D50: All or Some?

[djmedic]

yes I am a medic and I was taught and my protocols say give the 25g. Then question initial came up by an Intermediate working with me for the 1st time asked why I gave the whole thing since the last medic she worked with would give it in increments like Narcan.

So this isn't a simple thing I should know, coz I do know. The reason I was given by a few other medics is that it will screw up the Pt's BGL for up to a week. so this has been the question of the day out of curiosity in reference to the not giving the entire amp.

As for the Thiamine, I was taught for drunks and mal-nurished. but I started my medic in Buffalo, NY so this was almost a given on all Pts. So I began to just always give it. besides thiamine is a vitamin and does help facilitate the D50 and as we know if alcoholism is unknown or suspected we give it for Wernicke's.

I was curious if the general consensus of EMS was changing the way D50 was administered and recently heard of the change or not.

It appears Not.

Thanx to everyone for their responses

[Kaisu]

One of the things to remember is that 25gms of sugar is not a ton of sugar. A can of coke has 39gms. The patient needs to eat.

[Kaisu]

oops.. double post

[CBEMT]

In our protocols 100mg Thiamine actually precedes an amp of D50 for BGL under 60 if BGL is known. If patient is altered and no meter is available (possible, because they aren't required equipment), push them anyway, followed by 2mg Narcan.

[EMS49393]

Thiamine, also known as vitamin B-1 is an essential vitamin, required for life functions. As stated, it does convert food to energy. It is also necessary for brain and nervous system function. Any patient can be at risk for thiamine deficiency. Greatest risk goes to the mal-nourished and immuno-compromised population. It is safe to assume that any patient that isn't eating properly (alcoholics, homeless population, drug users, and frequent flier diabetics) can be thiamine deficient. You must also remember that alcohol itself destroys thiamine.

A thiamine deficiency can result in a condition called Wernicke's encephalopathy and as it progresses, the patient develops Korsakoff's psychosis, which is irreversible. It can also result in other neurological disorders secondary to the vitamin being essential to proper brain function.

The idea of giving thiamine with D50W is to prevent neurological injury/insult when there is not enough thiamine to convert the dextrose to energy. Thiamine is one of the common ingredients found in the "banana bag" given to the ETOH patient in the ER setting. Some of the recent research I have found states that thiamine can be giving within 24 hours of dextrose administration. All other research I've found on the topic states that thiamine should be given before adminstration of dextrose.

I NEVER say that a drug is benign, however there is only one contraindication to administration of thiamine, and that is hypersensitivity to the drug. In the case of this drug, the benefits far outweigh any risks in most settings.

I have just scratched the surface with my post. If you use google, you'll find research documents which have a wealth of information about this subject.

[Ridryder 911]

We have just quit carrying Thiamine. I personally liked it but alas I am not the Medical Director. I do have to agree, I have not personally seen or even heard of any recent cases of Wernicke's encephalopathy. Yes, it is commonly used in a Rally pack/Banana Bag along with Folic acid, Mg", MVI, etc..

Now, back to the original post. Not too long ago, EMS or JEMS magazine (I can not remember which one) addressed that maybe we are "overkilling" the usage of Dextrose. From what I remember; the discussion that even a diluted D10w was strong enough to reverse the majority of hypoglycemia episodes. The need of such a strong concentrations hypertonic solution was not needed or warranted.

I tend to agree. Over the past several decades I have yet found that such a strong solution was needed. The complications of rebound hyperglycemia, tissue extravasation, caustic irritation causing phlebitis.

I use the same similar philosophy of my use of Narcan. I administer enough to get the patient out of the crisis mode then treat appropriately. Yes, there are some patients with such low metabolism and severe hypoglycemia it may take a full 25gms or even more to cause an increase in a +L.O.C.

Of course dependent upon the situation, but I much rather have the patient ingest & intake a high protein, carbohydrate dietary meal. As discussed on previous posts such as pizza, even a PBJ. Again, previous assessment should had been made that the patient has adequate swallowing and mastication process.

I do believe we will see that higher concentration levels will be changed in the future. Again, similar to previous non-sense regime such as "coma cocktails" etc..

R/r 911

[jmp6753]

I have never heard of giving less than the entire dose of D50. As I have mentioned in a thread about D50 before, in our area we also commonly have people drink the dose (as long as they are conscious enough to protect their own airway and swallow) rather then multiple attempts at an IV on a person with poor vascular access. In our large "urban outdoorsman" population, we do also do the 100mg of Thiamine before the D50.

If your pateint has a BGL of less than 60, at what point would you consider a smaller dose?

[Ridryder 911]

If your pateint has a BGL of less than 60, at what point would you consider a smaller dose?

As soon as the patient is responsive enough to ingest a proper dietary supplement. Why do we want to cause a rebound? Getting the patient out of the crisis mode and then properly correcting the problem with long term treatment.

R/r 911

[EMS49393]

I have to admit, I'm the Queen of the diluted medication. Anything that can cause tissue necrosis and doesn't have to be pushed fast I try to dilute. Currently, my service only carries two such medications that I routinely dilute before IVP adminstration. D50W and promethazine. I like to dilute D50W down to 10%. Diabetics are notorious for having poor peripheral vascular access. I find it damn near impossible to push 50% dextrose though a 22 gauge catheter, which is often the only port in the storm. Rather than risk extravasation, I simply dilute it with a 60 ml syringe and a bag of saline. In those cases, I'll often give 12 mg, enough to wake them up for the trip to the ER. It seems to me that a sudden rise in blood glucose level from 20 mg/dL to 250 mg/dL would be considerably hard on the body. I prefer to see a steady rise to a comfortable 90-100 mg/dL. If the patient requires more dextrose to maintain glucose levels en route then I will administer more dextrose accordingly.

I HATE to get refusals on diabetics. I think that a hypoglycemic episode, one that renders a patient unconscious, or close to unconscious, indicates a need for evaluation by a physician. That episode can be directly related to patient non-compliance, but it can also be related to improper medication dosing, improper patient education, etc. You'd be amazed at how many fragile diabetics I run on that have never seen an endocrinologist or even a nutrionist. Some of these patients have no idea how to manage their diabetes. I take great care to pass that information along in my report to the ER nurses.

I'm pretty dedicated to the proper care of the diabetic patient. I do considerable extra reading on the disease and I'm determined to be the first in three generations to completely ward off this disease.

[mobey]

Hmmm ..I kind of like the dilution idea.

With a small bag of saline you could set it up as a drip couldent you? Maybe that would take too much time.

I would love to hear some more conversation on this subject.

I totally agree on the no transport thing, I too believe a trip to the doc is warranted.