strongly pinched near the tip _to procure a drop, causing a bad sample, versus milking the finger or holding it firmly at the base ands causing a veinous engorgement to generate enough blood?

 I've also never seen a pt revive from a 29 (nearly seizing and unconscious) to conscious and "hyperglycemic" rapidly. AND, a transient glucose of 249, even if it is correct, is not that big a deal.


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## medicasaurus (Jan 13, 2014)

Here in Canada D10W is the go to for a hypoglycemic and I have seen many patients fully regain consciousness on less than 250ml (25mg). Our guidelines here in BC is to bolus with reassessments for LOC every 100ml (10mg) and I would say it is rare to run in the entire 250ml as a bolus with most patients I have seen recovering around the 15-20mg range. Typically its is slowed to around 100ml/hr as the LOC is improved to prevent a hyperglycemia/rebound hypoglycemia. This is followed by a peanut butter and jelly sandwich or substitute. Hypoglycemia is normally a non-ALS call here as well (BLS being similar to EMT-A). 

I also think D10 is a better option than D50, but have little experience with D50.
http://www.ncbi.nlm.nih.gov/pubmed/15983093


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## Handsome Robb (Jan 13, 2014)

We titrate Up to a max of 25 gm.

I think that's what the poster above me means as well. 15-20mg of glucose in an adult isn't going to do much.


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## Akulahawk (Jan 13, 2014)

When it comes to D50, I'm going to push it very, very slowly through a running IV line, over about 5-8 minutes. The general idea is to let the running fluid dilute the D50. While I could make a D10 solution and use that, we normally didn't carry anything less than a 1000 mL bag, so that's the solution I came up for titration of the D50 to effect. Most of the time that I've given it, "the lights" usually started to come back on at around 20gm and usually the patient was fully awake/oriented right as I finished pushing the 25gm. If the patient became fully awake before that, I'd probably have stopped the IV dose because the patient woke up and hopefully is able to begin PO intake for more long-term maintenance of their BGL. 

Now if I'd had the ability to do D10 instead, I'd want it going in over 10-15 minutes. It's far more controllable than a D50 syringe is, and the glucose dose is the same if it's a 250 mL bag...


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## Medic Tim (Jan 13, 2014)

Akulahawk said:


> When it comes to D50, I'm going to push it very, very slowly through a running IV line, over about 5-8 minutes. The general idea is to let the running fluid dilute the D50. While I could make a D10 solution and use that, we normally didn't carry anything less than a 1000 mL bag, so that's the solution I came up for titration of the D50 to effect. Most of the time that I've given it, "the lights" usually started to come back on at around 20gm and usually the patient was fully awake/oriented right as I finished pushing the 25gm. If the patient became fully awake before that, I'd probably have stopped the IV dose because the patient woke up and hopefully is able to begin PO intake for more long-term maintenance of their BGL.
> 
> Now if I'd had the ability to do D10 instead, I'd want it going in over 10-15 minutes. It's far more controllable than a D50 syringe is, and the glucose dose is the same if it's a 250 mL bag...




Same with me. I prefer d10 but am not always able to use it for various reasons.  I rarely ever have to give the full amp.


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## dalmain (Jan 13, 2014)

Angel said:


> *if this were my call/my pt I don't normally check blood sugar until a couple mins after giving it (the entire 25gm).* Ive yet to have a pt come alert whilst pushing d50 (granted ive only been doing this for 5 minutes).
> 
> I guess if this DID happen then the dextrose did its job, document how much I gave, their BS and if they can eat/drink something fine. although you say 249 is "high" it could be their norm or on that pts lower end. my dad would consider this a good BS to have.
> 
> its all provider judgment like the others have said.



This was my train of thought too. I'm a medic but not that experienced. Back in school when I rode with Rescue the few times we got a hypoglycemic we pushed the whole 25g. But it makes sense that if the patient improves before, that you should stop and check the BS. 
On scene this patient was in bed on oxygen. He was hospice with an invalid DNR. I could not get any history on this person. Just that he was a diabetic. No allergies. He was flaccid but breathing. We pinched him for the BS off his left index. BS: 29. Lungs clear. Pupils constricted. First IV attempt blew. He was a bleeder. Got a 20g to the left AC. Flushed, got a 500 cc NS ready. I was pretty much directing at this point and my partner began the D50 slow push. Half way through the patient eyes opened and he was more alert than before. But not enough to swallow. I don't know what his typical state or original state was. Blood pressure was around 90/60. SaO2: 95%. His eyes followed me but he didn't speak. 
So for now on I'll titrate to effect.


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## mycrofft (Jan 13, 2014)

Yeah. Testing at too close intervals promotes other issues, especially if you start messing with insulin.

Sugar is not that darn dangerous. Running out is. And once that sugar is on board, you MUST take measures to get more carbs on board or spur gluconeogenesis because that sugar's going to burn out soon and fast.


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## Carlos Danger (Jan 13, 2014)

mycrofft said:


> Yeah. Testing at too close intervals promotes other issues, especially if you start messing with insulin.
> 
> *Sugar is not that darn dangerous. Running out is.* And once that sugar is on board, you MUST take measures to get more carbs on board or spur gluconeogenesis because that sugar's going to burn out soon and fast.



This is exactly why I push the whole amp.


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## Handsome Robb (Jan 14, 2014)

Extravasated sugar isn't very nice though...

I've got zero problems with giving the entire 25 grams of sugar. None. What I do have a problem with is the hyperosmolarity of D50 and the lack of understanding of that concept among EMS providers.

I know you two understand that concept...don't think I don't! Lol


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## Akulahawk (Jan 14, 2014)

mycrofft said:


> Yeah. Testing at too close intervals promotes other issues, especially if you start messing with insulin.
> 
> *Sugar is not that darn dangerous. Running out is*. And once that sugar is on board, you MUST take measures to get more carbs on board or spur gluconeogenesis because that sugar's going to burn out soon and fast.





Halothane said:


> This is exactly why I push the whole amp.


That's also why I push the whole 25g amp as well. Remember that's only 100 calories. It's enough to turn the lights on and keep them on for only a little while. So, once you've woken up the patient, you have to get them to eat something too for sustained effect. In terms of a car, the motor sputters and dies when you run out of gas. If you put a gallon of gas in the tank, you can run the car for a little while before it runs out of gas again, so after you've got the motor running, get to a gas station to properly fill the tank so you don't have to worry about running out of gas any time soon. 

Although the number isn't quite precise, at my current weight (and assuming that I burn calories at a steady rate), I burn 1.6 calories per minute. That 25g carb load (100 calories) should last me only about 1 hour and then the tank would be empty again.

Food for thought.


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## Handsome Robb (Jan 14, 2014)

Akulahawk said:


> That's also why I push the whole 25g amp as well. Remember that's only 100 calories. It's enough to turn the lights on and keep them on for only a little while. So, once you've woken up the patient, you have to get them to eat something too for sustained effect. In terms of a car, the motor sputters and dies when you run out of gas. If you put a gallon of gas in the tank, you can run the car for a little while before it runs out of gas again, so after you've got the motor running, get to a gas station to properly fill the tank so you don't have to worry about running out of gas any time soon.
> 
> Although the number isn't quite precise, at my current weight (and assuming that I burn calories at a steady rate), I burn 1.6 calories per minute. That 25g carb load (100 calories) should last me only about 1 hour and then the tank would be empty again.
> 
> Food for thought.



QFT.


Going to go out on a limb and say your body is more efficient than most of the unresponsive diabetics we run on. An hour is generous I'd say, depending on their size.


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## Akulahawk (Jan 14, 2014)

Robb said:


> Extravasated sugar isn't very nice though...
> 
> I've got zero problems with giving the entire 25 grams of sugar. None. What I do have a problem with is the hyperosmolarity of D50 and the lack of understanding of that concept among EMS providers.
> 
> I know you two understand that concept...don't think I don't! Lol


Extravasated sugar at lower concentrations isn't all that bad, actually. It's the higher concentrations that gets bad if it extravasates because it is so very hyperosmolar. That's why I push the stuff so slowly through a running IV line. I want the D50 to dilute as quickly as possible so it causes as little damage as possible.

The other reason I go so slow is so that I have a chance to catch an extravasated IV before too much gets out. Again, this limits the amount of potential damage that can occur if the D50 extravasates.


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## Handsome Robb (Jan 14, 2014)

Akulahawk said:


> Extravasated sugar at lower concentrations isn't all that bad, actually. It's the higher concentrations that gets bad if it extravasates because it is so very hyperosmolar. That's why I push the stuff so slowly through a running IV line. I want the D50 to dilute as quickly as possible so it causes as little damage as possible.
> 
> The other reason I go so slow is so that I have a chance to catch an extravasated IV before too much gets out. Again, this limits the amount of potential damage that can occur if the D50 extravasates.




Exactly how I give it.

I was diluting it but got hollered at for that so I stopped and went back to a running line.

I talk like I know what I'm doing...haven't been on the truck in 6 weeks lol.

Damn shoulder.


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## unleashedfury (Jan 14, 2014)

In my experience I have never been able to hammer the patient with D50.. stuff is like cement. So it takes some time to push it through a 18 or 20g.. 22 seems damn near impossible. 

I got my pee pee smacked for running fluid on a Diabetic call than needed some sugar. it was told to me start a saline lock give them the D50 if they wake up eat and sign off fine, If they don't transport. I still think that giving some fluid to get that D50 diluted and moving along is better than just flushing with a 5ml saline flush. 

OP I usually give half and see what kind of results I get, it isn't going to hurt to give it all, since the rest will go to waste anyways can't exactly box up a half used D50 and save it for later. If it takes a little or a lot to get them to wake up so be it. 

The key is if your going to Treat and Street ensure they get a much more long lasting carbohydrate. PB&J sandwiches are great for this. I always tell my patient afterwards they must eat before I leave.


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## Akulahawk (Jan 14, 2014)

unleashedfury said:


> In my experience I have never been able to hammer the patient with D50.. stuff is like cement. So it takes some time to push it through a 18 or 20g.. 22 seems damn near impossible.
> 
> I got my pee pee smacked for running fluid on a Diabetic call than needed some sugar. it was told to me start a saline lock give them the D50 if they wake up eat and sign off fine, If they don't transport. I still think that giving some fluid to get that D50 diluted and moving along is better than just flushing with a 5ml saline flush.
> 
> ...


Well, if you have any 60 mL or 100 mL syringes... just fill and do a slow flush with the big syringe and gently push the D50. Why not?

Also, if the patient wakes up with half, why not pop the top and have the patient suck down the rest of the D50 orally? It gets the full dose on board and the uptake is a lot slower than IV, followed by a PB&J chaser.


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## mycrofft (Jan 14, 2014)

We had a nurse extravascularly inject most of a big BristoJect of D50. Subject lost a lot of bicep, cost us thousands of dollars in plastic surgery and therapy to rehab the pt…who had placed himself in hypoglycemia on purpose to evade trial.


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## TheLocalMedic (Jan 17, 2014)

I think a big issue people don't take into account is how that patient _feels_ after you pump a whole amp of D50 into them.  I'll give you a hint: it's not great.  Typically end up with a headache and shakes.  Titrate to effect.  

   As an aside, and I don't remember who said it, but I have seen many many people wake up in the midst of that amp being given.  

Even better is D10.  We carry pre-mixed 250 ml bags that we can run in and shut off when the patient starts to come around.  Again, titrating to effect leaves the patient feeling better and you don't jack their sugar sky high.  

And as to the whole hyperosmotic issue, if you are administering D50 appropriately (either with a running IV or by drawing back every 10 cc's to get blood return and assure you haven't extravasated) you shouldn't run into any problems.  It's the idiots who slam a whole amp, blowing the vein in the process, or give it IM (yes, it's happened) that cause problems.


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## DrParasite (Jan 17, 2014)

It's been a while, but every unconcious hypoglycemic patient I have seen, we gave a full BristoJet of D50.  Usually a couple minutes later, the person regains conciousness, doesn't want to go, and eats a PB&J and some OJ.

We have even done it on a couple hypoglycemic AMS who weren't coming around quickly enough after the PB&J and OJ.  

Never had a bad reaction, always pushed it SLOWLY, always used a large cath and followed the d50 wiht thyamine (I think, it's been a while)

I would imagine, if the patient woke up mid push, we would disconnect the BristoJet, flush the line, and recheck the BGL.   But I don't remember seeing that happen.

I mean, all in all, hypoglycemia needs to be fixed now or else the person is going to die very soon.  hyperglycemia sucks, and the person might die, but they aren't going to die in the very near future.


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## Carlos Danger (Jan 17, 2014)

TheLocalMedic said:


> I think a big issue people don't take into account is how that patient _feels_ after you pump a whole amp of D50 into them.  I'll give you a hint: it's not great.  Typically end up with a headache and shakes.  Titrate to effect.



The problem with "titrating to effect" with D50 is that the offset of action can be very quick, especially if the patient is on certain combinations of insulins and oral meds. We might not notice that because we are usually able to get the patient some food right away, but 25g of dextrose isn't much at all in someone with a BG low enough to cause unresponsiveness. And these people feel like crap pretty much no matter what you give or how you give it, so that concerns me a lot less than the potential for rapid rebound hypoglycemia because I only gave them 12g of dextrose which was rapidly absorbed by the brain and muscles.

If you are using D10 it is a little different, because you can keep the infusion running while they eat something, so you may end up needing less than the whole 25g of IV dextrose.

Of course I'm not saying it's _wrong_ to give less than the whole amp of D50, but I just don't see any benefit at all in giving less than the full amp. As long as they don't have a bleed and as long as you aren't injecting into tissue, D50 is extremely safe. I think it's far better to give a little more than you need than to not give enough.


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## mycrofft (Jan 17, 2014)

DrParasite said:


> It's been a while, but every unconcious hypoglycemic patient I have seen, we gave a full BristoJet of D50.  Usually a couple minutes later, the person regains conciousness, doesn't want to go, and eats a PB&J and some OJ.
> 
> We have even done it on a couple hypoglycemic AMS who weren't coming around quickly enough after the PB&J and OJ.
> 
> ...



After six years working with diabetics , this is the most pragmatic and effective approach I've read in many months.


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## TheLocalMedic (Jan 20, 2014)

Halothane said:


> Of course I'm not saying it's _wrong_ to give less than the whole amp of D50, but I just don't see any benefit at all in giving less than the full amp. As long as they don't have a bleed and as long as you aren't injecting into tissue, D50 is extremely safe. I think it's far better to give a little more than you need than to not give enough.



Sure, there's nothing wrong with giving a whole amp, but (and I can't for the life of me find the journal article discussing this, although I've seen it enough to anecdotally confirm it) sometimes giving that whole amp will leave your patient feeling ill.  Headache, confusion, shakiness and pain are a few of the symptoms that were discussed.  Why not give the amp slowly, or give D10% instead, and titrate?  Once they're up and moving you can get them some carbs and then pull the IV and leave.  And you'll leave them feeling better than you would by spiking their sugar.


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## NomadicMedic (Jan 20, 2014)

Its the way you feel after eating 4 pieces of birthday cake. (Not that I've ever done that...) But many diabetics like to keep their sugar within a tight range. It doesn't do them any good to go from 20 to 350 with a full amp of dextrose, while getting them conscious and allowing them to eat will get the job done and be a little less stressful. Just my thoughts, YMMV.


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