Diabetic Emergency Question

[thowle]

Okay, today we were dispatched to a female patient with known diabetic related problems; the complaint was that the patient was eating breakfast, became disoriented and finally became unresponsive to verbal stimuli.

Prior to the patient becoming unresponsive, a family member gave a some orange juice to the patient, which rendered apparantly rendered very little positive results (because the pt later was unresponsive).


This seems like ( for an EMT-B ), a good time to administer Oral Glucose, I was thinking -- atleast until ALS arrived, and then they could do their own thing.

But my question is this, we were "taught" that if a patient is unresponsive, and/or cannot swallow that it is to be forseen as a CONTRAINDICATION, and seeing as how this patient is unresponsive -- what would the correct intervention be?

Of course, we would need to ensure ABC's, and monitor closely -- but would there be anything wrong with placing glucose on a tongue-depressor and inserting it by their gums so that it may absorb?

How would you handle this sitation? Waiting for ALS without giving any intervention seems quiet risky to me.

Thanks

 

[Jolt]

I think you can technically give glucose PR so you don't have to worry about aspiration, but that's all you...

 

[thowle]

You can technically give glucose PR, but that's all you...

Yeah, I don't think I would want to be the one administering it that way lol

 

[ffemt8978]

Okay, today we were dispatched to a female patient with known diabetic related problems; the complaint was that the patient was eating breakfast, became disoriented and finally became unresponsive to verbal stimuli.

Prior to the patient becoming unresponsive, a family member gave a some orange juice to the patient, which rendered apparantly rendered very little positive results (because the pt later was unresponsive).


This seems like ( for an EMT-B ), a good time to administer Oral Glucose, I was thinking -- atleast until ALS arrived, and then they could do their own thing.

But my question is this, we were "taught" that if a patient is unresponsive, and/or cannot swallow that it is to be forseen as a CONTRAINDICATION, and seeing as how this patient is unresponsive -- what would the correct intervention be?

Of course, we would need to ensure ABC's, and monitor closely -- but would there be anything wrong with placing glucose on a tongue-depressor and inserting it by their gums so that it may absorb?

How would you handle this sitation? Waiting for ALS without giving any intervention seems quiet risky to me.

Thanks

Remember the first rule of medicine: DO NO HARM

It's even riskier for you to give an improper intervention than to do the basics or nothing at all. Even giving oral glucose on a tongue depressor is contraindicated if the patient does not have a gag reflex. You could do more harm by letting the patient aspirate the glucose because they can't protect their own airway.

As a BLS crew, there's not much you can or should do until ALS arrives. ABC's, oxygen, vitals, and wait for ALS or transport to ALS intercept.

 

[thowle]

As a BLS crew, there's not much you can or should do until ALS arrives. ABC's, oxygen, vitals, and wait for ALS or transport to ALS intercept.

Okay, good deal. That's what I was needing to know.

 

[Katie]

It may depend as well on your state protocol. We're to consider glucose here for 1) "altered mental status with known diabetic history" and 2) "unconscious for an unknown reason." Absence of a gag reflex being listed as a precaution, not a contraindication. I had that question as well during class as to giving oral glucose to someone who is unresponsive. My instructor said to consider glucose placed between the cheek and gum (as indicated in our protocol). In this case the pt does not have to swallow; rather the glucose is absorbed via the gums. So to minimise the risk of aspiration we administer "10-15 grams of glucose paste between the gum and cheek" both for adults and kids, and have suction ready, etc.

 

[seanm028]

I was taught the same as you said you were, "don't give oral glucose to a Pt who is ALOC". I would call ALS and maintain ABCs while they were en route.

 

[emtbuff]

we were also taught and teach no glucose if unresonsive. However like others have said we have also done and seen it work by giving a small amount of glucose paste in the cheeck/gum area. Little bit at a time. With High flow O2 on and suction near by. If you suspect problems don't do so...and if all else fails and you dont' wanna do this maintain an airway transport and if ALS is availble either wait if they are close or meet up.

 

[MMiz]

Our protocols don't allow oral glucose for pts with an altered LOC or without a gag reflex. I understand that you could place it between gums and cheek, but I sure wouldn't want to risk messing with a pt's airway.

I'd monitor and ensure the ABCs while ALS was en route.

 

[paccookie]

If I were you, I would monitor vitals and provide oxygen while waiting for ALS to arrive. I wouldn't give oral glucose to an unconscious patient.

This would be an excellent situation for glucagon, but I know that's out of your scope of practice. It's even out of my scope of practice as an intermediate. I know protocols say to use D50 first, but I've seen glucagon have amazing results almost as fast as D50, plus you don't have to get an IV first and there's no risk of necrosis if your IV infiltrates.

If your patient is conscious and you don't have oral glucose for whatever reason (like you're in the first responder role), you can use cake icing or cotton candy. Although with cotton candy, blood glucose goes up quickly but drops quickly too. We used that at the fair a few times last fall with good results. lol

Christina

 

[Ridryder911]

A small amount of oral glucose can be safely administered orally, if the patient is placed in the coma position (on lateral side/recumbent) and placed between the cheek and gum (bucossa) or under the tongue (sublingual). Have suction on hand to suction as necessary. Again a small amount, not to induce or increase the risk of aspiration.

Careful monitoring of the airway is essential.

R/r 911

 

[Aileana]

I believe our protocols allow us to give a small amount of glucose paste buccally. As long as you place the patient so that they don't aspirate it (which, if they are unconscious, you're probably doing anyways). Having suction handy is always a good idea for that, as well as constant monitoring and ensuring ABC's.

 

[Momokahn]

I think this is a very interesting conversation topic. The comment I would like to have on it is this. Admin of glucose to an unresponsive pt. is a contraindication. I know you mean well thowle but the problem is two fold. Number 1. If you decide to "bend" this rule (contraindication) for the benefit of the patient you might find yourself being able to justify to yourself "bending" other contraindications in the future and it could turn around and bite you.

Number 2. I have to respectfully disagree with Ridryder911 about this being done safefully. At his level he might be able to do this safer than a "B" but the pt is still unresponsive. A line is the only way to avoid the airway possibly becoming compromised. Saliva will be produced once that glucose hits the mouth and there is no way we to stop it. Where goes sugar so goes water.

The bottom line problem thowle is this. Lets say you administer the glucose and have no problem then the pt codes on you for something totally unrelated. I would hate to be in the courtroom with the ambulance chasing attorneys when they try to shred you alive on something that had nothing to do with your teatment. It's the dam ugly world we live in.

Take care and keep up the good work.

 

[Ridryder911]

One must remember why the glucose is administered. Even in first aid, rescuers are taught to make a sugar paste to administer for those with decreased LOC.

As an EMT, one should be able to monitor an airway for aspiration, and decrease it again by placing the patient on the side and again with suction. Since oral glucose is not a liquid rather is a gooey paste like consistency.

Having decreased glucose to produce unresponsiveness is dangerous enough to possibly warrant the risk of closely monitoring the airway to prevent aspiration to occur. Again, remembering the reason for unresponsiveness and the reason for administering it. Cells deprived of glucose (hence: insulin shock) can even cause more problems other than aspiration of small amount of oral glucose.

The EMT curriculum advises to perform it with special attention and precautions as I described. If your protocols state differently, then I would contact medical control for advice... I would not be surprised that one would not be ordered to administer small amounts & again monitor airway.

R/r 911

 

[iamjeff171]

would you consider actually finding out what the pts blood glucose was to ensure this is in fact a diabetic emergency? it sounds like the pt was already getting plenty of glucose (food and orange juice) before they became unresponsive.

-Jeff

 

[Ridryder911]

Of course a FSBS should had been performed prior to differentiate between CVA and hypoglycemia, however; Hx if DM would be a precursor of the s/s ...

R/r 911

 

[Flight-LP]

Of course a FSBS should had been performed prior to differentiate between CVA and hypoglycemia, however; Hx if DM would be a precursor of the s/s ...

R/r 911

Darn,
Two pages of posts and I was about to call that one out. Beat me to it as usual. Key point here, before we start thinking about treatment, why not establish a possible diagnosis or at least cause of the altered LOC. Most diabetics do not get hypoglycemic while eating breakfast or fail to respond somewhat to OJ. If I was told that a pt. was eating and maintaining their medication regime and then became unconscious, I would start thinking outside of the "oh he/she is hypoglycemic box". A blood glucose level will confirm or disprove the hypoglycemic condition. Not too much of an issue with Oral Glucose, but if there is a continued interest in maintaining an EMS certification, I certainly wouldn't give Glucagon or D50 without getting one....

 

[chaplainwmdavwarneremt]

I'd monitor and ensure the ABCs, administer Oxygen while ALS was en route.

 

[oldschoolmedic]

Just something to consider, what happens if you put instaglucose in the unresponsive patient's mouth and my stupid paramedic self comes along and has to intubate the patient? Does anyone believe the possibility of introducing a sugar rich solution to a dark, moist, warm enviroment poses no problem?

Put nothing in their mouth (might not be hypoglycemia). Give them oxygen, get a baseline set of vitals, a blood glucose level, and keep them safe and comfortable until ALS arrives and can give them IV D50%, if indicated. Or better yet, load them into your unit, and meet ALS in route. Give them a report prior to arrival so they can have the appropriate gear with them when they get on your truck.

 

[skyemt]

we do not give oral glucose to someone without a gag reflex...

however, flight-lp, you beat me to my post?

presumably, ALS has already been called... but why so sure it is a diabetic emergency? it struck me as immediately odd to have that kind of emergency during breakfast, with no response to OJ...

as a basic i can say this... i see too many times where just because someone has a diabetic history, the mindset of the basic is to treat that condition.
diabetics, perhaps more than others, are prone to a great many OTHER afflictions that could cause these s/s...

if the s/s or events leading up to the episode are not really making sense vs what you might expect to see, it is time to take a step back and make sure you have a good assessment and history. ALS responding means you don't have to be hasty and administer a treatment you are not sure about...

and, MOST IMPORTANTLY, if that little voice in your head is saying "i'm not sure here", and you don't have ALS as a resource, CALL MEDICAL CONTROL FOR HELP. that is one of their many important functions.