What would you do in this situation?

JamesW said:
I just finished EMT-B school. Im not sure about insulin but i know for a fact that they can do glucagon.
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Glucagon is given for the opposite indication. Most states are absolute No's for prehospital insulin, but Texas is a little different than most states when it comes to protocols. I still know of only two systems that use insulin, though.
 
STXmedic said:
Glucagon is given for the opposite indication. Most states are absolute No's for prehospital insulin, but Texas is a little different than most states when it comes to protocols. I still know of only two systems that use insulin, though.
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We might be adding it soon... but even presidio doesn't carry it that I know of
 
STXmedic said:
Glucagon is given for the opposite indication. Most states are absolute No's for prehospital insulin, but Texas is a little different than most states when it comes to protocols. I still know of only two systems that use insulin, though.
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What is the reason for not letting them carry insulin?
 
TransportJockey said:
We might be adding it soon... but even presidio doesn't carry it that I know of
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No? Well cut that down to one; I thought they did.
JamesW said:
I know, I was stating the meds i know that Austin Travis county gives for blood sugar related emergencies.
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Yeah, glucagon is very common. I would hope they did.
 
JamesW said:
What is the reason for not letting them carry insulin?
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Even in the hospital, insulin doses must be witnessed by another person when drawn up. It is dosed in very tiny amounts, can be hard to dose when you don't know the pt's history very well, and can very easily kill someone.

Even in places that do carry insulin, I don't think anyone should be administering it pre-hospitally for a BGL of 200. Also, a BP of 200 probably isn't getting treated if that's their only complaint and they aren't symptomatic. Obviously this patient IS symptomatic... But if for instance somebody's chief complaint is ABD pain that's been going on for 3 days, and they have history of HTN, and they're moving around and in a lot of pain... Meh. A BP of 200 in and of itself isn't concerning - it's important to look at the whole picture.
 
Gurby said:
Even in the hospital, insulin doses must be witnessed by another person when drawn up. It is dosed in very tiny amounts, can be hard to dose when you don't know the pt's history very well, and can very easily kill someone.

Even in places that do carry insulin, I don't think anyone should be administering it pre-hospitally for a BGL of 200. Also, a BP of 200 probably isn't getting treated if that's their only complaint and they aren't symptomatic. Obviously this patient IS symptomatic... But if for instance somebody's chief complaint is ABD pain that's been going on for 3 days, and they have history of HTN, and they're moving around and in a lot of pain... Meh. A BP of 200 in and of itself isn't concerning - it's important to look at the whole picture.
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This is not always the case. It's certainly a good idea to have another person witness the amount of insulin drawn though, and many hospitals mandate this, but the last hospital I was in did not require another person to witness the insulin. Some people are quite sensitive to insulin, so any amount given to them can really affect their blood glucose level in short order. Prehospitally, a BGL of 200 isn't all that concerning anyway. Perhaps with a very long transport and following fluid admin might insulin be something to consider in small amounts if the BGL remains extremely high.
 
The other problem with insulin in a DKA or HHNK patient is that you do NOT want to lower the CBG too much too fast. IT can cause some nasty effects
 
I mean I guess it's a bit high... But we know he has some weird metabolic disorder, and maybe he hasn't been compliant with his meds, and I'm much more worried about whatever else is going on with him. Normal people can have elevated BGL during an MI, so I'm a bit concerned by what it might indicate... But I'm not too worried about the BGL itself - they can deal with it in the ER once everything else is stabilized.

So really you were right before - you were right to not like the elevated BGL. Given patient's history it might not actually mean much/anything, but it could also be more evidence to indicate that he's having an MI.

It's especially good to note this as basic, since you can't take a 12-lead, this could help guide your treatment/transport decisions.

Just my thoughts.
 
Just did a bit of internet research, and people don't really agree on this, but the BGL itself may indeed be a problem after all... According to one source, "There is an inverse linear relationship between admission glucose concentration and chance of surviving to hospital discharge following myocardial infarction". That is to say, the higher someone's BGL is upon admission following an MI, the lower their survival rate is... It seems like we don't know for certain whether actively controlling the BGL makes a difference but it's a topic that is being researched.
 
Is the point they're researching the patient's BGL when admitted to the hospital from the ED or the patient's BGL when the patient arrives at the ED? Even though I've done precisely zero internet research into this matter at all, I highly suspect that the point that's being looked at is hospital admission. One of the reasons I suspect this is the case is that it's a whole lot easier to track serial BGL's on patients that are in a clinical setting than in the prehospital setting and unless the prehospital providers were all on-board with collecting that data, I doubt that checking an MI patient's BGL is going to be high on their "to-do" list.

Insulin is quite the interesting stuff... and not stuff that I would feel all that comfy with giving in the field to patients that don't already have a Type I DM diagnosis and therefore don't have insulin in their daily regimen, such as dealing with nutritional, correctional, and sliding scale doses.

The garden variety hyperglycemic patient probably doesn't need insulin right away. In any event, when the body is put under stress, cortisol is released and one of the outcomes of that is gluconeogenesis which leads to hyperglycemia anyway... at least "hyper" relative to their normal BGL.

At this point, if a BGL is checked, the info is "good to know" but leave the control of BGL to the ED. If the BGL isn't "HIGH" on the meter, it's better to be a bit elevated than too low. If you draw some blood and it looks like red Karo syrup, the BGL is probably way too high. ;)
 
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