Insulin

[xrsm002]

Do any services out there carry Insulin? I'm just curious had a patient's family that thought our service carried it.

 

[STXmedic]

I believe the system medic417 works for carries insulin (rural Texas system). Try shooting him a pm if you have specific questions.

 

[xrsm002]

Nope just curious since there are different types of it what versions carry it. Had a call where I could have benefitted the patient.

 

[VFlutter]

Nope just curious since there are different types of it what versions carry it. Had a call where I could have benefitted the patient.

Just curious, how could it have benefited the patient?

I can think of very few, if any, situations where prehospital insulin would be beneficial.

Many people forget that insulin is considerd a high risk medication and accounts many adverse effects and medication errors.

 

[Akulahawk]

Just curious, how could it have benefited the patient?

I can think of very few situations where prehospital insulin would be beneficial.

Many people forget that insulin is considerd a high risk medication

My question as well...

 

[Wheel]

Just curious, how could it have benefited the patient?

I can think of very few situations where prehospital insulin would be beneficial.

Many people forget that insulin is considerd a high risk medication

Very high risk, and it often takes months to regulate for most diabetics, as it effects everyone differently in how they process it. I have talked to many ER docs that won't deal with it except in extreme circumstances, and they admit any patient that needs it to the ICU. I can't imagine a circumstance that I'd want it.

Edit: not to mention storing it would make it unreasonable for us to carry

 

[VFlutter]

There is no good way generically dose insulin. Dosing is highly patient specific based on the patient's renal function, metabolic status, diet, etc. I do not see any decent way to dose it on a hyperglycemia patient in the prehospital environment.


Agreed, most ER Physicans will be very conservative if treating at all. They will defer to the ICU or Endocrinologist

 

[JPINFV]

HyperK patients I guess. DKA patients simply aren't worth the trouble prehospitally and without labs.

 

[xrsm002]

Well bgl >500

 

[xrsm002]

Thanks all for your input, patient family assumed we as EMS providers carried insulin.

 

[xrsm002]

The patients glucometrr said 1000

 

[xrsm002]

Okay they might use benefited from it. But I doubt it would have worked that quick.

 

[JPINFV]

Okay they might use benefited from it. But I doubt it would have worked that quick.

Why do you think they might have benefited from it? The negative effects of hyperglycemia specifically isn't acute. The effects of things like DKA are much better managed by things like fluids prehospitally. Insulin in the hospital is actually continued even after the BGL is decreased until the anion gap is normal ("closed") (sodium - chloride - bicarb = 12), even if that means providing dextrose.

 

[Handsome Robb]

HyperK patients I guess. DKA patients simply aren't worth the trouble prehospitally and without labs.

That'd be the only reason I could see for it. HyperK.

Even if the pt's CBG was 1000 mg/dL the last thing they need is to get slammed with insulin and have a rapid change in that CBG level. DKA and HHNK patients are generally brought down pretty slowly. They also get more than just insulin. Plus fixing their CBG doesn't fix the metabolic acidosis.

 

[mycrofft]

Okay they might use benefited from it. But I doubt it would have worked that quick.

"Regular" insulin works quickly, especially IV (inject into a port of a running IV). Quick in, quick out.

HOWEVER:

1. DKA needs much more than insulin and its side effects can be forestalled (not cured) through other means.

2. Other hyperglycemias by themselves are not emergent, although they can cause trauma through accidents.

3. Once you give insulin to any patient but especially an unstabilized one, you are off to the races, trying to give just enough and not test too often, chase glucometry readings up and down with meds and sugar, etc., potentially causing :
4. Iatrogenic insulin-induced hypoglycemic seizures.

We had a family who twice called for an ambulance because they had run out of insulin and thought we'd provide it. Nope.

 

[VFlutter]

The patients glucometrr said 1000

A blood sugar of 1000 should not be treated with SubQ Insulin. The patient needs to be in an ICU with an Insulin drip, aggressive hydration, and close electrolyte monitoring. It is not treated instantly, it will take hours to days. There is absolutely no reason to attemp this in the back of the ambulance.

Okay they might use benefited from it. But I doubt it would have worked that quick.

What benefit?

No, it will work that quickly. That is the problem. Quick enough to cause electrolyte shifts and potassium redistribution.

If you drop the patients sugar from 1000 to 800 what have you accomplished? Have you fixed the problem? Or merely chasing a number

until the anion gap is normal ("closed") (sodium - chloride - bicarb = 12),

Most providers have a very poor, if any, understanding of anion gap acidosis.

 

[Akulahawk]

HyperK patients I guess. DKA patients simply aren't worth the trouble prehospitally and without labs.

In the prehospital HyperK patient, I can see providing albuterol to that patient, but I just can't see insulin being given in the prehospital arena... not that it doesn't work differently, but rather because each patient's needs are so very different...

 

[JPINFV]

In the prehospital HyperK patient, I can see providing albuterol to that patient, but I just can't see insulin being given in the prehospital arena... not that it doesn't work differently, but rather because each patient's needs are so very different...

At the hospital I'm at, 10 units insulin plus 25 mg D50 is what I've seen done every time for hyperK following calcium. I've yet to see any of the teams go with albuterol to internalize potassium.

 

[Akulahawk]

At the hospital I'm at, 10 units insulin plus 25 mg D50 is what I've seen done every time for hyperK following calcium. I've yet to see any of the teams go with albuterol to internalize potassium.

I'd rather use insulin + D50 than albuterol for internalizing K. Albuterol is what we do carry in the field and it does internalize K a bit, just not as well. My thought process is simply to begin the process of internalizing the K with the albuterol and let the hospital continue with calcium and then insulin + D50. That is, if the K is that bad... known prehospitally to be that bad. Usually we just don't suspect K being that bad unless we're looking at extricating a crush patient. Outside of that, I don't think our protocols even touch using albuterol in that manner.

Anyway, that doesn't deal with a hyperglycemic patient. The most I'm going to do in the field (short response time) is probably begin fluid replacement in the hyperglycemic patient. I know there's much more that needs to be done...

 

[xrsm002]

Thanks for all the input I've learned some new things tonight.