Hypoglycemia

[JakeEMTP]

Ok, we got called to a residence Monday night for " diabetic complications". UOA, we found the patient sitting on the bed. The patient is a known diabetic to us.

We obtain a BGL and get a reading of a whopping 33. My partner started an IV while I started getting things ready. IV successful, we hook up the line and start flowing fluids. Administer 25g D50 and get another BGL. It goes up to 112. We ask her husband if he has any orange juice, and he returns and she drinks it. Take another BGL. 78, WTF! She eats a Little Debbie cake and it goes down to 68.

We administer a second 25g D50, and her BGL goes up to 276, Woot! Call the hospital, and talk to a Doc about a no transport. He didn't even want to talk to her. I mean, her V/S were within normal limits, sugar was good, A&O x 4. We get the no transport order and take another BGL whilst packing up. 178. The time elasped between 276 and 178 was maybe 5 min.

Anyway, I wasn't happy about leaving her. We loaded her into the ambulance and proceeded to the hospital, a 12 min ride. The last FSBS we took was just prior to arriving at the ED and it was 142.

Now, I realise 142 is a good number. But what could cause her BGL to fluctuate some much and in such a short period of time?

[akflightmedic]

What medicines was your patient on?

Here is a great article for your reading pleasure.

By the way, OJ fell out of favor a few years ago; another medical urban legend dis proven with solid science.

I am trying to find that article for you as well. Other juices are preferred over OJ, something to do with the acids slowing absorption rates and the end result being less than that of other juices or tablets, etc.

http://archinte.ama-assn.org/cgi/content/abstract/150/3/589

Can any of the others weigh in on this or provide some more info???

[JakeEMTP]

AK,

Our patient was taking Humulin 70/30. She had taken it in the morning and her BGL was 164 then.

She couldn't locate her other medications for us, but knew she had a "heart pill", took Advair for Asthma as well as Albuterol, she had a CPAP machine beside the bed.

We've picked her up before. Usually, she responds quite favorably to the D50. This time however, it didn't go quite as well as we had planned. :?

I understand about the OJ. Great article, Thanks.

[ccmedoc]

What medicines was your patient on?

If she was taking oral hypoglycemic meds...some antibiotics interfere with their action.

You would need to know if she had a preexisting condition resulting in hypermetabolic state, such as recent injury, illness, surgery, etc.

Any herbals she may have been taking?

There are a few odd ball herbal "remedies" that produce a type of refractory hypoglycemia. I could drudge up a case study or two when I have more time..

By the way, OJ fell out of favor a few years ago; another medical urban legend dis proven with solid science.

I think I would have given some oral glucose (sucrose gel) instead of the common OJ, Peanut butter and jelly, and the such.

If an individual drops their sugars to below 150 mg/dl after 25g of dextrose, I would give at least another 12g and transport to the hospital. I have seen individuals, both IDDM and NIDDM, take 125g of dextrose and burn it up in less than 20 min. A general rule we use is, if the patient does not have a blood glucose of over 225mg/dl after the first 25g, we will monitor for a few minutes and see if they drop. If a drop is seen, transport is advised and additional dextrose prepared for administration.

edited for content and grammar..

[Eydawn]

Notice that they said glutose (glucose gel) sucked as well? I can vouch for that as of an experience last night... a fellow lab instructor (IDDM) ate a salad for dinner, got loopy, sucked down the gel tube, and *then* blacked out. Good thing we had a surplus of paramedics instructing! He's fine. Got razzed for the rest of the night and had to have his wife come get him, though.

For a quick up, juice (not OJ, agreed) seems to work better than the stupid toothpaste tube; but if not followed by something more substantial, they crash again pretty quickly.

Why, if we are allowed to give straight sucrose, are we not allowed to carry granola bars? The allergy risk? And I am also curious as to what the fluctuations could have been from... were the samples taken from the same arm? Had the patient taken insulin recently? I'm not particularly sure as to why you'd see such rapid up and down flux... although I have seen it before in folks with IDDM and had to watch them for low BGL.

It's definitely perplexing!

Wendy

CO EMT-B

[JakeEMTP]

I appreciate the feedback.

You know, we have been to this residence at least 6 times that I know of since I've been here, approximately 1 year. We thought it would be the same old, same old. It just goes to show you we never really know what we will be presented with.

Lesson learned and duly noted.

[AZCEP]

The need for an education in nutrition is apparent.

The initial blood sugar level was probably due to a combination of factors. Several of which aren't even mentioned here. Is it possible this patient was experiencing some other medical problem as well? Standard issue infections can cause a change in the response to a typical dose of insulin, and are pretty common this time of year.

The first dose of dextrose you administered was used up rapidly by the cells that were responding to the insulin that was there. Once it was gone, the BGL started dropping. Using OJ can be acceptable, but the amount you will need to give is enormous and can cause some nausea. Excess acid load into the stomach, where the sugar isn't going to be absorbed from. Apple or grape juices are a more readily available source of fructose. They pass into the small intestine and are absorbed more quickly. With the OJ, you were waiting for the sugar to make it to the small intestine to be absorbed. This can take some time, particularly in the patient with other medical issues. While waiting, the body is still burning the "quick fix" dextrose that you administered.

Glutose gel works much the same way, and should not be used as a substitute for something with a mixed macronutrient present. Peanut butter and jelly is good because it is relatively cheap, and it has protein, fat, and carbohydrates to balance the absorption.

70/30 is 70% long-acting, 30% short acting insulin. The idea being to mix the onset and durations of the two into one simple to administer solution. This patient obviously needs to consider that there are some better options available, but that is for the endocrinologist to decide. I am curious which "heart pill" she is taking though. Most cardiac meds do not mix too well with insulin, and have to be monitored very closely until the dose is figured out.

[JakeEMTP]

The need for an education in nutrition is apparent.

Agreed. Hopefully she will get to see a Nutritionist at the hospital.

I am curious which "heart pill" she is taking though. Most cardiac meds do not mix too well with insulin, and have to be monitored very closely until the dose is figured out.

I am trying to find this out as it did cross my mind also, and concerned me. I'm off today but working tomorrow. I'll see if I can obtain that info from the ED.

[DwayneEMTP]

...I think I would have given some oral glucose (sucrose gel) instead of the common OJ, Peanut butter and jelly, and the such.

Why is that? I've come to believe that once you've raised the BGL that the proteins are what she would need to plateau, right? (With, as I've learned today, the exception of the OJ)

As AZ said, it seems that more straight glucose is going to be metabolized quickly by whatever mechanism is causing the issue now....Particularly with a no transport I'd think that putting something more complex into her belly would be important. :-k

Just curious...

Dwayne

[brock8024]

I love the diabetic patient. They are always interesting to help and deal with. I have had pt's with FSBS in the 30's and be talking to me and others in the 60's and be out of it. I always try to start with the oral stuff unless they are out of it. D50 is a aweosme drug and love watching it work so fast. When my pt wakes up I tend to go with a PB sandwich and a glass of milk. I only have them drink OJ if that is all that is in the house. Normally with the milk and PB the sugar stays up.

I try to take my pt's to the ER to atleast get checked out. I mean I am already there so why not. Plus who knows what is going on that the pt is not telling me or that I do not know. There are many reason why the FSBS is low.

The hospital where I work they have came up with a intersting formula on how much D50 to give. I know that they do not give a full 25g. I think it is 100-FSBS x0.3 or someting. I will try to find out but the actual one is.