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Remeber343

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You are D/T a SNF for a 76 Y/O female, C/C unconscious unresponsive is breathing. Additional from dispatch is that the pt has HX of diabetes, pt's BGL is "Low" and the RN is currently giving Oral Glucose. When arriving, Nurse states the PT was fine early today, when she came to check on her 30 mins ago, the pt would not answer her or respond. Rn states due to the low sugar, she started administering oral glucose to try and bump it up a bit. Pt has HX of low sugar, but has never been unresponsive during her stay and this wonderful SNF. RN states pt is at this facility for failure to thrive.

You arrive to find your PT Seated in the hospital bed, RN administering Oral Glucose. Pts ABCs are intact, besides the fact their are globs of Glucose in her mouth that she is unable to clear due to the fact she is altered, AOx0/4, pt groans to painful stimuli. Skin: Pink Warm Dry HEENT: Pupils pinpoint, nonreactive to light. Chest = Rise & Fall, Lung clear = Bilat. All Extremities are intact, no signs of pedal edema.

Vitals: 140/68, HR 110, BGL "Lo", Temp 98.2, 96% spo2 on RA

Pt has meds for HTN, Chronic Px, and a few others for cholesterol and such. Tell me how you'd go through this and your thoughts!
 
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Clear the Oral glucose from her airway and start a line, D50 titrated to pt arousal, if no response, look for other s/s and possible causes for the AMS. Transport to the ED for evaluation of possible new onset DM/Unk. AMS.
 
get rid of the oral glucose and look in a disapproving fashion at the rn, 1g/1ml glucogon i.m(its all i could give for this), re asses bgl after 3-5 mins and transport. consider a basic airway if still not a&ox4. re check bgl on transport to hospital.

i'd begin to think the low bgl isnt the main issue here. ecg show anything interesting?
 
Let's do our own dex to find out if it really is "low", and then address the blood sugar issue accordingly. (IV, D-50)

What is her RR? Depth? Pattern? Anything unusual about it?

Just, exactly, what meds is she on for her chronic pain?

What is her typical demeanor? Any history of hiding/hoarding pills? What about depression? Has she had any recent labs drawn? If so, what were the results?
 
I'm not sure how quick I'd be to give narcan on this one. There's no note of irregularities or inadequacy in her respiration. 96% on RA + good skin signs tell me she is perfusing well and *probably* isn't hypoxic which leads me away from an OD although we could have ended up catching it very early on. Even then I'd expect her to be bradycardic and hypotensive not the opposite. She has an Hx of HTN though so I can see that counteracting it the usual HypoTN you would expect. What's her normal BP? Also what med is she taking for it? There are many different meds used to treat HTN and they all act on different receptors....

Another thought, we all jumped straight to narcs for the chronic pain maybe the meds prescribed aren't opiod based? To the OP: Better med list please. If you didn't get one that's a problem, you picked her up from a medical facility that has a chart on her.

Obviously you treat the BGL first with D50 or Glucagon if you can't get a line :P
 
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IV then some D50, if that solve things then we can look into other options.


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Let's see a med list. Chronic pain doesn't mean narcotic medications. I'm not disagreeing but I want more info first. Also, like I said, tachycardic and hypertensive vs bradycardic and hypotensive but she does have an hx of HTN.

Also has she been sick? Bed sores? Failure to thrive could mean non ambulatory and that could cause bed sores which could cause sepsis. If she's non-ambulatory she very well could have a foley, UTI leading to Urosepsis maybe? She's not hypotensive (has hx of HTN) or febrile but being older she may not have the immune response capabilities.
 
the great thing about narcan is it wont (not suposed) to hurt if your not od. so based on what i have been told and my scope... Remove the gobs of oral gulcose and give the "nurse" the look... consider npa/opa but you didnt give us respiration rates... give 0.4 NARCAN.. transport. thats all thats in my scope though. i cant even check bgl.

IF ALL ELSE FAILS PUT SNACK SIZE SNICKERS UP RECTUM TO CORRECT LOW BLOOD SUGAR
 
Wait so you can give Naloxone but you can't check a BGL? Wow. Smash pointed out in another thread that it really could hurt if it doesn't work and the pt requires intubation and sedation/analgesia post-intubation.
 
NVRob said:
Wait so you can give Naloxone but you can't check a BGL?
Click to expand...

Really? That makes me lol



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Sorry for the delayed reply guys, its been a crazy day. This call happened probably a month ago, but i'll give it ago. Next time i'll try to include more info on the OP, first time putting one of these up. I also kindly educated the RN on proper usage of Glucose :P

RR: 12, Resps were fairly normal for her. Pt is usually able to walk with assistance, pt normally Ao3/3 and is usually able to communicate w/o any problems. Pt was on Oxycodone, which the pts PCP just bumped the dose up. No hx of pill hoarding, no recent trips to the hospital or draws done.

No HX of recent illness, but then again, the RN was just back from her 3 days off and did not get a report from the previous RN (whats new about that....seems like they never communicate) Negative on the Foley or bed sores.

You are able to establish an IV line, give an AMP of D50. The pts sugar now reads from "Lo" to 230. Pt now is able to open eyes and is able to look towards you w/eye when verbal stimuli. Pt is still "not back to normal" states RN. You then give .4 Narcan, slowely titrating it up. After a few minutes the pt is able to move spontaneously, turns head towards you when you speak to her, pt is able to speak, but is more of "word salad". Pt is still A&Ox0/3.

On a earlier note i should have mention... This particular SNF, or USNF, is known to have OD pt from time to time...
 
And Joe - Narcan isnt totally harmless, as they said, it can cause issues with intubations. But also, if you give it to some druggy, it can cause them to go in to withdraws and cause sz. Rare, but if it is a long time drug user, and that stuff is in their system, it can cause some serious issues later on. Thats why you normally only give enough just to relieve resp. depression.
 
What issues with intubation does narcan cause, I'm curious, never heard of this happening?
 
truetiger said:
What issues with intubation does narcan cause, I'm curious, never heard of this happening?
Click to expand...

Mainly them awakening and yanking the tube, cuff inflated and all, out of their gob....
 
Some agency's that use narcs for intubation sedation and post intubation management. It can cause the RSI mess to be less effective. Some agency's don't use narcs for sedation so for them it's not really a problem. There's a thread about it if you want to look it up. Each person has their own take on it.
 
Makes sense, we use versed/etomidate and succs/vec so it wouldn't be an issue for us, hence it not coming to mind.
 
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