Pushing D50

[EMT Foose]

Something I've really been debating a lot..

What is the general consensus of pushing D50 through a line that will not aspirate? Also taking into consideration the common D50 patient- long term diabetic with crappy veins, or veins that are near impossible to cannulate.

Personally I would prefer to utilize glucagon and hunt for a better IV site rather than take a gamble...but I'm just a para-maybe.

What does everyone think?

[Mateo_1387]

Something I've really been debating a lot..

What is the general consensus of pushing D50 through a line that will not aspirate? Also taking into consideration the common D50 patient- long term diabetic with crappy veins, or veins that are near impossible to cannulate.

Personally I would prefer to utilize glucagon and hunt for a better IV site rather than take a gamble...but I'm just a para-maybe.

What does everyone think?

If you cannot aspirate blood from an IV line and can easily push fluid through the catheter, then I would go ahead and bolus 100 mL of saline and check for local edema around the catheter. I say that if there is none then the line is patent. If you start to notice edema with the fluid administration around the catheter site, then do not use the IV. You may be able to pull the catheter out a little and then aspirate blood, as the tip of the catheter may be sitting on a valve in the vein.

[RomeViking09]

If you cannot aspirate blood from an IV line and can easily push fluid through the catheter, then I would go ahead and bolus 100 mL of saline and check for local edema around the catheter. I say that if there is none then the line is patent. If you start to notice edema with the fluid administration around the catheter site, then do not use the IV. You may be able to pull the catheter out a little and then aspirate blood, as the tip of the catheter may be sitting on a valve in the vein.

As a rule of thumb if you can't aspirate the line then the line is not patent, now then again most rules have their limits. Like you said what if the end of the catheter is on a valve. What is the patient like? LOC, D-Stick? If the patient is only slightly altered I think IM glucagon is the best bet, if the patient's D-Stick is LLL (Low Low Low) I am going to hunt for a better IV or even go IO if needed. just my view on the topic.

[speedygodzilla]

As a rule of thumb if you can't aspirate the line then the line is not patent, now then again most rules have their limits. Like you said what if the end of the catheter is on a valve. What is the patient like? LOC, D-Stick? If the patient is only slightly altered I think IM glucagon is the best bet, if the patient's D-Stick is LLL (Low Low Low) I am going to hunt for a better IV or even go IO if needed. just my view on the topic.

What happens when the diabetic with the IO in their leg wakes up and wants to refuse transport?

I would never go IO on a diabetic low D-stick reading unless they look like they didn't have the stores for Glucagon to convert. Even than I would use medical to the pt's advantage.

If the IV doesn't aspirate than look for swelling and an easy drip from the bag. Also pain noted at the site, but if your giving D50 they probably can't tell you about the pain.

[RomeViking09]

What happens when the diabetic with the IO in their leg wakes up and wants to refuse transport?

I would never go IO on a diabetic low D-stick reading unless they look like they didn't have the stores for Glucagon to convert. Even than I would use medical to the pt's advantage.

If the IV doesn't aspirate than look for swelling and an easy drip from the bag. Also pain noted at the site, but if your giving D50 they probably can't tell you about the pain.

if they can't tell me not to do the IO then they go in the back of the truck an give the D50 En route to the ER, they can take up the IO with the ER staff, then need to go anyway

[FireMedic65]

Very good points. If I don't get a flash when starting an IV, I consider it a failed attempt.

D50 is very hard to push through any IV. I wouldn't attempt to try pushing it through anything smaller than at least a 20g and that's pushing it. I like 18s, they flow a little better, but we don't need to get into Poiseuille's law.

Even if you have a patent line, with a good flash, good flow of a saline flush, the D50 will still take some effort to push.

Glucagon is usually a second choice because it takes longer.

[RomeViking09]

Another point on D50, how many patients do we push a full amp (25g) of D50 and get a refusal for transport when we should be talking our patient into going to the ER to be checked out. The number of times I have heard a medic say "well your sugar was just a little low, you don't need to go to the hospital just sign here" when dealing with a patient they found altered or unresponsive makes me sick. If the patient is to altered to eat something then they need to be checked by a doctor even if the only reason their sugar is low is something as simple as they did not eat dinner last night. I work under the

you call we haul theroy, I would much rather get called in to a supervisor's office to explain someone calling to complain about me trying to talk them into going to the ER then having to go back and work a full arrest on a patient I talked out of going to the hospital. Just my two cents on D50 in EMS

[FireMedic65]

What is the ER going to do for them? Recheck their BGL? Say "yea, your sugar must have been low". Now wait here until we find you a ride home and wait for another bill in the mail. Their sugar was low, we fixed it. Do you put a bandaid on someones papercut, then haul them into the ER for blood work and a full round of antibiotics?

[RomeViking09]

What is the ER going to do for them? Recheck their BGL? Say "yea, your sugar must have been low". Now wait here until we find you a ride home and wait for another bill in the mail. Their sugar was low, we fixed it. Do you put a bandaid on someones papercut, then haul them into the ER for blood work and a full round of antibiotics?

If someone has a low blood sugar due to other causes the ER can do blood work we can't do, ER docs can adjust their medications, the ER can admit them if they need to be monitored b/c of the result of the blood work. I am not saying you take in a paper cut, or someone not hurt in an MVA where someone else called 9-1-1 b/c they saw a MVA happen. I am saying that we don't need to keep brushing off low blood sugar as a waste of our time to take them to the ER. Unless you have some magic way of doing full blood work on them in the field that the rest of us do not have, how do you know what caused their sugar to drop and how do you know all they need is a quick fix? Lets look at a short list of causes of low blod sugar that will not be fixed by D50 and a refusal shall we....

Overmedication with insulin or antidiabetic pills (for example, sulfonylurea drugs)

Use of medications such as beta blockers, pentamidine, and sulfamethoxazole and trimethoprim (Bactrim, Septra)

Use of alcohol

Missed meals

Reactive hypoglycemia is the result of the delayed insulin release after a meal has been absorbed and occurs 4-6 hours after eating.

Severe infection

Cancer causing poor oral intake or cancer involving the liver

Adrenal insufficiency

Kidney failure (Acute or Chronic)

Liver failure (Acute or Chronic)

Congenital, genetic defects in the regulation of insulin release (congenital hyperinsulinism)

Congenital conditions associated with increased insulin release (infant born to a diabetic mother, birth trauma, reduced oxygen delivery during birth, major birth stress, Beckwith-Wiedemann syndrome, and rarer genetic conditions)

Insulinoma or insulin-producing tumor

Other tumors like hepatoma, mesothelioma, and fibrosarcoma, which may produce insulin-like factors

Now if you can rule all of those out in the field then just let them go, but since 90% of those can be checked with basic labs at the ER I would say take them into the ER.

(Starting new topic on this one in patient care section)

[ERDoc]

If someone has a low blood sugar due to other causes the ER can do blood work we can't do, ER docs can adjust their medications, the ER can admit them if they need to be monitored b/c of the result of the blood work. I am not saying you take in a paper cut, or someone not hurt in an MVA where someone else called 9-1-1 b/c they saw a MVA happen. I am saying that we don't need to keep brushing off low blood sugar as a waste of our time to take them to the ER. Unless you have some magic way of doing full blood work on them in the field that the rest of us do not have, how do you know what caused their sugar to drop and how do you know all they need is a quick fix? Lets look at a short list of causes of low blod sugar that will not be fixed by D50 and a refusal shall we....

Overmedication with insulin or antidiabetic pills (for example, sulfonylurea drugs)

Use of medications such as beta blockers, pentamidine, and sulfamethoxazole and trimethoprim (Bactrim, Septra)

Use of alcohol

Missed meals

Reactive hypoglycemia is the result of the delayed insulin release after a meal has been absorbed and occurs 4-6 hours after eating.

Severe infection

Cancer causing poor oral intake or cancer involving the liver

Adrenal insufficiency

Kidney failure (Acute or Chronic)

Liver failure (Acute or Chronic)

Congenital, genetic defects in the regulation of insulin release (congenital hyperinsulinism)

Congenital conditions associated with increased insulin release (infant born to a diabetic mother, birth trauma, reduced oxygen delivery during birth, major birth stress, Beckwith-Wiedemann syndrome, and rarer genetic conditions)

Insulinoma or insulin-producing tumor

Other tumors like hepatoma, mesothelioma, and fibrosarcoma, which may produce insulin-like factors

Now if you can rule all of those out in the field then just let them go, but since 90% of those can be checked with basic labs at the ER I would say take them into the ER.

(Starting new topic on this one in patient care section)

I've got to agree. By getting the sugar up you've won the battle but not the war. The important thing here is, why are they hypoglycemic. Most pts don't require much more of a workup but there are those that do. I feel it is completely inappropriate/malpractice to make someone sign the form. If they don't want to go, that is a different situation.