What would you do for hyperglycemia?

[nypamedic43]

mobey its Brady page 1285-1287. since we have no other info from the OP, a BGL of 558 in some people COULD be DKA. (not likely but could be) normal treatment of hyperglycemia is IV fluids and insulin as directed ( we dont carry insulin)

from Brady " if BGL cannot be quickly determined, draw a red top tube of blood for analysis and start an IV of normal saline. Following this, administer 50 ml (25g) pf 50% dextrose solution. the additional glucose load will not adversely affect the ketoacidotic patient because it is neglible compared with the quantity present in the body"

I have never given dextrose to a hyperglycemic patient, its just been fluids and cardiac monitor and transport.

[mobey]

from Brady " if BGL cannot be quickly determined, draw a red top tube of blood for analysis and start an IV of normal saline. Following this, administer 50 ml (25g) pf 50% dextrose solution. the additional glucose load will not adversely affect the ketoacidotic patient because it is neglible compared with the quantity present in the body"

I have never given dextrose to a hyperglycemic patient, its just been fluids and cardiac monitor and transport.

This must be "Paramedicine for dummies"

Seems they are refering to the old "cocktail" for uncx patients?

It does not however state the Tx for hyperglycemia is dextrose. It is saying if you can't get a BGL, just give the sugar. Exen if they turn out to be hyperglycemic, the amount of Dextrose you are giving will not injure them.

Luckily.... I think all ambulances can assess sugars these days, so that does not apply.

Fluids in Hyperglycemia is always a good discussion! Please explain your above Tx plan....

, I have to agree with crotchity on this one, treat the patient, not the machine.

So hold off the Insulin unless they have S&S of Hyperglycemia?

I will never understand reactive medicine.

If I ever have a silent MI, I really really hope I'm not in your county

[HERBIE1]

In the absence of a glucometer, I recall reading about giving sugar of some type to a known diabetic who has an altered mental status. The rationale being that a few more grams of sugar won't significantly impact someone's hyperglycemia, but it could save someone's life if their sugar was low. If we KNOW the person's level is high, then I have NEVER heard of giving more dextrose, glucose, fructose, or any sugar compound. That makes absolutely no sense.

[chbare]

Yes, hold off on the insulin. We should not be giving insulin in the field. You have no idea what underlying electrolyte issues exist and without that knowledge, we should not be giving insulin. In addition, the primary therapy for DKA and HHNKC will be isotonic fluid administeration. Once whe have labs we can look at insulin and changing fluids/adding electrolytes such as potassium supplementation.

Some of these patients are exceeding complicated to manage. Also, we still have no idea how this patient is clinically. OP, care to fill us in please?

[Eydawn]

By underlying electrolyte issues, are you referring to K+ and the use of insulin to move K+ from blood serum into the intracellular compartment, putting us at risk for serum hypokalemia and cardiac side effects?

Or are there others I'm not aware of?

Wendy

CO EMT-B

[mobey]

Yes, hold off on the insulin. We should not be giving insulin in the field. You have no idea what underlying electrolyte issues exist and without that knowledge, we should not be ......

I was not advocating for insulin in the field, I was responding to the old mentality of "treat the patient not the monitor". It is a piss poor catch all that exudes unprofessionalism.

The way you explained the rationalle for witholding insulin exudes common sence and sound clinical judgement.

These blanket statements just do not work, and should not be handed down to our up-and-comers.

[chbare]

By underlying electrolyte issues, are you referring to K+ and the use of insulin to move K+ from blood serum into the intracellular compartment, putting us at risk for serum hypokalemia and cardiac side effects?

Or are there others I'm not aware of?

Wendy

CO EMT-B

That is a potential concern.

I was not advocating for insulin in the field, I was responding to the old mentality of "treat the patient not the monitor". It is a piss poor catch all that exudes unprofessionalism.

The way you explained the rationalle for witholding insulin exudes common sence and sound clinical judgement.

These blanket statements just do not work, and should not be handed down to our up-and-comers.

Thanks for clarifying. You can expect significant changes after isotonic fluid administeration and the decision to use insulin takes many factors into consideration. Initially withholding insulin is never a bad decision until we know what is going on. Again, these patients (DKA & HHNKC) are often rather complex and difficult to manage. Over zealous insulin therapy can lead to disastrous consequences, so it's not something I take lightly.

[DwayneEMTP]

I've seen quite a few diabetics with BGLs over 500, yet none of them have been in big trouble when there were no comorbidities, at least not that I could determine or learned of later.

Chbare are you saying that there are times when pts crump, (not talking zebras), from straight forward uncontrolled diabetic issues at this level? What would be the likely mechanism in such a patient?

Not a challenge but a genuine question. The only time that I've really seen even altered hyperglycemia they've been around 1000 or so. But my experience with such things is certainly not deep. One other time I had an altered diabetic at 1550 per ER blood work, and he was dead about 5 hrs later, though there was no reliable information as to how long he may have been in such a state before discovered and EMS activated.

Pretty cool thread...

Dwayne

[Kiwiology]

The first thing I'm going to do is divide that number by 18 so I can get it in mmol/l which Kiwi understands

I know I'm just gonna sound like everybody else but its either HHNK or DKA ... give him some fluid and transport

No insulin pre-hospital

[scubanurse]

Question... would we be running fluids wide open and pushing 1000cc of NS or LR into a patient with potentially undiagnosed and certainly uncontrolled diabetes? Wouldn't there be a concern about kidney function, as in if they aren't functioning fluid overloading the heart and leading to lots more issues?

I'm all for giving fluids and they way it was explained to me was you want to almost dilute the sugar in the blood... but I am hesitant to push through a lot of fluids on the way to the hospital, unless it's over a long period and you can closely monitor ECG and lung sounds....

Am I way off base?