Altered LOC. Diabetic Pt with known Hx of Narc OD

[lightsandsirens5]

OK,

So you are on an ILS engine dispatched to a 22 YOM, known diabetic, unresponsive, cold, breathing slowly. Pt also has a fairly extensive Hx of Narcotic OD. On scene you find an approx 6'2" male estimated weight 40-45 kilos, lying on bedroom floor. House is an absolute wreck. Pt is not responsive to pain, eyes are kind of halfway open, pt will occasionally very slowly move around, occasionally will tighten his hands around whatever happens to be in them. He is incontinent. Skin is cold, dry and a little on the pale side of pink. (I mean COLD). Initial VS: BP is 66/40 according to mechanical NIBP. P is 70, (Carotid). R is 10. Unable to get an SPO2. 3 lead is showing a NSR at 70. Temporal scan is approx 82* F. Pupils are equal and fixed, neither dilated or constricted, maybe on the smaller side of normal. Friends on scene have no idea ho long pt has been down, no idea when he ate last, no idea what all meds he is on, no idea about anything in general. Of course the ambulance has an extended response time, and when they show up they are a BLS crew. No ILS crew was available. (No ALS either for that matter, my county doesn't have any medics yet.) So I end up riding in with the pt in the ambulance. Both my BGL meter and the ambulance crews read ERR. Two attempts with each meter. No joy. So we load this dude up and head towards town. I get a 20 ga in his ankle (The only vein anywhere worth trying. I seriously considered an IO) and start flowing NS (the only fluid on the ambulance). According to my county protocols, we use a modified "coma cocktail." I suppose it is more like a "coma two part mix" ( :-? ) of Narcan and D50. But protocols don't say which comes first. It says that in the case of a severely decreased LOC, if unable to determine cause, administer, Narcan and D50% (or D25 for peds).

So my question is, What would you do first? After not being able to get a BGL after 4 attempts, I went with the Decreased LOC protocols. I ended up giving Narcan first (2ml of 1mg/ml) with no improvements, then was just getting ready to do D50% when we hit the ER. So I let the ER handle that one. I never did hear what the guy's problem was.

So people, Narcan or D50% first?

 

[TransportJockey]

RR is a little lower than I like, but not bad. I would have gone with D50 first. There are some meters the rear ERR instead of low when it's too low to pick up.

 

[JPINFV]

Based solely on what's provided, I'm going to have to say either neither or a small trial of D50. Diabetes does not cause hypoglycemia. Insulin and some hypoglycemic other agents used to control diabetes cause hypoglycemia. Now what's the likelihood that this patient is compliant with his medications and diet?

Cold, dry, pale, incontinent is making me think hyperglycemia (both hypo- and hyperglycemia can read as error depending on how far it is out of range) with polyuria than hypoglycemia, or even opioid overdose.

 

[Shishkabob]

D50. Lack of sugar kills /causes damage faster than a decreased respiratory state that we can bag for a bit.


But I'm also not necessarily thinking a hypoglycemic event.

 

[JPINFV]

D50. Lack of sugar kills /causes damage faster than a decreased respiratory state that we can bag for a bit.


But I'm also not necessarily thinking a hypoglycemic event.

However, hypothermia (albeit, I'll be honest and say that I question a temporal temperature on a hypertensive patient) and hypotension will also kill fairly quickly. I'd also ask why you couldn't give both? Assuming that it's a low-err and you aren't giving the full 2mg, then if either intervention works you'll be able to determine which is working based on a follow up BGL measurement. Going from error to 40 or 50 is a good way of knowing that it's hypoglycemia, and not an OD.

 

[Pittsburgh77]

I personally would elect to give IM glucagon, because D50 is thick solution. With only having a 20g in the ankle, have a second person look for a better vein then consider giving D50 if I can have better venous access.

Then I'd administer Narcan as a secondary measure if the pt. didn't respond to the initial dose of Glucagon.

 

[MrBrown]

I could probably give him some glucagon myself and if that didnt work 50ml of 10% glucose IV

Could be hyperglycaemic too or some sort of massive neurological event.

 

[Melclin]

Cold, dry, pale, incontinent is making me think hyperglycemia (both hypo- and hyperglycemia can read as error depending on how far it is out of range) with polyuria than hypoglycemia, or even opioid overdose.

Or its a hypo and he's had a hypo-g seizure + incontinence. He does kinda sound a bit post-ictal. But, yeah I agree with you.

The weight and the blood pressure point to an non ketotic hyperosmolar state too. Or that could just be his heroine chic physique. Do you know what type of diabetes this guy had?

My vote is still on glucose first even though I'd guess hyper. The dextrose in d-50 and the time left before he'll get insulin in hospital are both small enough for a trial of glucose to be pretty harmless if it is a hyper and the action that keeps him out of a nursing home for the rest of his life if it is a hypo (although if it is HONK or HHNK or HHNKSNGKNSKNASGE#%@ or what ever you call hyper g hyper osmolar states, based on he's temp he probably boned anyway).

You didn't mention much about his resp status, but if we assume his 10 resps appear to be of adequate Vt then I'm not sure he really needs narcan, at least, not immediately.

 

[Melclin]

I personally would elect to give IM glucagon, because D50 is thick solution. With only having a 20g in the ankle, have a second person look for a better vein then consider giving D50 if I can have better venous access.

Why not just dilute it?

RR is a little lower than I like, but not bad. I would have gone with D50 first. There are some meters the rear ERR instead of low when it's too low to pick up.

With a temp low like that, resps of 10 is could be fine given the reduced metabolic demand.

 

[Smash]

I could probably give him some glucagon myself and if that didnt work 50ml of 10% glucose IV

Could be hyperglycaemic too or some sort of massive neurological event.

With a 189cm tall male weighing 45kg (ie a skeleton) do you think he would have any glycogen to convert?

He is profoundly hypothermic, and there is nothing so far that is presenting out of the ordinary given his temperature. I would be very much inclined to sit on my hands and drive him very gently to hospital. Until we can start proper rewarming, pretty much anything we do is potentially going to end very badly for him. I would not be giving him a fluid bolus, nor any narcan. The only thing I may feel compelled to give would be some 10% dextrose, and I wouldn't necessarily feel good about that either.

The only thing this patient needs right now is some rewarming, and that really needs to be done carefully in a controlled environment with appropriate support.

 

[Akulahawk]

Sounds a LOT to me like a hyperglycemic event... but given that he's COLD and hypotensive, with the BG meter reading "err" and his history, I'd still have to go with the D50 and naloxone. I think that patient is in for a rough ride, if he survives. Also, if you give the D50 and you still get an "err" reading, chances are pretty darned good that the levels are high, not low. Also, since 2mg of naloxone was given w/o improvement, he's either too cold or he's not on an opiate right now...

His blood might just be about as thick as motor oil...

And Smash brings up another excellent point that I was considering getting to: He's going to need rewarming. You aren't going to be able to do it all that well on scene or in the ambulance. I'd want a PR temp, if I can get one done. He's also going to need LOTS more testing and that can't be done on scene or in the ambulance either.

 

[Melclin]

Wow, so I just plugged the temp into a converter to change it to Celsius and its a bit lower than I realised. Not that I suppose it makes much of a difference but I'm just curious. Where are you? What's the ambient temperature?

 

[TransportJockey]

With a temp low like that, resps of 10 is could be fine given the reduced metabolic demand.

Heh, I skimmed it hte first time and didn't notice the temp thing, so you're very right on that.

 

[Aidey]

Narcan would probably be given first since we can give it IM or IN. One person can do that while someone else does the IV. I don't know that I would give D50. I agree D10 would be better for him, along with a good fluid bolus. Just guessing I think this guy is hyper, not hypo.

 

[lightsandsirens5]

Ahhh....ok. I see the argument behind the D50% before the Narcan.

I didn't have the ability to do a rectal temp, so temporal was the best I had. And yea, 6 disposable hot packs don't go far. :-(

As for the D50% thru a 20. I have pushed it thru a 22. Took a little while, and I didn't even think to dilute it. :wacko: But that was back when I was just out of class. I'd been on my own for maybe a week.

Ambient temp when we found him was about 60. RH prolly around 60%. He was last seen normal at 2000 the evening prior. Call out was at 1030 the following morning.

I didn't even think about his resps being low because of the hypothermia. :wacko: I feel like a total idiot right now.

Pittsburgh, I was the only Intermediate on the call. No other units available, no ALS available.

And I am assuming that by glucagon y'alls mean that stuff you give IM? Unfortunately we don't get to carry that. Besides, he barely had anything to inject it into! lol

So Smash, you would not give any fluid other than TKO? Or am I misunderstanding? Why not give him some warm fluid? Will bring his BP up a little and give him some warmth. Or am I way off and totally missing something obvious here?

 

[reaper]

Also remember that if his Temp is any where near correct. IM is going to take a very long time to act.

D50 or D10 IV, then Narcan if no response

 

[46Young]

I personally would elect to give IM glucagon, because D50 is thick solution. With only having a 20g in the ankle, have a second person look for a better vein then consider giving D50 if I can have better venous access.

Then I'd administer Narcan as a secondary measure if the pt. didn't respond to the initial dose of Glucagon.

I mix D50 into a 250 bag of NS for diabetics w/ brittle veins. Just take out 50cc's and inject the D50, and you're ready to go. I do it all the time. I only bother with glucagon IM if no IV access, and he's emaciated to begin with, anyway.

For the OP, I would go with Linuss, and treat for suspected hypoglycemia based on the inability of the glucometers to get a reading. The possible hypoglycemia will do the most damage. If he's high, the 25G of D50 isn't going to make or break him. They'll float him down in the ED. Next, I would reassess L/S and give another 250cc bolus if still hypotensive. Then, I would go with narcan in 0.4 mg increments if only his respiratory effort and air exchange prove inadequate. Rewarming in the bus would be attempted, but with such a short txp time, it's not going to help much. Time permitting, go for a 12 lead, because you may find something. Nothing more we can do other than monitor his respiratory/ventilatory status and other vitals.

 

[Smash]

So Smash, you would not give any fluid other than TKO? Or am I misunderstanding? Why not give him some warm fluid? Will bring his BP up a little and give him some warmth. Or am I way off and totally missing something obvious here?

Unless I knew what temperature the fluid was, and could accurately measure his core temperature, I would be inclined to hold off on giving a fluid bolus. My thinking is (feel free to disagree): This patient is very, very unwell. However, he has been very, very unwell for some time. So, in the next 20 minutes or so that I am caring for him, as opposed to the last 14+ hours (or more) is it likely that, with limited technology and treatment at my disposal, is it likely that I am going to meaningfully improve his outcome? Or, is it more likely that I am going to do harm?

Specifically for this patient: He obviously has some long standing medical and social problems that are rather complex to manage on their own, even without this acute episode.
We must assume that he has been lying flat on the floor for the 14 hours or so that he hasn't been seen. So, aside from the possibility of hyper/hypoglycemia (one could argue either way, but without accurate labs it is rather an academic point) and the obvious hypothermia, there is a reasonable likelihood that he has a crush injury as well. So we have a dilemma.
His blood pressure is acceptable at this stage due to his hypothermia. We expect to see hypotension in hypothermia. We also expect to see bradycardia, so his heart rate is actually higher than I would have thought to see, but that's ok. Essentially his basal metabolic rate is so low that he doesn't need to have a fast heart rate or a big blood pressure to fulfill is energy requirements.

So what happens is we tend to get some stasis, some pooling of very cold blood in the extremities as the slightly warmer blood stays in the core and hopefully keeps him alive. If we then go and poke in some fluid through a peripheral line, we tend to move that very cold fluid from the extremities back to the core.

Now, the big thing we worry about with hypothermic patients is how fragile their hearts are. A cold heart is a heart that desparately wants to fibrillate, and it will use any excuse to do so. So when we start moving cold fluid back to the core, we give the heart that excuse, and into VF we go. Not good.

So it would seem like warm fluid might be a good idea, but the danger there is that as we introduce warm fluid to the peripheries we can induce some vasodilation, once again flooding the core with cold.

We also have here a potential for crush injury, which, under normal circumstances we would manage with copious administration of fluid and possibly sodium bicarbonate and furosemide. But in this patient we run a bigger risk of moving not only the cold, but also all the potassium, myoglobin and all the other nasties back into central circulation and the heart. Bad.

So, what I would do: Handle with extreme care. Very gentle ride to hospital. Dextrose is probably fine. I'm not convinced of whether it is hypo or hyperglycemia, but a small amount of 10% is probably not going to do any harm. There is absolutely no indication for naloxone, so I wouldn't give any. I wouldn't be giving any fluid either. Nor would I intubate. I would just drive very, very carefully to hospital.

This person has more problems than I can hope to treat, and I have more potential to cause extreme harm than good.

 

[MrBrown]

To quote a great ambo I know; he needs to go to the place where the doctors are with much of the fastness so they can have a fossick around in his noggin

 

[Melclin]

He obviously has some long standing medical and social problems that are rather complex to manage on their own, even without this acute episode.
We must assume that he has been lying flat on the floor for the 14 hours or so that he hasn't been seen. So, aside from the possibility of hyper/hypoglycemia (one could argue either way, but without accurate labs it is rather an academic point) and the obvious hypothermia, there is a reasonable likelihood that he has a crush injury as well. So we have a dilemma.
His blood pressure is acceptable at this stage due to his hypothermia. We expect to see hypotension in hypothermia. We also expect to see bradycardia, so his heart rate is actually higher than I would have thought to see, but that's ok. Essentially his basal metabolic rate is so low that he doesn't need to have a fast heart rate or a big blood pressure to fulfill is energy requirements.

So what happens is we tend to get some stasis, some pooling of very cold blood in the extremities as the slightly warmer blood stays in the core and hopefully keeps him alive. If we then go and poke in some fluid through a peripheral line, we tend to move that very cold fluid from the extremities back to the core.

Now, the big thing we worry about with hypothermic patients is how fragile their hearts are. A cold heart is a heart that desparately wants to fibrillate, and it will use any excuse to do so. So when we start moving cold fluid back to the core, we give the heart that excuse, and into VF we go. Not good.

So it would seem like warm fluid might be a good idea, but the danger there is that as we introduce warm fluid to the peripheries we can induce some vasodilation, once again flooding the core with cold.

We also have here a potential for crush injury, which, under normal circumstances we would manage with copious administration of fluid and possibly sodium bicarbonate and furosemide. But in this patient we run a bigger risk of moving not only the cold, but also all the potassium, myoglobin and all the other nasties back into central circulation and the heart. Bad.

So, what I would do: Handle with extreme care. Very gentle ride to hospital. Dextrose is probably fine. I'm not convinced of whether it is hypo or hyperglycemia, but a small amount of 10% is probably not going to do any harm. There is absolutely no indication for naloxone, so I wouldn't give any. I wouldn't be giving any fluid either. Nor would I intubate. I would just drive very, very carefully to hospital.

This person has more problems than I can hope to treat, and I have more potential to cause extreme harm than good.

This. Also I would suggest that the worth of running warm fluids is questionable anyway, considering the difficulty in warming the bag with any consistency and keeping the fluids warm as they travel down the line in that environment. I seem to recall a study in EMJ about quite hot saline returning to room temp over the length of a normal giving set. We do after all use a similar but reversed idea to chill room temp beer :wub: .

I'd love to sit down with a bunch of gear carried on an ambulance and Apollo 13 a solution to regulating warm fluid infusions.

Surely though, moving him would return more cold/nasty filled blood than the act of cannulating. Would it not perhaps be advisable to haemodilute this guy a bit before moving? Which is worse? Moving him and returning cold/nasty blood, or cannulating him/moving him and returning cold/haemodiluted nasty filled blood? Perhaps even add in the possibility of doing some good if you can regulate you warm fluids in the truck (Ignoring the absence of reliable warm fluids and the single 20g access, which I suppose largely precludes this idea). In what way will the ED manage him differently in the first 20 mins of their care (while the junior registrar finishes his panic attack and they convince the ICU to let them borrow one of their warming thingies)? That's not rhetoric, I'm actually not aware of how they would go about it. Are we maybe just delaying a risky treatment rather than avoiding it?


Also to anyone, Question: Does the derangement of blood glucose significantly impair shivering?