Stroke and hyperglycaemia

[Melclin]

Called at 2330 to an 82YOM, conscious collapse and cannot get up.

Pt present GCS 15, L sided hemiplegia, mild difficulty swallowing, aphasia and a BSL of 3.9mmol/L (70mg/dl).

Per our guidelines, this is hypoglycaemia but its clearly not causing his presentation.

I was wary about treating it at all but I was told by my clinical instructor to do so. I then suggested that I give him 2.5-5 grams and do another BSL from there. I was told to give the full 15 gram intial dose per guidelines. I didn't, instead giving 10 grams and found his next BSL to be 14.1 (255).

Not happy.

Q.1 Thoughts about treating hypoglycaemia in ?stroke pts? According to most medical texts a BSL of 3.9 is not really even hypoglycaemia. Profound hypo has to be treated, but at what point do you start shying away from treating?
Q.2 Regarding the association between hyper-G and increased mortality, is that more as a biomarker showing damage, predicting worse outcomes or is it the actual hyp-g causing the issue and as such will iatrogenic hyper-g cause problems?

I'd look it up myself but its so frustratingly hard to do research now that I've lost my journal privileges.

(FYI, this chap turned out to be having an intracerebral bleed and was admitted for observation).

 

[sirengirl]

Pt present GCS 15, L sided hemiplegia, mild difficulty swallowing, aphasia and a BSL of 3.9mmol/L (70mg/dl).

I was wary about treating it at all but I was told by my clinical instructor to do so. I then suggested that I give him 2.5-5 grams and do another BSL from there. I was told to give the full 15 gram intial dose per guidelines. I didn't, instead giving 10 grams and found his next BSL to be 14.1 (255).

Q.1 Thoughts about treating hypoglycaemia in ?stroke pts? According to most medical texts a BSL of 3.9 is not really even hypoglycaemia. Profound hypo has to be treated, but at what point do you start shying away from treating?

70 is "borderline" hypgl for my protocols and in this instance (where I would be calling ALS for the CVA) I would not treat because he doesn't have a strong ability to swallow. Were I a paramedic at this point I would consider pushing D50 but nothing like the amount you were told to administer. I agree that hypgl needs to be treated but that is not the main concern here. If you have the time to scoop and go and while you're blaring down the road for definitive care, sure, but the BGL is not the problem and solving that isn't going to help his CVA.

 

[mycrofft]

Welcome to the diabetic teeter-totter

Ditto sirengirl, CVA definitly takes precedence. Tx that first.

Speaking outside any diabetic protocols, 70mg/dl isn't very bad in and of itself, but it may actually be "70 on the way to 20". A 255 due to a sugar bolus won't hurt the pt and a subsequent glucometry shold be done to see if it comes back down. Much below 70 could be bad, and much lower is definitely bad.

When you are working short term with blood sugars, two axioms apply: aim a little high, and don't try to make minute to minute corrections with pharmacy, you will throw them way out of whack and it will eventually be to the hypo end. If in the immediate run you aim for high 100's or low 200's and wait at least ten minutes between treatments to allow for homeostatic factors to kick in (you can test all you want but hold the Rx) then things ought to be fine.

Just to get too picky, I know blood irritates brain tissue, I wonder if blood with additional osmolar pull from glucose has any different effect?

 

[Melclin]

It did come down quite quickly. It was 11.4 (200) when we got off stretcher 15 or so mins after the second BSL.

They 70 on its way to 20 idea is interesting. Do you think a small bolus was indicated in this case? If so what sort of dose would you be looking at?

 

[lightsandsirens5]

I have to agree with mycrofft.

However, I do remember my ILS instructor going into great detail about giving glucose during a possible CVA, especially a hemorrhagic stroke. It has been a while, so I do not remember what all he was talking about, but I do believe it had to do with the increased osmotic pull. Either that or something about how a higher BGL was bad bad juju in a CVA cause if they are hemorrhaging the increased glucose levels would cause increased neurological damage.

Gosh darn! It was so interesting in class, why don't I remember it! :wacko:

 

[RatMed]

Couple of shifts ago I had a seizure, then ALOC patient with BGL of 75mg/dl. After iv glucose, in a minute he was GCS 15 and feeling fine. Until we met he's been perfectly healthy and has never had a seizure before. So BGL 70mg/dl may be a bit low in some patients (other possible causes for his seizure were ruled out in the ED).
My treatment would be the same as you first intended: 2-5 grams of glucose iv to raise BGL to a safe range. 200mg/dl is a borderline though. Above that you risk a cerebral edema and from what I remember (though may remember wrong), high BGL also increases cellular metabolism and you don't want that in stroke-affected brain tissue.

Once again sorry for my crappy english.

 

[MrBrown]

Brown agrees maybe 25-50ml* of glucose to get his blood sugar up

* we give 100ml of 10% glucose standard

 

[CAOX3]

Is it possible you walked the tunnel, this guy doesn't scream diabetic to me and with his BGL and presentation I'm going with CVA all the way. Obviously if the guy is severly hypoglycemic you need to address it but I don't think that was the case here, he is borderline maybe.

Blasting him with D50 isn't in his best interest we don't want to increase cerebral edema if it isn't necessary, if he has a BGL of 15 obviously that needs to be addressed. Did you notice worsening symptoms after the D50 administration?

 

[Akulahawk]

If he's on the low side, give him the Dextrose, after all, like mycrofft said, he could be 70 on the way to 20. Bring him up into, or perhaps a little above normal because hypoglycemia can quite easily mimic a CVA. If that doesn't improve his symptoms, don't do another Dextrose... it won't help. I would highly suspect CVA at that point as the cause of his symptoms.

Remember what D50 will do if it extravasates, especially at full concentration! Fortunately, it'll be well on it's way to proper dilution by the time it reaches the brain, but perhaps not completely diluted, so you might still see some osmotic pull from brain tissue that it comes in contact with in a bleed, thus possibly causing some additional injury. I would suspect that a greater amount of injury would come from the bleed itself anyway, so... one dose of 25g Dextrose (in whatever concentration you like) and a BGL now brought up to normal or a little higher, isn't going to be bad in the grand scheme of things while eliminating a cause of CVA symptoms.

And of course, if I'm wrong, them I'm wrong...

 

[Melclin]

Brown agrees maybe 25-50ml* of glucose to get his blood sugar up

* we give 100ml of 10% glucose standard

By the letter of the law, ours is 15 first up followed by 10 titrated to response. 10% obviously.

Is it possible you walked the tunnel, this guy doesn't scream diabetic to me and with his BGL and presentation I'm going with CVA all the way. Obviously if the guy is severly hypoglycemic you need to address it but I don't think that was the case here, he is borderline maybe.

Blasting him with D50 isn't in his best interest we don't want to increase cerebral edema if it isn't necessary, if he has a BGL of 15 obviously that needs to be addressed. Did you notice worsening symptoms after the D50 administration?

He wasn't a diabetic and I didn't for a moment think that his presentation was being caused solely by his BSL. We don't use D50 for that reason. Blasting people, whoever they may be, doesn't work out that well. We use D10. Anway I gave him 10 grams. His neuro symptoms didn't worsen but he had about 5 mins of largely asymptomatic bradycardia with a rate of 40. No idea if they were related, but I thought for a moment he was ganna peg out on me right then and there

If he's on the low side, give him the Dextrose, after all, like mycrofft said, he could be 70 on the way to 20. Bring him up into, or perhaps a little above normal because hypoglycemia can quite easily mimic a CVA. If that doesn't improve his symptoms, don't do another Dextrose... it won't help. I would highly suspect CVA at that point as the cause of his symptoms.

Remember what D50 will do if it extravasates, especially at full concentration! Fortunately, it'll be well on it's way to proper dilution by the time it reaches the brain, but perhaps not completely diluted, so you might still see some osmotic pull from brain tissue that it comes in contact with in a bleed, thus possibly causing some additional injury. I would suspect that a greater amount of injury would come from the bleed itself anyway, so... one dose of 25g Dextrose (in whatever concentration you like) and a BGL now brought up to normal or a little higher, isn't going to be bad in the grand scheme of things while eliminating a cause of CVA symptoms.

And of course, if I'm wrong, them I'm wrong...

My thought was along the lines of you can always put more in but you can't take it out. If I hang a bag of D10, give 10 grams and find his BSL is still a fraction low or that it comes good but drops again in a few minutes I can always just open up the line and run some more in. Are there any issues with that line of thought?

 

[Akulahawk]

My thought was along the lines of you can always put more in but you can't take it out. If I hang a bag of D10, give 10 grams and find his BSL is still a fraction low or that it comes good but drops again in a few minutes I can always just open up the line and run some more in. Are there any issues with that line of thought?

We don't have D10 here in Sacramento in the field, at least the last time I worked here. I think I recall seeing a bag or two of D5W, but that would have been for reconstituting meds, not administration directly to a patient. Most of the companies here use D50. I don't shove that stuff in as fast as I can get it down the line. I open the line up a bit and push the D50 in slow, letting it dilute some. I also do it in 5-10 gm increments. I've noticed that most of the time, about when I have given about 20 gm, the hypoglycemic patient's lights turn back on...

I don't have any issues with your line of thought as it's actually similar to how I do it with D50, just the concentration of the med is different. And you're right. Any med you give can't be retracted. Always good to remember that, especially when you're giving meds that can profoundly and adversely affect your patient especially if you give the wrong med.

 

[Melclin]

We don't have D10 here in Sacramento in the field, at least the last time I worked here. I think I recall seeing a bag or two of D5W, but that would have been for reconstituting meds, not administration directly to a patient. Most of the companies here use D50. I don't shove that stuff in as fast as I can get it down the line. I open the line up a bit and push the D50 in slow, letting it dilute some. I also do it in 5-10 gm increments. I've noticed that most of the time, about when I have given about 20 gm, the hypoglycemic patient's lights turn back on...

I don't have any issues with your line of thought as it's actually similar to how I do it with D50, just the concentration of the med is different. And you're right. Any med you give can't be retracted. Always good to remember that, especially when you're giving meds that can profoundly and adversely affect your patient especially if you give the wrong med.

Good to know. I'll keep that in mind.

 

[mycrofft]

Tirate titrate titrate.

Isn't it ironic that one treatment used to be (is?) mannitol IV to help decrease cerebral edema? Of course, you want it INSIDE the blood vessels.
200mg/dL...in my former pt population (inmates), many were "surviving and operating" on the streets with blood sugars in excess of 200 all the time. They had a tendency towards other risky behaviors (alcohol and drug abuse, smoking tobacco, getting shot, etc) and the sequelae to long term diabetic apathy could be lost in (or exacerbated by) those behaviors too.
Hyperglycemia resembling a CVA? Please expand.

 

[Akulahawk]

Isn't it ironic that one treatment used to be (is?) mannitol IV to help decrease cerebral edema? Of course, you want it INSIDE the blood vessels.
200mg/dL...in my former pt population (inmates), many were "surviving and operating" on the streets with blood sugars in excess of 200 all the time. They had a tendency towards other risky behaviors (alcohol and drug abuse, smoking tobacco, getting shot, etc) and the sequelae to long term diabetic apathy could be lost in (or exacerbated by) those behaviors too.
Hyperglycemia resembling a CVA? Please expand.

I can see that happening, but I suspect you'd have to catch the patient at exactly the right time to see a good CVA mimic, if it occurs at all. More likely we'll just get a story of the lights slowly dimming.

 

[Smash]

By the letter of the law, ours is 15 first up followed by 10 titrated to response. 10% obviously.

The letter is designed for the lowest common denominator, who unfortunately are low, and common.
Tight glycaemic control in patients is a reasonably unclear and controversial area. In this case I don't really see that 3.9mmol/l warrants intervention, but if you did give something then I can't see why you would go ahead and give the full whack rather than a small titrated dose.
It's not an easy situation when your CI is pushing yo in a direction you don't want to go in. Keep calm and carry on, it'll be over soon.

 

[mycrofft]

TIght glycemic control invites a positive feedback cycle.

I worked the subacute section for six years, and our #1 headaches were unstable diabetics. We hated new doctors because they would start "chasing fingersticks" (rapidly responding to glucometry with insulin) when what needed doing was to give the pt either some sugar (if low), or if somewhat high, just wait a little longer for homeostasis to kick in and the extra sugar consumed to metabolize out. Rule of thumb was to let a new insulin regime, if it did not cause hypoglycemia, run for ar least three or four days before jiggering with it. We hospitalized as many diabetics for overzealous Rx as we did all othe reasons.

 

[Smash]

Indeed, it's the old "chasing numbers" problem, with providers wanting instant gratification over something that takes time to settle down. And then it's not even really clear what "tight" glycemic control constitutes, or even if it really matters that much.
I seem to recall that part of the problem is that we tend to aim for what a "normal" number would be, without taking into account what the body's normal stress response would be in the natural history of the disease process.
Anyhoo, as stated above, I think Melclin's reasoning is sound, but it's probably not worth the fight in the long run.

 

[Smash]

Oh, and in general I like the "can put more in, can't take it out" way of thinking with most meds, most of the time. Unless I need to correct acute midazopenia, in which case if some is good, more is better.

 

[MrBrown]

Brown proposes an easy fix - Smash becomes Melclin's CI

 

[Hunter]

Considering that this Pt did have a stroke I would not consider giving this PT D50 at all, seeing as I can't completely confirm wether or not its hemorrhagic stroke or an ischemic stroke since my truck doesn't come equipt with portable CV scans. I wouldn't even be as concerned about the hypo/hyperglycemia as I would with getting this Pt to the hospital. From a Medics point of view I would eventually get around to giving him some glucagen IM. But as BLS this would've been more of a scoop and go.

As far as a BSL of 70 that's not terrible... officially it should be 80-120mg/dl as far as my text book says but you also gotta remember that all Pt's are different, an instructor of mine had a patient once with a BSL of 15mg/dl and the guy was walking, talking and acting completely normal.