crotchitymedic1986 Posted December 23, 2008 Posted December 23, 2008 Sure it can, seen it many times. So, let me clarify your position doc: you are in an ambulance, that is not temperature controlled 100% of the time, using a glucometer that gets bumped around all over the place (probably cheapest glucometer that can be bought), and you have an unconscious insulin dependent, diaphoretic, diabetic patient in front of you. Your glucometer reading says 102, and you know the patient took their insulin, but has not eaten. You are claiming that you would not give D50 ? If so, what needs to happen for you to give D50 ?
WolfmanHarris Posted December 23, 2008 Posted December 23, 2008 Crotch are you referring to glyconeogenesis? This would occur (I'm doing this from memory so please correct me if I'm wrong) when glucose demand in the cells causes glucagon to breakdown glycogen via gylcolysis which would increase the BGL but not necessairly the cellular glucose as the insulin deficiency would prevent the glucose's uptake. So BGL would be up but the cells would still be starving, so now fat and protein would be broken down into glucose via glyconeogenesis. This creates free fatty acids and ketones and creates diabetic ketoacidosis. Or in the case of some insulin activity HHNK. I'm not sure how this would happen in hypoglycemia as the glucose demand would be high and wouldn't any source that would be used could be by the insulin that is present? And if both the BGL was low and the insulin was also so low that it wouldn't uptake any of the circulating glucose, wouldn't the patient already be in such poor condition that we'd be seeing arrhythmia and likely be doing CPR? Once again, I'm not being rhetorical. This is my understanding of it and it could be faulty in all or part but I wanted to try it from memory not just parroting from my text. - Matt
crotchitymedic1986 Posted December 23, 2008 Posted December 23, 2008 Doc, please read my last question, we posted at about the same time so you may have missed it. Glyconeogenesis and glycolysis can play a role. You have to realize that these patients often have other medical problems and are on medications that can excerbate the issue. Besides that, glucometer strips on ambulances are not maintained at the manufacturers suggested temperature (usually 50-85 degrees), as ambulances that are housed outdoors (and even those housed indoors) frequently have internal temperatures that exceed either or both extremes. I realize that you are used to using glucometers in a controlled environment, and have a lab that can do a stat chem 7 panel. Many EMS providers do not do "controls" or have their glucometers calibrated to insure accuracy. I would bet you that if I checked every reserve truck in your state today, 25% of them would have expired glucometer controls on board, or would not even have control solution on board. It is sad, but many emts do not clean the patients finger with alcohol -- there is a good chance the patient was eating something sweet before they went unconscious, so now they have sugary fingers which gives an abnormal result. You can not put glucometer readings over and above obvious signs, symptoms, and history.
p3medic Posted December 24, 2008 Posted December 24, 2008 Am I the only one concerned about giving Romazicon to this patient?
ERDoc Posted December 24, 2008 Posted December 24, 2008 Sure it can, seen it many times. So, let me clarify your position doc: you are in an ambulance, that is not temperature controlled 100% of the time, using a glucometer that gets bumped around all over the place (probably cheapest glucometer that can be bought), and you have an unconscious insulin dependent, diaphoretic, diabetic patient in front of you. Your glucometer reading says 102, and you know the patient took their insulin, but has not eaten. You are claiming that you would not give D50 ? If so, what needs to happen for you to give D50 ? It would need to not be malpractice and dangerous for the pt for me to give the D50. I have a desire not to harm my pts that I wish I could share with you. So what if you have a diaphoretic, AMS diabetic. There are many other things, including a stroke, that can present with the exact presentation you give, including several that would be complicated by hyperglycemia. If you have nonfunctioning equipment then you should not take your ambulance out on the road, no questions asked. If you do take it out you are a danger to your pts. "So, Mr. Crotch, let me get this straight. You took it upon your self to give a high concentration of sugar to my client to treat his supposed hypoglycemia despite that fact that you had evidence to the contrary. Despite a normal sugar reading you still took it upon yourself to give this deadly medicine and now, as Dr. Brain his neurologist has testified, this patient has suffered severe brain damage that will leave him in a wheel chair and unable to speak for the rest of his life. Your protocols clearly state that Mr. Smith did not meet the criteria to be given the sugar but you still decided to give it anyway on the false assumption that you knowingly were using faulty equipment. Do you normally practice medicine without a license? My client will be more than happy to take his $2.5 million in cash or money order." Get real man, if you practice anything near what you preach here you are a serious danger to your pts.
okmedic Posted December 24, 2008 Author Posted December 24, 2008 Am I the only one concerned about giving Romazicon to this patient? You will have to explain why you withhold romazicon in a pt with strong evidence to suspect a Benzo overdose with respiratory depression.
p3medic Posted December 24, 2008 Posted December 24, 2008 My concern is that giving flumazenil to a polysubstance OD may do more harm than good. This is a patient with a history of depression that the family reports took a benzo and opiate. We have no idea what else the patient may have taken, or how chronic his benzo use is. Controlling his airway would seem to be the priority after narcan failed, IMHO.
CBEMT Posted December 24, 2008 Posted December 24, 2008 Am I the only one concerned about giving Romazicon to this patient? Nope. It was pulled off my state formulary years ago because patients were dying after EMS used it like Narcan, which is NOT what its intended or recommended use is.
aryan51 Posted December 26, 2008 Posted December 26, 2008 Just a couple quick questions from a humble student... With the question brought up of a "normal" BGL in an insulin dependent patient presenting with diaphoresis and slurred speech, while you may be suspecting a stroke given the BGL and the contraindication of D50 due to (from what I understand) possible brain tissue necrosis in a hemorrhagic stroke scenario that is not able to be assessed in the field, would it be harmful to give glucagon to attempt to raise glucose levels without adding D50 to the bloodstream? To try to rule out a higher symptomatic level? Just wondering... Also, was it not the practice of administering "coma cocktails" to unconscious patients before glucometers were available on the ambulance? That's the reasoning I've heard for them, but I still wonder why pupils weren't added to the assessment of the need for narcan. With the addition of glucometers and better assessment techniques I don't see the need for blind medication administration of any kind.
chbare Posted December 26, 2008 Posted December 26, 2008 It would need to not be malpractice and dangerous for the pt for me to give the D50. I have a desire not to harm my pts that I wish I could share with you. So what if you have a diaphoretic, AMS diabetic. There are many other things, including a stroke, that can present with the exact presentation you give, including several that would be complicated by hyperglycemia. If you have nonfunctioning equipment then you should not take your ambulance out on the road, no questions asked. If you do take it out you are a danger to your pts. "So, Mr. Crotch, let me get this straight. You took it upon your self to give a high concentration of sugar to my client to treat his supposed hypoglycemia despite that fact that you had evidence to the contrary. Despite a normal sugar reading you still took it upon yourself to give this deadly medicine and now, as Dr. Brain his neurologist has testified, this patient has suffered severe brain damage that will leave him in a wheel chair and unable to speak for the rest of his life. Your protocols clearly state that Mr. Smith did not meet the criteria to be given the sugar but you still decided to give it anyway on the false assumption that you knowingly were using faulty equipment. Do you normally practice medicine without a license? My client will be more than happy to take his $2.5 million in cash or money order." Get real man, if you practice anything near what you preach here you are a serious danger to your pts. Take care, chbare.
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