Hyperglycemia treatments?

[Keith]

Excuse my ignorance if I may have missed a treatment in my studies, but I figure this is a good place to ask. I know there are numerous types of insulin on the market, that range from 3-24 hour doses, and from man-made to pig produced versions. My question is, other than rapid transport and perhaps some iv fluid, is there anything we can do for this? Some type of trade secret, or anything of the sort? Again, sorry if I just missed a simple answer, or didn't study hard enough, but I was just wondering.

 

[Ridryder911]

Treating hyperglycemia is not as easy as treating hypoglycemia. One has to truly understand the pathophysiology of hyperglycemia.

Knowing and treating the problem is not as simplimatic as it appears. One must know what type of hyperglycemia is occurring. Yes, there are several types (DKA, Osmolytic, etc) and truthfully we should not be treating the numbers. Other associated tests such as ABG, urinalysis, and a CMP should be evaluated before officially treating hyperglycemia. All of this information is needed before an accurate treatment is obtained.

Yes, you are correct in there are several Insulin types, but in emergency situations there is only one that is utilized and given IV form. Regular insulin is the fastest acting, but is not routinely administered using this out of a hospital scenario. Yes, some patients are on a sliding skill and have a pronounced history of hyperglycemia and have instructions to treat and monitor their glucose levels at home using different types of insulin and variable dosages. Something that is not routinely done for all patients. These patients are considered "brittle diabetics" and close monitoring and treatment is advised.

I personally am also cautious in "flooding" hyperglycemia patients. Poor BUN, Creatinine and renal performance is common in patients with hyperglycemia. Not knowing renal perfusion is dangerous.

The usual treatment is closely monitor the patient and supportive treatment in the field setting for a reason. My protocols are to closely monitor the patient, glucose, EtCo2, ECG and of course oxygen if needed and then fluid administration of 500 to 1000ml/hr.

R/r 911

 

[Keith]

Much apprecited, I'm just always looking to learn more, an this was something that I have been pondering lately. I'm more than willing to take any lesson or any advice that will help me to preform in the field better. I'm a huge fan of criticism, and love any input I can obtain. I'll be the first to admit if I don't know what I'm doing, even if I should, and I always want to learn more. Thanks for the input, escpecially from someone that seems to be as qualified as you are.

(p.s.- in not a kiss ***, just trying to educate myself, ha)

 

[Markhk]

There are a lot of medics out there that want to run fluids into the patient like a waterfall, thinking it can flush out the ketones or something.

Our County had to put out a "lessons learned" bulletin to warn all medics to instead treat hyperglycemic patients with ALOC using only a NS drip at TKO and treating the patient in-extremis.

 

[BruceD]

== Do not use this for patient treatment ==
(dunno why I always feel compelled to say that since everyone knows that lawyers do not affect medical care in any way and would never go after anyone trying to innocently give educational information...)

This is probably way more information on the 'insulin drugs' than you wanted, because you asked about treatment, but it helps me to go back over things and you said you like to learn...

In general: for hyperglycemia
Rapid onset hyperglycemic drugs also have the shortest durations and inversely, the slowest onset have the longest durations of action.

Some common ones you may come across are:

'Ultra short acting' - usually used after meals
(I believe these are all recombinant human insulins)
Lispro -- These first three may peak within 3 hrs and be gone w/in 6.
Aspart
Glulisine
Inhaled insulin (not sure how often this one is actually used)

'Short acting' - these also are usually used after meals.
Regular insulin (human!) - may peak in ~5hrs and vanish in ~12.

'Intermediate Acting' - usually used for basal insulin requirements
NPH - peak in ~6hrs, last ~18
Lente

'Long Acting' - also used for basal insulin requirements
Ultra-lente - I believe may not leave the system for up to 36hours
Glargine (trade: Lantus) - these last two can be detectable for up to 24hrs.
Detemir (trade: Levitimir)

Insulin molecules form complexes together, but can not be rapidly absorbed until they break into monomers. To slow down the onset of action, Zinc (lente/ultralente - gives a cloudy appearance) or a protein (esp NPH - can't give to pt's with FISH allergies & can react to other medications) is added.

Another factor that affects duration of insulin action is the injection site (abdomen is fastest, hip is slowest of the common injection sites).

Patients may be on no medications, oral medications, or a combination of the above. Doctors typically prescribe to try to duplicate the bodies normal insulin response to meal times, while keeping the blood suger down long term. So the medications are very patient/situation dependent and generally require a bit of advanced practice to properly figure doses for basal requirements.
--
I too would want to use caution in giving diabetics too much fluid volume.

 

[Ridryder911]

Just recieved this publication today on how Hyperglycemia is related to (r/t) AMI's:
http://www.americanheart.org/downloadable/heart/1204576452729topTenHyperglycemia_ACS.pdf

http://pt.wkhealth.com/pt/re/aha/ed...rYJpkvrnvxnRn31q!1253064403!181195628!8091!-1

 

[Ops Paramedic]

We all miss classes or lectures, otherwise we would'nt be students!!

I have to agree with what the others say. Our protocols does also not allow for insulin (in any form) to be administered pre hospital. Hence our hands are just as tied up as yours it would appear.

Remember that the best person to learn from with regards to diabetes, is not a medical professional, but rather a diabetic and his/her family. These people know the disorder backwords, as for them they have to deal with it in many aspects of life everyday, which we as professionals take for granted. Are your hands still tied up if you have a family member who knows what's potting or are they a bit looser now??

And treatment wise?? Hypoglycemic patients are nice to treat, as you see a fairly fast and positive response, also has a sudden onset. In contrast hyperglycemic patients slowy (up to a few days), without showing major symptoms, increase their blood glucose levels. When you get to a patient where the glucometer does not even give you a reading (other than "Hi"), make your wheels round and get to hospital. do not stay and play. As posted by Rid, and would like to add: Never forget ABC prior to establishing an IV, as it often causes a tunnel vision effect of: I must get this IV up, and before you know it, there is a 15 minute delay in getting the patient to hospital.

Hoping the info helped a bit...

 

[piranah]

please remember that hyperglycemia (if im correct) can cause a metabolic acidosis and that there is why you should take charge of the situation.... now understanding you cannot tell for a fact that a persons Ph is below 7.35, but there are signs such as muscular spasms, hyperventilation, but the best thing you can do for this patient is in my opinion ventilate,ventilate,ventilate....because i wouldnt administer sodium bicarbonate although one of the bodies buffer you can actually quite easily over medicate them into alkalosis and the renal buffer is to slow so you would teach your patient how to breath short inhalation and long smooth exhalation. through pursed lips much like the respirations you would teach a COPD'er.....just some info...

 

[Ridryder911]

please remember that hyperglycemia (if im correct) can cause a metabolic acidosis and that there is why you should take charge of the situation.... now understanding you cannot tell for a fact that a persons Ph is below 7.35, but there are signs such as muscular spasms, hyperventilation, but the best thing you can do for this patient is in my opinion ventilate,ventilate,ventilate....because i wouldnt administer sodium bicarbonate although one of the bodies buffer you can actually quite easily over medicate them into alkalosis and the renal buffer is to slow so you would teach your patient how to breath short inhalation and long smooth exhalation. through pursed lips much like the respirations you would teach a COPD'er.....just some info...

What? Actually, it is Ketoacidosis produced by inability to use the glucose bound due to the insulin. The cell basically burns itself and goes towards the fatty portion as a last result.

The patient is probably is going to exhibit deep respirations from "blowing off" ketones in the form of ketoacidosis (Kussmaul's Respiration's). Teaching is not going to help this patient, it is not COPD. Rather again, the body is removing waste. The muscle cramps as well is NOT produced by the respiratory system, rather bythe build up of lactic acid and again a symptom of cellular destruction. NaHcO3 is not going to hurt, doubtful it is going to help without changing the problem (hyperglycemia). This is when it is a good point to monitor EtCo2 as well.

I take care of hyperglycemia patients routinely in the unit. I have seen patients glucose in the thousand (1200 mg/dl) and one can smell the ketones (which smells like acetone). Arrhythmias, is not uncommon as well. The usual treatment of course is IV Regular Insulin (possibly IV Insulin drip), with a Sodium Bicarbonate IV drip. DKA and non-DKA (hyperosmolar) are real dangerous type of conditions. Renal failure to end stage failure is not uncommon to see as well.

R/r 911

 

[piranah]

but rid...im not in a unit im in the back of a truck i don't know the ABG workup so if i did administer sodium bicarbonate how am i to know the dose...i cant so it would be dangerous and probably idiotic to administer...(not trying to sound like an *** at all im just going through my thought processes and find the faults, thank you for your input..and when i said metabolic acidosis i rewally kinda meant DKA but thought youd know what i ment and yes the "blowing off of the keytones" is what i was saying but if they have a build up of acids since renal is slow and i couldnt give the bicarb isnt ventilation the right track......in the back of a truck i mean..

 

[Ridryder911]

Actually, acid base and electrolyte balance is a little more in-depth and usually confuses many. Some EMS services do administer NaHCO3 in the field, either (50 meq) push or mixed in 1 liter of 0.45% NaCl or NSS and infused over 30 minutes to an hour. I routinely will call medical control and get an order for a bicarb drip. Yes, it can be controversial not knowing the ABG/Ph yet some EMS units do have ABG units on them as well. As well, one has to be concerned about the K+ and Na+ levels.

Again, one has to do as per medical control, but as well one needs to think outside the box. The reason we discuss such.

Here is a link to pediatric diabetes and DKA, but the same concepts..
http://www.jems.com/Images/pediatric_dka_tcm16-107992.pdf

R/r 911

 

[piranah]

I feel i have a fairly good grasp of my acid-base balence ideas and have been shooting them through my head consistantly and i find acid base balance facinating and i also find that most disease processes, trauma, and other things all effect it.....

 

[ResTech]

Rid... you are way more of a nurse then paramedic! You are a library of knowledge but you portray so much of "what we do in the hospital" mentality and expect everyone else to know it and apply it in the field. EMS is to stabilize... all your work-ups with ABG's, renal perfusion, and other advanced diagnostic studies that should be done prior to tx is what we call definitive care!

We treat what we see in the field and once in a nice, clean ED with 101 departments to call... then you can do all your tests and get more specific with tx once the DOCTOR develops the plan of tx!

If you have a symptomatic hyperglycemia pt., a 250-500cc bolus isnt gonna hurt. Take a hx from pt. and family and you can tell if they're is some renal insufficiency and go from there.

Dont get me wrong, if I was effed up... your the guy I would want... but I feel you advocate on a micro and in-hospital level.

 

[Ridryder911]

Actually, it is not so much as in the hospital but many do not know the "new advances" and care in EMS. Patient care is patient care... I have argued to quit thinking inside the box. The box will be changing, one needs to be prepared.

I heard the same thing on the introduction in the field of 12 leads, RSI, pain management, even pacing EJ's were first discussed.

In fact, one of the test questions on CCEMT/P answers is that a portable ABG analyzer be on a EMS unit. Remember, just because your EMS is not as progressive does not mean all EMS is not progressing.

I did not disagree with a fluid bolus, but I have seen bi-lateral IV's come in .."to dilute them down"...

EMS is changing. It has to, it has no other option. There will NOT be enough beds and rooms for the number needed. If one observes, it has hit the majority ED's in the U.S. Yes even rural areas. Technology is changing along with this, so think of the possibilities and changes.

Just asking, did anyone read where Bill Brown (NREMT/CEO) is formally recommending the Paramedic Practitioner level? Anyone else curious on what "tests" and practices, treatment will occur?

R/r 911

 

[bonedog]

We use an ISTAT on car here, for those that have a Critical Care endorsement.( we often respond to rural area's and personally have been on 5 hour transports)

In these pt's it is great to monitor the K+ and watch for the changes,especially when the insulin takes effect, these often co-relate with the ecg changes.


ABG's are a must when replacing K+. Fluid rescusc is standard tx, titrating the insulin to insure no precipitous crash in blood glucose levels, it imperative to prevent cerebral edema

Rid is bang on about our advancement, the more tools, the more tx regimes, the better.

God knows the hospitals cann't handle the load anymore.

One buddy of mine advocates quick transport, forgoing most tx. I am of the opposite nature, unless it is a time dependant call, I do everything that needs to be done, because of the inevitable wait in the hallway.

 

[triemal04]

We use an ISTAT on car here, for those that have a Critical Care endorsement.( we often respond to rural area's and personally have been on 5 hour transports)

In these pt's it is great to monitor the K+ and watch for the changes,especially when the insulin takes effect, these often co-relate with the ecg changes.


ABG's are a must when replacing K+. Fluid rescusc is standard tx, titrating the insulin to insure no precipitous crash in blood glucose levels, it imperative to prevent cerebral edema

Rid is bang on about our advancement, the more tools, the more tx regimes, the better.

God knows the hospitals cann't handle the load anymore.

One buddy of mine advocates quick transport, forgoing most tx. I am of the opposite nature, unless it is a time dependant call, I do everything that needs to be done, because of the inevitable wait in the hallway.

There, you see? This is the attitude that comes about when there really is an educational requirement to become a paramedic, or even a lower level provider. This is how people think when they actually are willing and have to learn about something before they do it, and aren't in it for the flashy thingies and woowoo's.

Why is it that Canada has things figured out but the US system is still so completely f*cked up?

 

[Outbac1]

Thanks for the compliment. However all is not perfect in the Great White North.

Myself I try to judge each call on its own. Some are easier to treat on scene, then transport. Others it is better to move to the truck and tx enroute. At some hospitals we can offload our pt in a short time. While at others we are held in line and tx continues. Just because you arrive at a hospital you are not absolved from responsibility to care for the pt. Other cases if we can fix them on scene we can leave them. Eg: the hypoglycemic pt we fix with D50. If we are sure they are well and truly capable of careing for themselves and they refuse transport, we leave them. We prefer that they have someone there to look out for them, but it is not necessary. The diabetics we treat regularly all refuse transport. If we don't transport they don't pay. So our service is free.

The more we can do for our pts prehospital the better off healthcare will be. It will be cheaper and more efficient in the long run. To do that though you need well educated paramedics who can understand the situation. Afterall Paramedics still make housecalls. Changes won't happen overnight, but you have to start somewhere.