Diabetic Emergency Question

[bonedog]

Here in BC only the first responders (usually FD) don't have IV's. Most basics can start IV's and tx hypoglycemia, if unable to establish IV they revert to glucagon. First line tx is sl/buccosal glucogoo... in recovery postion. ALS isn't usually dispatched on these calls, although we do appreciate pink hair...

If the patient has a pre-existing lesion, the hypoglycemia may mimick a CVA due to the decreased perfusion. Twice I have tx this presentation in care homes, the nursing staff were ecstatic that we were able to cure the "stroke".

 

[TransportJockey]

If this were me, I'd keep watch on ABC's and either do an ALS intercept or wait for them to show. Here in NM it's a contraindication to use oral glucose on ALOC pts. Although if I was partnered with an EMT-I, they could start IV

 

[enjoynz]

Interesting that this post should come up, when I was talking to another Ambulance officer just yesterday, about hypoglycaemia (how we spell it in NZ).
Here AO level (EMT - b) are allow to give IM Glucagon, but it does take a while to mix the powder to the liquid.
I saw something interesting on Christmas day, that I've never seen before.
My daugther got a lolly in the form of a spray (something like a breath freshener), the latest fad!
I was talking to my friend about it, and said that it would be good to have something like that to carry on the ambulance. You could just spray it under the pt's tongue, even if they had a lowered LOC.
Your thoughts?

Cheers Enjoynz

 

[John E]

Given the conditions stated...

it seems to me that the proper course of TX for an EMT-B would be to monitor ABC's and call for ALS. Others have pointed out that it could very well not be a diabetic situation at all, why would you administer any sort of glucose if the patient is suffering from something unrelated?

I wish the poll that's being used had an option that included monitoring and calling for ALS instead of "do nothing but monitor".

John E.

 

[triemal04]

Risk vs Reward, just like most medicine. If you know that hypoglyemia is the issue and ALS is not and will not be available, AND the transport time to the nearest ER is extended, then your options are limited. Use small amounts of glucose and monitor the airway closely.

But, if ALS is nearby, then why? Hypoglycemia is a problem that is easily corrected with the right equipment/knowledge, so why potentially make things worse if you don't have to.

 

[bonedog]

As diabetic's are easily diagnosed and tx, I would think having basic's give IV dextrose/thiamine would be preferable, although I suppose that is the way our system is set up. I suppose state side ALS must be readily available in most areas, so that is why diabetics are tx by them only?

 

[skyemt]

i rather think that diabetics often have complicated medical histories, due to the numerous system failures that are secondary to the diabetes...

it is precisely why most protocols allow basics to treat diabetics under a narrow set of circumstances, where the treatment or oral glucose is not likely to do much harm...

 

[certguy]

diabetic problem

Given the fact the pt. was given OJ prior to becoming unresponsive , if the problem was hypoglycemia , this should've kept her from going uresponsive . At this point I'd be looking for a different problem . Many people have a tendency to tunnel vision on one possibility rather than consider all . I'd be considering the following ;

What are pt's vitals ?
How's her resperatory effort ?
What's the rest of her hx ?
What's my transport time to the nearest facility vs. ALS ETA ?

Oral glucose is contraidicted due to unresponsiveness . I would consider inserting a NPA , 15 LPM by non - rebreather , suction if needed , if her respirations aren't effective , assist ventilations . Look for other clues to her condition ( accidental OD , CVA , cardiac , etc. ) . If I can get her to ER before ALS arrives , or can arrange an intercept , load and scoot . Watch the vitals closely the whole time , note any change in condition , and be ready in case she crashes or comes around and becomes combative . An extra set of hands in the back never hurts .

We need more options in that poll .

 

[BossyCow]

Vitals certainly! Before administering insta-glucose I would want to know what the pts blood sugar was. I don't see much of an issue with the breakfast thing. The pt was at the breakfast table as I see it and early morning is a prime time for low blood sugar. The OJ may or may not have been sweet enough or in time to make a visible difference. Also I would be looking for a possible meds mixup. Very common for diabetics to take the wrong med if they are sleepy or not paying attention.

If a glucometer reading showed low blood sugar, if the pt had a gag reflex, if there was suction available and the pt was placed in the position Rid described, I would most likely give them the oral glucose, just a pinch between cheek and gum. If the saliva was an issue, it would be addressed by the positioning, the saliva would run down and out of the mouth. Placed toward the front of the mouth rather than back in the throat, it can be absorbed by the tissue and be where it can be removed by suction if the pts LOC drops futher.

 

[futureemt]

Okay, I know I didn't start school yet and I understand the gag reflex with the tablet, but they make a Oral glucose gel, we have it at work. Wouldn't that be safer and absorb faster???

 

[certguy]

diabetic problem

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....

BINGO ! I was beginning to wonder if anyone else would pick up on it till you guys did . Can we say " tunnel vision " boys and girls ? The food intake and OJ with meds shouldn't indicate a hypoglycemic problem . We're dealing with something else here , accidental OD or CVA perhaps . Not knowing exactly what we're dealing with , it'd be prudent to be prepared for the worst case scenerio and anything else is cake .

 

[basic]

I was taught not to administer oral gluclose if they had no ability to swallow or an ALOC. So, I would monitor ABC's while ALS was en route, as well as continue my assessment.

 

[futureemt]

BINGO ! I was beginning to wonder if anyone else would pick up on it till you guys did . Can we say " tunnel vision " boys and girls ? The food intake and OJ with meds shouldn't indicate a hypoglycemic problem . We're dealing with something else here , accidental OD or CVA perhaps . Not knowing exactly what we're dealing with , it'd be prudent to be prepared for the worst case scenerio and anything else is cake .

Okay, I just heard this. I know with low blood sugar you can drink OJ...but someone told me you can give milk too...anyone hear about this one?

 

[emtwacker710]

personally, because of the area I'm in als is 5 minutes away max, if that, so i would moniter abc's and gather history and all that fun stuff and wait for als to do an iv and all their special stuff

 

[TKO]

Bringing threads back from the dead, are we? Ok, I'll go along....

After an assessment and Hx with BGT to determine that this is a sugar issue, I would follow my Hypoglycemia protocol (BGT > D10W bolus > Thymine > transport). HOWEVER, if this pt was geriatric, IDDM with paper skin and spidery rolling veins, I would probably reconsider the I.V. to prevent causing an infection. I could go with Glucagon SQ instead....but I would need something from the fridge to go. So I might use glucogel, especially if I have a 20 minute transport time and no carbs to go with us.

As it stands with glucogel, it is pretty common practice (around BC, Canada anyway) for BLS and ALS to roll pts into a semi-prone position and apply glucogel to the buccal pouch as gravity will keep the gel from mucking with the airway. Again, this is a common practice, but the Canadian Diabetic Association states that glucogel is a macromolecule that can not be absorbed through the buccal membrane and must be swallowed to be effective.

Although, many of us seem to have experiences to the contrary.

 

[TKO]

Hey Bonedog, good to see another BCAS employee around (if you still are around here) !!

You must not get out much past Alpha territory these days. There are a lot of EMRs still working in the system, and they can't start IVs or admin any drugs, except entonox and can assist with pt prescriptions and give Nitro w/existing prescription.

 

[TKO]

Okay, I just heard this. I know with low blood sugar you can drink OJ...but someone told me you can give milk too...anyone hear about this one?

Sure if that's all you have to work with. Milk contains Lactose, which is a more complicated form of glucose. However, if the pt is lactose intolerant you won't be doing them any favors. Breads and high-carb products work very well because they are readily converted into fuel for the body and is the bods first choice. Refined sugars are not necessarily the best choice.

A cheese sandwich is a great definitive treatment once the pt's LOC improves.

 

[Meursault]

Again, this is a common practice, but the Canadian Diabetic Association states that glucogel is a macromolecule that can not be absorbed through the buccal membrane and must be swallowed to be effective.

Although, many of us seem to have experiences to the contrary.

I have a feeling your experience is accurate. I've always been taught that glucose can be absorbed through mucous membranes, hence oral or rectal (thank God, not in my protocols) administration. From my limited experience with cell bio, glucose is not a macromolecule. I have no idea where they're coming from.

 

[TKO]

Glucogel itself is a compound that is a macromolecule, not the glucose component. I can't now find the reference to this finding, and I am not a biochemist, but I can provide it when I finish my tour in a few days.

Or perhaps someone knowledgeable will be able to corroborate what I have started here.

 

[Meursault]

I thought that might be the case, but I checked and the manufacturer of GlucoGel states that it's just a 40% dextrose gel, and several other manufacturers describe their products as containing pure glucose.

I couldn't find anything relevant about oral glucose on the Canadian Diabetes Association's site. If you can find that paper, post it, because I'm curious now.