Pt with High BLG

[SWM_Medic]

So I have a couple of questions. I had a call tonight for a pt with high BLG. I arrived to find a 63 y/o female with type I diabetes and a blg of 559. Now the standard of care for my system is to start and IV and transport. So I started a 20g IV running tko with normal saline(it's all I carry). Now has normal saline shown to be of any benefit to someone with blg this high? Now the pt told me she started taking prednisone for asthma that she was diagnosed with last week. She was under the impression that the prednisone caused to spike in her blg. Is that so? If it is, how does it do that? It's just a steriode I can't seem to figure how that effects the body on that level. Any thoughts?

[ccmedoc]

Prednisone is a steroid very similar to cortisol. In the body cortisol stimulates gluconeogenisis by the liver, often 6 to 10 fold increase from what would be considered normal. The cortisol may reduce the amount of glucose used by the tissues, and make them a bit resistant to the insulin, further raising BGL. Lipolsys is also stimulated increasing glucose levels, as well as acid levels.

This is a potentially complicated subject, but this is a basic description of the mechanism you are looking for. Cortisol can be stimulated by stress, whether it be trauma, psychological, surgery, illness, etc. Prednisone being similar to cortisol..well you see how the blood sugars could be elevated?

You should do some research online..I will see if I can find some journal articles in PDF format..

[chbare]

I agree, elevated sugars related to steroids are not uncommon related to physiology discussed above.

To answer the question regarding fluids and sugars. In many cases fluid replacement is crucial in patients with highly elevated sugars. (HHNKC and DKA) Remember, these patients are in a state of hypovolemic shock and usually critically volume depleted. Most patients will receive isotonic volume resuscitation long before insulin.

In fact, I had a DKA patient a few nights back with a sugar of about 820 mg/dl. He had the typical metabolic acidosis, wide anion gap, increased BUN to Creat ratio, + serum ketones, hyperkalemia, etc. In the first hour, we gave two liters of NS and his sugar fell to 600 mg/dl simply from fluid replacement. Then, we started an insulin gtt, and gave two liters of NS with 20 KCL over the next few hours. Finally, we hung D5NS with 20 of K and gave him a couple of liters. No ICU beds, so I had him all night. In 12 hours he received over six liters of fluid, and finally had his insulin DC'd in the am with BGL's in the 200's and an anion gap that was closing. So, yes, fluids are in fact very important when talking about some diabetic emergencies.

Take care,

chbare.

[SWM_Medic]

That makes alot of sense. Thanks for the feedback.

[saboats]

The above is correct. NACL is normally the best thing that EMS can do for someone with hyperglycemia. Fluid and Insulin are the basic treatments, since we prob don't have the insulin, start the fluid. If the pt develops either DKA or HHNK they are going to get fluid loaded in your favorite ICU. Absolutly correct!

Scott, NR/CCEMTP,