Treating hyperglycemia on a BLS level.

[piranah]

remember TREAT YOUR PT NOT YOUR TOYS.......ive had that pounded in my head and it helps.....i had a guy with a BGL that read..."high, over 600" i was like...hmmm so i took a sep. site with diff. glucometer...same....while doing my assessment realized gang green of the L big toe....pt was + ETOH and even the hospital glucometer was out of range...he needed labs.....anyway...you never know...always treat your pt....cuz the time you dont itll bite you in the butt.

 

[BossyCow]

There is an actual scale that can rule out ankle fractures diagnostically without x-ray. Its got like a 95-98% sensitivity and specificity. It escapes my mind the name of it.

I remember an ER shift with a woman about my age with a 'twisted ankle'. She walked into the ER from her car only because her husband made her go to the ER. She's moving the ankle around with full mobility and standing on it saying.. "It can't be broken, I can move it just fine.. it hurts a little, but not bad"

On the wall was her x-ray with a twin of the broken ankle I had about a year prior. I was in unbelievable amounts of pain, with my vision going into that tiny little shrinking circle with any movement at all.

Morale of the story is: People are different. Anatomy is different. Pain is subjective.

 

[marineman]

What kind of meters does everyone use that you're getting such high readings or are you citing lab results? Our meters only go to 500, anything over that comes up as high.

To the original question without worrying that the number you posted isn't really that high, at the basic level for a patient that has a high blood sugar and is in an emergency state the best you can really do is aggressive BVM ventilations (not popping their lungs or anything just slightly faster than normal and make sure you're getting an adequate but not excessive volume). People with high blood sugar will naturally have an increased breathing rate and depth to rid themselves of the excess ketones, don't expect to work any miracles using this technique but it's about as good as you're going to get in the field as a basic.

At the ALS level it's the same thing with the possibility of giving fluid to slightly dilute the blood but neither one will really help that much, the patient needs insulin which we don't have.

 

[artman17847]

There is an actual scale that can rule out ankle fractures diagnostically without x-ray. Its got like a 95-98% sensitivity and specificity. It escapes my mind the name of it.

...could you be thinking of the Ottawa foot, ankle or knee rule?

 

[JPINFV]

People with high blood sugar will naturally have an increased breathing rate and depth to rid themselves of the excess ketones, don't expect to work any miracles using this technique but it's about as good as you're going to get in the field as a basic.

There was an interesting discussion in another EMS forum regarding Kussmaul's and when to take over breathing. Just remember, acidosis will kill just as easily as hypoxia.

 

[lightsandsirens5]

Keep them comfortable and transport.

Higest BGL I ever actuall saw was 910. A 15 y/o male pt. Was on insulin by IV and was out cold for my entire 12 hour ER clinical shift.

 

[marineman]

There was an interesting discussion in another EMS forum regarding Kussmaul's and when to take over breathing. Just remember, acidosis will kill just as easily as hypoxia.

Maybe one of the more experienced members can correct me if I'm wrong but I believe at a certain point the Kussmauls respirations will slow down and the patient will no longer have the breath odor as the body is shutting down and basically realizes that it's a futile effort. That's the point I would personally begin bagging the patient. If they are having Kussmauls respirations then their tidal volume and rate should be adequate that I won't help any by bagging unless something is causing hypoxia still and the bag on the NRB won't stay inflated.

That's my take on it but who knows vent or rid could come and tell me I'm completely off base so we'll wait and see what they have to say.

 

[VentMedic]

Maybe one of the more experienced members can correct me if I'm wrong but I believe at a certain point the Kussmauls respirations will slow down and the patient will no longer have the breath odor as the body is shutting down and basically realizes that it's a futile effort. That's the point I would personally begin bagging the patient. If they are having Kussmauls respirations then their tidal volume and rate should be adequate that I won't help any by bagging unless something is causing hypoxia still and the bag on the NRB won't stay inflated.

This is what I was referring to by DKA vs HHS (Hyperglycemic Hyperosmolar state) in an earlier post.

Once glucose gets over 600 mg/dl it may not display the same symptoms as ketoacidosis. There is a differential diagnosis to be made here.

 

[medic417]

Is there anything that can be done for the pt?
For example, BGL of 220, what can you do for them?

Enjoy your conversation with them enroute to the hospital.

Now once you become a paramedic there are many things you will be able to do for the patient. Insulin is one option but honestly unless this patient has other signs and symptoms besided the 220 probably no more than an IV with normal saline.

My advice to you is to go forward with your education. Get your paramedic degree and be there to provide the best patient care possible.

 

[Sasha]

Enjoy your conversation with them enroute to the hospital.

Now once you become a paramedic there are many things you will be able to do for the patient. Insulin is one option but honestly unless this patient has other signs and symptoms besided the 220 probably no more than an IV with normal saline.

My advice to you is to go forward with your education. Get your paramedic degree and be there to provide the best patient care possible.

Hmm.. I've never heard of anyone's protocols that allow the adminstration of insulin.

 

[medic417]

Hmm.. I've never heard of anyone's protocols that allow the adminstration of insulin.

Funny we carry 2 types. But then again I am from very rural, very poor area with many that can not afford to properly care for diabetes, and with no hospital close by round trip is at least 4 hours many time longer for our outer areas. Often I have patients into normal ranges and ready to go home by the time we get to the hospital. Amazing what Paramedics with proper education can do. Sadly though many even at Paramedic certification are not truly educated so they are not allowed to actually do very much for their patients.

 

[marineman]

In WI we are allowed to transport patients on an insulin drip, and it is within the scope for CCEMTP's on the CCT trucks but I don't know how many of their medical directors allow them to carry it.

 

[JPINFV]

In WI we are allowed to transport patients on an insulin drip, and it is within the scope for CCEMTP's on the CCT trucks but I don't know how many of their medical directors allow them to carry it.

I'm going to take a leap and say that insulin is in the scope of a paramedic running critical care calls (since WI doesn't have an official CCEMT-P certification) in the sense that they can transport/monitor it, but not initiate it.

 

[Sasha]

Funny we carry 2 types. But then again I am from very rural, very poor area with many that can not afford to properly care for diabetes, and with no hospital close by round trip is at least 4 hours many time longer for our outer areas. Often I have patients into normal ranges and ready to go home by the time we get to the hospital. Amazing what Paramedics with proper education can do. Sadly though many even at Paramedic certification are not truly educated so they are not allowed to actually do very much for their patients.

Oh get off your high horse.

 

[medic417]

Oh get off your high horse.

What did I do? Sometimes I think you hate me or something. I have done nothing but respond to answer your post.

 

[VentMedic]

I'm going to take a leap and say that insulin is in the scope of a paramedic running critical care calls (since WI doesn't have an official CCEMT-P certification) in the sense that they can transport/monitor it, but not initiate it.

Not in most of CA or FL. An RN (MICN -CA) will usually accompany the patient. There are other drips that they can monitor but not titrate. Neither state has an official state title of CCEMT-P. The scope in CA, is of course, on a county by county basis. Florida's scope can be medical director dependent for specialty.

 

[JPINFV]

^
...but I thought we were talking about WI?

 

[akflightmedic]

I have worked for a few services that allow paramedics to carry, initiate and administer insulin.

 

[VentMedic]

I have worked for a few services that allow paramedics to carry, initiate and administer insulin.

In Florida? How did you store it?

 

[marineman]

I'm going to take a leap and say that insulin is in the scope of a paramedic running critical care calls (since WI doesn't have an official CCEMT-P certification) in the sense that they can transport/monitor it, but not initiate it.

No we don't have a CCEMT-P certification level but we do have specialized CCT ambulances that will depending on the patients needs usually carry at least one medic who has passed the CCEMTP class and shown proficiency in more critical care areas. Those units as far as I know usually don't carry insulin due to the storage requirements (insulin is quite finicky) but they can either get some from the hospital prior to transport or if a patient is already on insulin they can titrate what they have going.

At the standard paramedic level depending on your service protocols we can transport a patient on an insulin drip but any problems and we divert to the nearest hospital since we're not allowed to titrate or change the drip at all.

Edit: Wisconsin has 3 approved drug lists, one for the normal paramedic practice, one for IFT's for paramedics (we're allowed to oversee more drips then), and one for advanced service medics on flight teams or CCT rigs.