32 yo Male - general illness

As ERDoc has said, the fact that he was also septic is not surprising. I see a lot of DKA patients, and infection is often the underlying cause.
 
Bear in mind that the sodium is not usually truly low in DKA. There may, however, be pseudohyponatremia, which is not clinically important except as a confounder.
 
Special K, y'all leave DKA at home routinely?
 
NomadicMedic said:
Dispatched at 0205 to a private residence for a 32-year-old male who is "not feeling well." Dispatcher says it may be a diabetic problem.

You arrive to an apartment building. The caller's Apartment is on the second floor, nicely furnished. Clean. Very angry girlfriend meets you at the door. She says, "he does this stuff for attention all the time. And I'm sick of it."

You walk into the apartment and see a guy sitting on the couch. Actually kind of sprawled there. There's a puddle from fresh vomit on the beige rug. And he just looks wiped out.

You walk in and say, "Hey, I'm the paramedic. What's going on tonight?"

He says, "I don't feel very good..."

And go.
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As a BLS crew assuming no ALS is available,

I'd ask him questions while another EMT would do obtain vitals (pulse ox/SpO2, Pulse/resp rate, blood pressure, blood glucose reading,).

- I'd ask him first an open question if he knows why he might be feeling like this. His response would help me determine a general impression, level of consciousness, etc. I'd be observing for any aphasia, altered mental status, skin color, temp, etc.

- I'd ask of any symptoms, OPQRST, SAMPLE, if he has a history of diabetes. I'd pay special attention to last oral intake and what specifically was ingested and when. I'd ask him when he threw up, how much looks expelled, color, all that fun stuff.

By the end of these questions, we should have vital signs established. I'd have a better understanding of what specifically needs treated.

We'd load him in the ambulance and head to the closest appropriate facility.
 
NomadicMedic said:
OK. You get a set of vitals and it looks like this:

HR: 120
BP: 118/62
Resp: 28
Pupils: PERRL
BGL : "hi"

He mumbles, "I took some insulin, I don't member how much. Either eight or 10 or 12 units of Humalog..."

He seems confused, asking several times if you were gonna take him to school. He also says he took some other medication. Maybe a pain pill?

His girlfriend says he hasn't been taking care of himself and he hasn't had much to eat or drink or manage his blood sugar for the last couple of days. She's royally pissed. Stomping around and slamming doors.

He has a history of back pain and PTSD, for which he takes OxyContin, Klonopin, Valium, Cymbalta and some other meds that he can't remember.
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Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50. EMT administers oral glucose while en route to closest hospital.
 
MikeC said:
Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50. EMT administers oral glucose while en route to closest hospital.
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Hold up a second. Why would you give him sugar?
 
MikeC said:
Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50. EMT administers oral glucose while en route to closest hospital.
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Why do you suspect ALS would administer glucagon or D50 to a DKA patient whose BGL is greater than 600?

Based on the description oral glucose is contraindicated in this scenario......for more reason than one.

Sent from my SAMSUNG-SM-G920A using Tapatalk
 
correction no glucose should be administered, and insulin not glucagon would be indicated.
 
MikeC said:
correction no glucose should be administered, and insulin not glucagon would be indicated.
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I'm curious, how many ALS agencies do you know of that would treat this person with Insulin? I don't know of many that even carry it on their trucks.

I know several ER docs that wouldn't even do that, they would let the endocrinologist investigate why it's so high and lower it at a much more controlled pace.
 
DrParasite said:
I'm curious, how many ALS agencies do you know of that would treat this person with Insulin? I don't know of many that even carry it on their trucks.

I know several ER docs that wouldn't even do that, they would let the endocrinologist investigate why it's so high and lower it at a much more controlled pace.
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No insulin would have to be given at the ER. I don't know of any ALS that carries it either.
 
I think our CCT trucks carry insulin. If they do, I don't know how often they actually use it.
 
MikeC said:
No insulin would have to be given at the ER. I don't know of any ALS that carries it either.
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Probably not a good idea to start giving insulin without a full electrolyte panel. The treatment for a "hi" BGL isn't necessarily just insulin. It's slightly more complicated than that.
 
medichopeful said:
Probably not a good idea to start giving insulin without a full electrolyte panel. The treatment for a "hi" BGL isn't necessarily just insulin. It's slightly more complicated than that.
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This^^^. You need a starting point in which to base your BGL titration off of. Not to mention D5, or D10W alongside of the Insulin drip.

Cerebral edema is bad. Very bad.
 
MikeC said:
Ok so Ketoacidosis is the field dx. I'd call for ALS if available to meet en route who would most likely administer Glucagon or D-50. EMT administers oral glucose while en route to closest hospital.
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The bad news is, you would probably do this. You didn't realize that glucose, dextrose or glucagon was contraindicated until we pointed it out.

This is just one example of why I believe that EMT-Bs should not be the first level in a tiered response.
 
NomadicMedic said:
The bad news is, you would probably do this. You didn't realize that glucose, dextrose or glucagon was contraindicated until we pointed it out.
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Agreed
NomadicMedic said:
This is just one example of why I believe that EMT-Bs should not be the first level in a tiered response.
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disagree. Just because one EMT didn't know something, doesn't mean no EMTs know that. I happen to know this, and I am pretty confident that most EMTs know it too.

If we are going for least common denominator, how many medic skills and drugs should be taken away because a medic somewhere doesn't know something, or makes a mistake?
 
DrParasite said:
Agreeddisagree. Just because one EMT didn't know something, doesn't mean no EMTs know that. I happen to know this, and I am pretty confident that most EMTs know it too.

If we are going for least common denominator, how many medic skills and drugs should be taken away because a medic somewhere doesn't know something, or makes a mistake?
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Sorry. I think most BLS providers lack the education to do anything more than very simple treatments (read: splints and ice packs) and most lack any sort of critical thinking skill that will determine transport decision or level of care needed.

CPAP for cardiogenic shock? EpiPen for some diffuse urticaria on the trunk? Sugar for DKA? Narcan for a head bleed?

Let's teach EMTs how to drive safely. How to move patients safely and how to act more as a mobile CNA and limit their role to BLS IFT.
 
@DrParasite I agree we can't "blanket term" all EMT's as such, just like we can't do the same with all paramedics.

The sad fact of the matter--as is in life--is we cannot force anyone to take education seriously. So to apply this to even the prehospital environment basically boils down to this:

You're only as good as your own ambition.

I cannot teach ambition, or self-motivation, but I can sure flick a pebble at an ocean of EMT's and medics who talk a big game, but do not deliver. Why? They have no internal drive, period.
 
VentMonkey said:
@DrParasite I agree we can't "blanket term" all EMT's as such, just like we can't do the same with all paramedics.

The sad fact of the matter--as is in life--is we cannot force anyone to take education seriously. So to apply this to even the prehospital environment basically boils down to this:

You're only as good as your own ambition.

I cannot teach ambition, or self-motivation, but I can sure flick a pebble at an ocean of EMT's and medics who talk a big game, but do not deliver. Why? They have no internal drive, period.
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Absolutely agree in regards to ambition being important, simply stated you cannot not teach anything to anyone whom doesn't want to learn. And you cannot make someone "Want" to learn, but you can make it a culture and use other types of social pressures to make this a norm. It is not something you can do over night, it has to be grown and nurtured.. Admittedly no small or simple task, yet not out of the realm of possible.

NomadicMedic said:
The bad news is, you would probably do this. You didn't realize that glucose, dextrose or glucagon was contraindicated until we pointed it out.

This is just one example of why I believe that EMT-Bs should not be the first level in a tiered response.
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Was actually stunned when I had first read the comment regarding Tx a DKA Pt with Glucose, and felt the same as you. Because of what you and Ventmonkey had pointed out I agree that the tiered system is not ideal for Most systems.
 
DKA is one of the more time consuming/labor intensive things we treat acutely in the ICU. As a medical resident in the ICU we spent many nights up trending electrolytes/glucose/metabolic panels every couple hours adjusting fluids and drips.

From a prehospital standpoint I'd say start on fluids get to a hospital. What's really needed is several hours or a night or close monitoring and frequent labs.
 
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