Any thoughts on giving Thimaine during DKA?

[blinnbuc89]

We had a pt the other day that had not eaten in over a week, with poor diet prior to that and he FBGL was 300-550, consistently for over a week. She is ID-DM and was given 2-3 times prescribed amount of insulin. So clearly her body was not utilizing the carbs and she was obtunded for approx 4 days. I gave 100mg Thiamine IM and she went from GCS7 to GCS14. I got reamed for this. Any thoughts?

 

[usalsfyre]

We had a pt the other day that had not eaten in over a week, with poor diet prior to that and he FBGL was 300-550, consistently for over a week. She is ID-DM and was given 2-3 times prescribed amount of insulin. So clearly her body was not utilizing the carbs and she was obtunded for approx 4 days. I gave 100mg Thiamine IM and she went from GCS7 to GCS14. I got reamed for this. Any thoughts?

What lead you to believe she was B12 deficient? It's probably the most "benign" med in a typical EMS box, but there should still be some though behind giving it. How long was it before she woke up? It it was nearly instantaneous, it was more than likely the needle that woke her, not the thiamine.

 

[blinnbuc89]

Well B1 deficiency certainly seems possible with 0 oral intake in a week, with poor diet for an exteded time prior to that. Her change in mentation began after approx 15-20 minutes. I am in a rural area, with no hospital within 35 miles of pt's location. I should have consulted Medical Control first, I know now, but as a vitamin what can I harm? My thinking was this: Thiamine is a necessary co-enzyme for glucose to be broken down and converted to ATP for energy. Her BGL was excessively high, with little to no response to insulin. So, she had plenty of insulin and plenty of glucose, but no way for her bod to utilize it. Sound about right?

 

[blinnbuc89]

Ok, got my report and here is my Narrative:

M10 dispatched to XXXX Hwy 156 for a fallen party who is out of reach of oxygen tubing. M10 arrived to find a 78 Y/O Female on floor leaning on recliner, unconscious and varying from barely responsive to painful stimuli to unresponsive.

Pt is presenting poorly at this time and appears to be atraumatic. Family states that she has been in an obtunded state for 3-4 days with a BGL of 300-500, consistently, and was to begin hospice care today, as she was diagnosed with lung cancer and colon cancer early this month and has a poor prognosis. Family is advised to seek medical attention for pt.

Vital signs obtained at 08:46. Pt has a GCS of 7 and RTS 10. BGL is 482. PMHx: DM-ID, HTN, colon and lung cancer. Pt takes anti-hypertensives and is allergic to PCN, pollen, and amoxicillin. Pt has not eaten anything in approximately one week. Pt has been given copious amounts of insulin (Humalog) over past 3 days, with little effect on BGL or level of mentation.

Husband of pt refuses transport AMA. He signs AMA refusal form and is advised to call back if he changes his mind or the pt becomes more ill. Pt is rolled on to back board to facilitate movement to bed. Pt is lifted with help of family (pt is morbidly obese and weighs approximately 360 lbs) and placed on bed. Pt rolled off of backboard and realigned on bed. Head of bed is raised to approximately 30 degrees to facilitate breathing. Pt is placed back on home oxygen via NC @ 4 LPM. At this time pt incontinence is discovered. Pt left in care of husband and son.

Crew is outside decontaminating equipment when husband walks up to M10 and advises crew that he desires to nullify the aforementioned AMA refusal for treatment and transport. He would like for the pt to be transported to Conroe Regional Medical Center, this is where her doctor is generally located at.

M10 crew then went back inside with stretcher and moved pt to stretcher by sheet draw. Rails x2, straps x2. Pt moved to M10 and loaded/secured in unit. Pt placed on NRB @ 10 LPM. IV access is attempted (R wrist x2 and L forearm x1) and is unsuccessful. Pt is still obtunded, GCS7, RTS10. Pt is not intubated, due to clear airway, good respiratory effort, no IV access. Pt placed on 4-lead. 4-lead shows sinus tachycardia with ST-elevation in lead III and aVF. 12-lead is obtained and shows sinus tachycardia with no elevation present in all leads.

Vital signs were reassessed at 09:32. M10 began transporting pt to CRMC non-emergency traffic. Pt initially remained obtunded throughout transport. Vital signs reassessed at 10:00. Pt is given 100mg of Thiamine IM R deltoid (Thiamine is given to facilitate the breakdown of glucose for use in cellular respiration. FBGL is extremely high and pt has been given copious amounts of insulin. Pt also has had no oral intake for approximately one week, and a poor diet prior to that, so Thiamine deficiency (beriberi) is possible and pt is presenting with S/S of beriberi.) at 10:00. Radio report is called in to CRMC at this point pt becomes more alert, responsive to verbal stimuli, AOx0.

M10 arrived at destination. Pt is unloaded and taken inside to ERXX. Pt information is given to nursing staff. Pt is, at this point, conscious and AOx3. Pt moved to bed by sheet draw. Rails raised x2. Pt left in care of ER staff and husband. General impression of pt is much better and improving. End of report.

 

[usalsfyre]

I can see the thought and it seems to have worked. Most of the B12 deficient patients I've seen have been alcoholics, so I tend to think "months" of poor oral intake not "days" (large homeless population for a long time).

As far as getting reamed, I recommend you get on friendly terms with your medical director (I assume he's at SJ in Bryan?). That way when a can't think outside the box supervisory minion bothers you...you can ask him if he's talked to the OMD about what the problem is.

 

[blinnbuc89]

Well I'm out in San Jacinto County, and to be honest our MC is.... I don't know. I think College Station Medical Center to be honest. I hate CSMC and while I was working in CS I would take EVERYONE to SJ, well all stable pts anyway. They are so rude at CSMC.

 

[usalsfyre]

Well I'm out in San Jacinto County, and to be honest our MC is.... I don't know.

Not to pick on you, but that's scary. Find out who your actual medical director is, introduce yourself and attempt to get to know them. It will do nothing but help you.

 

[blinnbuc89]

No no, I don't know our Online Med control. I know who the Medical Director is. As for OMC, from what I gather from the Protocol book, its whatever doc picks up the phone at CSMC. Sounds strange, are other places like that?

 

[usalsfyre]

No no, I don't know our Online Med control. I know who the Medical Director is. As for OMC, from what I gather from the Protocol book, its whatever doc picks up the phone at CSMC. Sounds strange, are other places like that?

No different from here. Where being friendly with the medical director helps is when you don't EXACTLY follow the letter of the protocol, but still do the right thing for the patient, you now have an avenue too keep supervisors who think the protocol is the absolute last word off your back.

 

[blinnbuc89]

Ehhh they are pretty lax around here usually, but I'll keep that in mind. Thanks for the input.

 

[usalsfyre]

Who reamed you? If it was the ED nurse, I'd just walk off in mid sentence....

 

[jwk]

I'm still trying to figure out why an EMS unit would even be carrying Thiamine. Is this a routine drug for y'all?

 

[TransportJockey]

Every service I've worked for in Texas and NM carries thiamine... I always thought it was a pretty common drug to carry.

Sent from my PC36100 using Tapatalk

 

[usalsfyre]

I'm still trying to figure out why an EMS unit would even be carrying Thiamine. Is this a routine drug for y'all?

It's been on every EMS unit I've ever worked on. Administered prior to dextrose in the malnourished patient to prevent Wernickie's encephalothapy.

 

[lightsandsirens5]

As far as getting reamed, I recommend you get on friendly terms with your medical director (I assume he's at SJ in Bryan?). That way when a can't think outside the box supervisory minion bothers you...you can ask him if he's talked to the OMD about what the problem is.

HIGHLY recommend this. Saved my behind from an unpleasant chewing once or twice.

 

[blinnbuc89]

My sup wasn't real excited about it. I just got done talking to my Lieutenant and all is good. I had to write up an incident report on another call that, after being read, led to a series of incident reports. So after that I talked to him and said I had a lapse in judgement on a call and didnt call OMC. He asked about the call and I explained everything and he pulled up my PCR and looked at it. He asked why I did it, so I explained to him and my partner, another medic, what my thought process was. He just looked at me at the end and said hmmm. And asked if I could sign his CE booklet for CE Hours. He said that its ok because Thiamine is so benign, and that my action worked, and prevented me from intubating, so really, I did the most with the least and that he wouldn't have ever thought to do it and thanked me for bringing up the discussion to see if the MD will look at revising the protocol. Then I grilled up some chicken and made some beans, and fed the station so my job is safe. Never underestimate the power of food.

 

[jwk]

It's been on every EMS unit I've ever worked on. Administered prior to dextrose in the malnourished patient to prevent Wernickie's encephalothapy.

Gotcha - did a quick read. Would you be more likely to use this on "frequent flyers" with a well-known history than a patient you've never seen before?

 

[blinnbuc89]

Gotcha - did a quick read. Would you be more likely to use this on "frequent flyers" with a well-known history than a patient you've never seen before?

Probably most likely to use on a homeless person, excuse me, 'urban outdoorsman'. Or a drunk college student to ruin their drunken-ness.

 

[J. Burdett]

We had a pt the other day that had not eaten in over a week, with poor diet prior to that and he FBGL was 300-550, consistently for over a week. She is ID-DM and was given 2-3 times prescribed amount of insulin. So clearly her body was not utilizing the carbs and she was obtunded for approx 4 days. I gave 100mg Thiamine IM and she went from GCS7 to GCS14. I got reamed for this. Any thoughts?

Good job but still call for your orders!

Magnesium is also needed to create the co-enzyme TPP (thiamine pyrophosphate). Given the hyperglycemia the pt was more than likely also experiencing hypomagnesmia secondary to HHNS induced osmotic diuresis. This pt probably needed "banana" bag along w/ a fluid resuscitation. The pt was more than likely severely dehydrated.

 

[blinnbuc89]

Good job but still call for your orders!

Magnesium is also needed to create the co-enzyme TPP (thiamine pyrophosphate). Given the hyperglycemia the pt was more than likely also experiencing hypomagnesmia secondary to HHNS induced osmotic diuresis. This pt probably needed "banana" bag along w/ a fluid resuscitation. The pt was more than likely severely dehydrated.

I absolutely agree. I could not get an IV going on her so fluid was out of the question, she was morbidly obese. I still would not have give any magnesium, Thiamine is pretty benign so it wasn't really a big deal, where mag may have become a big deal. But yes, I understand your reasoning. Finally all those stupid biology classes I had to take for my degree paid off. Hooray.