Blood sugar levels

[Hutsy]

it appears from your post you have some very valid things to contribute

This is exactly why I dont post much. I have just barely scratched the surface of EM and feel I have mostly nothing to contribute with. Baby steps... Glad to see my topic has piqued your interest though, keep it up.

Marc

[crotchitymedic1986]

You also need to be suspect of any blood glucose reading in the field, for a variety of reasons in any patient:

1. The glucometers are slung around, dropped, and are exposed to heat/cold extremes that the manufacturer does not approve of.

2. Read number one above but exchange glucometer with glucometer strips.

3. Many EMS agencies do not run "controls" as often as recommended. Most hospital glucometers have controls ran at least once per 24 hours.

4. You are measuring surface capillary blood, there are a variety of illnesses and conditions that can cause an inaccurate reading. Some simple examples, an obese patient, or a patient who knew their sugar was dropping so they put some sugary food in their mouth with the same finger you tested, and you failed to clean it properly.

Hopefully, your teacher will tell you on day one to "TREAT THE PATIENT, NOT THE EQUIPMENT", but if not, you have just received your first EMS lesson. Study hard grasshopper !

P.S. In the old days an amp of D50 and 1-2 amps of bicarb was standard treatment for all out of hospital arrests (including trauma). Not saying that was good or bad, just throwing in some history for perspective.

Edited August 20, 2011 by crotchitymedic1986

[tniuqs]

Interesting post crotch ... so if (dependant on scope of practice) Paramedics could treat hyperglycemia in the field for a suspected MI and the "studies" indicated improved mortality morbidity, then how would one know or what signs / symptoms would one use ? Your point on QA/QC and due diligence is taken at face value, this should be a given but worth mentioning if one is starting out and you really have nothing to add to thread at this progressive juncture.

The days of treat your patient based on "just clinical observation" are just about over in EMS this "old school teaching point" has been taken out of context, it was if I can recall way back when. It was do not defibrilate a patient that is sitting up and talking to you .. oddly enough now, that we can cardiovert we actually do treat the machine, the wonders of modern science eh what ?

The reason why we are now viering away from this old school concept is because of 12 lead ECG, Pulse Oximetry, ETCO2, the Masimo rainbow COHGB, iStat ABGs, Stat lytes, Troponin, CPK, Myoglobin (bedside testing) field ultrasound and who knows what next .

D50W and 2 amps bicarb .. wow you really are old.

[crotchitymedic1986]

Point well taken tnuigs, new is not always bad. But let me give you this presentation: Known diabetic, unconscious and diaphoretic, all V/S normal, including your glucometer reading which states 120 (you are in a public setting, not near the patient's family, so all you have to go on is the med-alert bracelet that says IDDM. So what do you do ?

I am starting an IV and pushing 1/2 amp of D50, and saving the patient's life (old school style), how many of you would not because your machine told you not to ?

Edited August 20, 2011 by crotchitymedic1986

[tniuqs]

Hmmm interesting presentation, age ? colour ? V/S ? ECG ? SPO2? ETCO2 ?

First I would support A B C ---> then look for other reasons in decreased LOC, most likely do another BGL, would I give a half an amp nope not these days.

I would try to rule out CVA, Head Injury, MI, ETOH, or siezure as one could be actually increasing morbidity/ mortality as direct result of pushing D50W on spec.

Counter query .. if this was a know ETOH abuser would you push D50W on that patient too ?

Late edit ... could you answer the first question I posed ?

Edited August 20, 2011 by tniuqs

[crotchitymedic1986]

I apologize, you did ask 2 questions, but I am not sure I understand them. #1. I am not advocating not using your technology, but I submit that your generation is too reliant on technology and often lack some basic assessment skills, much like we no longer use as much of our memory, as there is no need to, since you can quickly look up anything on the internet. I did not have a pulse oximeter, so I had to know breath sounds and severity of event without looking at a digital readout. This leads to undertreatment in my opinion, as I often encountered patients in the ER that EMS did not treat appropriately, because the pulse ox was good in a sitting position, if they had made the patient walk 10 steps (or lay them flat)they would have seen that the patient was in far more distress than they recognized. #2 In cardioversion, I hope you are not just treating the machine. Just because a patient has a rhythm that is too wide, too narrow, or too fast does not necessarily mean cardioversion is necessary.

And the choice to not treat the patient in my scenario would have lead to that patients death. I have had four patients in my career who were severely hypoglycemic with a normal glucometer reading. Yes you should try to rule out all the conditions you listed, but how could you in the field ? The better answer is to look at the patient. The patient is normotensive (I stated all v/s were normal which was intended to include every test you have at your disposal). So you are left with diaphoretic and unconscious, with a known diabetic history. Seizures, head injury, and ETOH rarely produce diaphoresis (yes possible). A cardiac event could produce diaphoresis, but usually does not produce unconsciousness with normal vital signs. CVA or an aneurysm could produce unconsciousness and diaphoresis, but again you would probably see a shift in V/S. So hypoglycemia is the most likely cause. So you push half an amp of D50, and see if the patient responds, if they do, you push the other half (draw blood first if you can so you will know if your machine was faulty). Worst case scenario, you have raised that blood glucose reading from 120 to something in the 200's, which is nothing for a diabetic. If the D50 fails to work, then you can pretty much rule that out and move on to your other possibilities that you can not rule out in the field.

Edited August 20, 2011 by crotchitymedic1986

[chbare]

Worst case scenario?

http://emedicine.medscape.com/article/794583-treatment#2

[tniuqs]

I apologize, you did ask 2 questions, but I am not sure I understand them. #1. I am not advocating not using your technology, but I submit that your generation is too reliant on technology and often lack some basic assessment skills,

Ahem .. sorry to inform you but I know I am way older than you .. your point being comparing old vs new and that the newer grads have less clinical evaluation ability an EPIC FAIL based on your "stereotyping" .

much like we no longer use as much of our memory, as there is no need to, since you can quickly look up anything on the internet.

Curious I do not have the internet on my phone to "look" up anything, your quite correct that my memory is weakening but that due to age ... curiously it has been said of some of my junior partners if they knew half of what I "forgot" they would be in good stead .. <insert blush smiley> what was your point again I forget.

I did not have a pulse oximeter, so I had to know breath sounds and severity of event without looking at a digital readout.

Even the best of the best Health Care providers are proven they can not to recognize life threatning hypoxia until sats of 77% and then only some using "cyanosis" as an indicator, then listening to breath sounds well another red old herring Jjust perhaps take a look at Bryan Bledsoes "handouts from his webpage" concerning administration of 02 .. outcome statistics in the non ischemic CVA patient, MI, and Poly Trauma ...your very possibly doing harm to your patients with NRM @ 15 lpm.

This leads to undertreatment in my opinion, as I often encountered patients in the ER that EMS did not treat appropriately, because the pulse ox was good in a sitting position, if they had made the patient walk 10 steps (or lay them flat)they would have seen that the patient was in far more distress than they recognized.

Your talking to an RRT .. this is called the "road test" / "exercise tolerance" of course O2 demands will increase with exercise, who stresses a patient to get a lab value needs a good swift kick in the ass.

#2 In cardioversion, I hope you are not just treating the machine. Just because a patient has a rhythm that is too wide, too narrow, or too fast does not necessarily mean cardioversion is necessary.

When I see VTach I treat it otherwise if delayed I just may be treating V fib PDQ .. the unstable of course being my rule of thumb.

And the choice to not treat the patient in my scenario would have lead to that patients death. I have had four patients in my career who were severely hypoglycemic with a normal glucometer reading. Yes you should try to rule out all the conditions you listed, but how could you in the field ?

Are you certain ? Firstly anecdotal recollection another attempt to rationalize FAIL ... So just how many survived to door with your iatrogenic induced hyperglycaemic ? Back to clinical observation, pupils, reflexes, smell +++

The better answer is to look at the patient. The patient is normotensive (I stated all v/s were normal which was intended to include every test you have at your disposal). So you are left with diaphoretic and unconscious, with a known diabetic history. Seizures, head injury, and ETOH rarely produce diaphoresis (yes possible).

Seizures can be the result of a hypoglycaemic reaction as can high ICP even MI ..but your missing my entire point there are diabetics that are alcholics ever hear of Wernicke-Korsakoff encephalopathy ... do you even have thiamine ?

A cardiac event could produce diaphoresis, but usually does not produce unconsciousness with normal vital signs. CVA or an aneurysm could produce unconsciousness and diaphoresis, but again you would probably see a shift in V/S. So hypoglycemia is the most likely cause.

Your making quite a stand on the diaphoretic patient as the diagnostic feature here, hence my third question what is the ambient temp ? I used to do a senaro about a hockey player fresh out of the shower and c/o of CP ... every one worked him up as an MI when he was 26 and had CP from a muscular skeletal, then an industrial acid spill 46 y/o just out of a emergency shower complains of CP because the water is just above frezzing and has an MI as a direct result of fear and sudden imersion into cold water ... hmmm the bright ones in the class .. well they used diagnostic tools provided.

So you push half an amp of D50, and see if the patient responds, if they do, you push the other half (draw blood first if you can so you will know if your machine was faulty). Worst case scenario, you have raised that blood glucose reading from 120 to something in the 200's, which is nothing for a diabetic.

Are you reading the links posted in this thread ? really ? are you aware that you could be causing harm in the Head Injury, the CVA, the MI patient the peaks and valleys decreasing total lifespan ... yeah ok grasping at some straws there.

If the D50 fails to work, then you can pretty much rule that out and move on to your other possibilities that you can not rule out in the field.

Yup and give narcan a go then and keep giving drugs until the patient wakes up EH ?

late edit .. dang chbar beat me to the punch line ... again.

Edited August 20, 2011 by tniuqs

[crotchitymedic1986]

Well lets let the members decide. How would the rest of the room treat this patient ?

[Vorenus]

1. The glucometers are slung around, dropped, and are exposed to heat/cold extremes that the manufacturer does not approve of.

2. Read number one above but exchange glucometer with glucometer strips.

Hopefully, your teacher will tell you on day one to "TREAT THE PATIENT, NOT THE EQUIPMENT", but if not, you have just received your first EMS lesson. Study hard grasshopper !

Regarding your point 1 and 2:

I can`t really agree. Our glucometers (Medisense Precision Xceed) can be stored in an enviroment from -25 Celsius to +50 Celsius and operate in a temperature scale from +10 to +50 Celsius. I`d have to look up the exact data for the stripes, but they won`t vary that much.

That`s a pretty solid range of a temperature scale for the operation of a medical machine. Honestly, I`m pretty confident in our glucometers, never had

a moment where I had to suspect that it was giving me wrong numbers.

Of course, I do not operate in a region with extreme temperature, I guess I wouldn`t be that confident if working in Sibiria or the desert, but here it`s enough.

Gotta agree with your statement about treating the patient not the machine!

If you see an Asystole on the monitor while the pt. is still speaking with you - the ekg is most propably wrong...