Weird Call

[usalsfyre]

I agree about folks running in a 1000mls wide open under pressure infusion, it's an education issue. I have the same problem with providers pushing 25gms of dextrose right off the bat on simple hypoglycemia. 10-12gms of dextrose will usually do the trick.

Simple hypoglycemia is not an acute illness that changes fluid requirements that much. However, I would wager that the pt who requires 100gms of dextrose (4 AMPS of D50) has another underlying condition.

 

[mycrofft]

Was pt IDDM or NIDDM?

This sounds like an oral overdose, or (and I've only heard about this) the insulin was given into adipose tissue (fat, which can absorb or mechanically retain meds) not subcutaneous, causing a delayed but prolonged absorption.
Oral sugar is still a good way to reverse hypoglycemia if it is safe to do so, and is less likely to start a blood sugar versus insulin (endo or exogenous) positive feedback cycle where you wind up treating your own treatment.
Too bad no urine or blood test for ketones or HgA1C. Chronic diabetic pts, especially with co-morbidities, can be victims of insidiously slow maltreatment due to many variables.
Had a coworker give the D50 straight IV bolus, the pt resisted and it cost him a nice chunk of distal bicep, and us over $10,000 to rehab and plastic surgery him. The coworker was dealt with by promoting him to supervisor.

 

[jjesusfreak01]

Had a coworker give the D50 straight IV bolus, the pt resisted and it cost him a nice chunk of distal bicep, and us over $10,000 to rehab and plastic surgery him. The coworker was dealt with by promoting him to supervisor.

What do you mean by "resisted"? Did the patient try to pull the IV so you couldn't flush afterwards?

 

[mycrofft]

He didn't want to get better, the pt jerked his arm away.

If he got better he was going to federal prison, if he seized he was going to the hospital and maybe get some time away, or get away entirely. Over 18 months he willfully self-induced hypoglycemia multiple times, ended up with bilat retinal detachment, and was noncompliant postop (after laser tx) so he cold not be airlifted.

 

[Jay]

En route to the hospital, his sugar once again dropped to below 2 mmol. Gave another amp of D50, along with the hanging D5W. Long story short, his sugars dropped twice more, and gave D50 each time, and it would come back up, but then start to drop again. We got him to the hospital and they did their usual blood work and CT. CT was unchanged from about 3 weeks previous. All blood work was within normal ranges. Insulin level was also fine.

I just don't know about this one, it just threw me off, and had no idea what to think of it. Any ideas? If I find out more, I will let you guys know. Thanks!

I would say to treat the patient, not the patients numbers. There are a lot of opposing factors to take into consideration here namely (a) what is normal for the patient (above average numbers perhaps), (b) what has the patient had to eat over the last 24 hours or even if they have had enough to eat, you mention that they are bariatric, (c) was the patient dehydrated, (d) are there any other factors contributing to the diabetic condition such as a problem with the Pt's insulin receptors that were perhaps not noted in their Hx or still yet to be Dx'd.

The list can go on and on but I don't think that this is too uncommon due to the numbers being so different from one Pt to the next.

Also, you mentioned a Hx of A-Fib which is sometimes linked to hyperthyroidism in which the hypoglycemia can be secondary to. You did say that they are bariatric so it's an unlikely link but a possibility never the less.

 

[MrBrown]

The thought of sparky-half trained ambo's dishing out D50 doesn't worry me as much as it would if they didn't all want to use large bore cannulas

Our Paramedic level Officers have always been able to give 10% dextrose, however it must be into a line that is free flowing into a large vein under gravity.

I don't like giving people black arms that do not work.

Oh, 100ml of 10% dextrose is ten grams.