Weird Call

C

colafdp

Forum Lieutenant
Messages
101
Reaction score
0
Points
0
Hi All, I'd like some people's insight into this call. Picked up a 60 y/o male this morning who was unresponsive...BGL was 1.9 mmol/L. I started a line then gave D50. Sugar came up to 3.0mmol with improvement in LOC. Everything else checked out relatively normal. Pt has hx of chronic subdural bleeds, NIDDM, and A Fib. He's also a bariatric patient.

His temp was 37.8C
BP - 130/66
SPO2 - 100% with 6lpm via Simple
Pulse 66-88bpm
ETCO2 - 37

En route to the hospital, his sugar once again dropped to below 2 mmol. Gave another amp of D50, along with the hanging D5W. Long story short, his sugars dropped twice more, and gave D50 each time, and it would come back up, but then start to drop again. We got him to the hospital and they did their usual blood work and CT. CT was unchanged from about 3 weeks previous. All blood work was within normal ranges. Insulin level was also fine.

I just don't know about this one, it just threw me off, and had no idea what to think of it. Any ideas? If I find out more, I will let you guys know. Thanks!
 
Last edited by a moderator:
Giddi said:
Insulin producing Tumor?

(forgot the latin name)
Click to expand...

Insulinoma.

More likely, it was an overdose of a hypoglycemic drug like metformin or the like.
 
Inaccuracy in meter? Testing site? I hate to say so, but human error?
 
emt.dan said:
Inaccuracy in meter? Testing site? I hate to say so, but human error?
Click to expand...

If the initial BGL was normal, the labs on admission to the hospital would have shown a high BGL after all that D50.

Yep, a weird call.

What was the patient's affect like? Did his mental status deteriorate with the drops in BGL en route to the hospital?
 
All in all, there were 4 glucometer's used (2 of ours, 2 in the hosp, plus the blood work) and his mental condition would deteriorate with the associated drops in BGL. I will be phoning the hospital later to see if they came up with anything.
 
abckidsmom said:
More likely, it was an overdose of a hypoglycemic drug like metformin or the like.
Click to expand...

Odd bit of pharmacology info here. Metformin, on it's own will not cause hypoglycemia, even in overdose, nor will some of the other diabetes meds. The Sulfonylurea class of diabetic medications will cause hypoglycemia if taken in excess, or not enough food is consumed.

I found that out one day after having a patient take a double dose of all of his medications (he forgot he had taken them earlier). It was one of the few times poison control has ever been helpful.
 
Aidey said:
Odd bit of pharmacology info here. Metformin, on it's own will not cause hypoglycemia, even in overdose, nor will some of the other diabetes meds. The Sulfonylurea class of diabetic medications will cause hypoglycemia if taken in excess, or not enough food is consumed.

I found that out one day after having a patient take a double dose of all of his medications (he forgot he had taken them earlier). It was one of the few times poison control has ever been helpful.
Click to expand...

I could not bring the sulfonylurea class to mind. That's what I was trying to say. I thought metformin was in that class. Thanks for clearing up my error.
 
How long was the transport time?
 
This is way out of my pay grade, but...you mention the PT was bariatric. Maybe because of his size the standard doses of dextrose just weren't enough to maintain his BGL? I'm probably way off here but it's just a thought.
 
I know you said his hx was NIDDM, but I wonder if he had recently started supplementing his oral DM meds with insulin, and perhaps self-administered too much.
 
I don't know, I'm not a doctor ..... yet.

Surpised you are still using D50 we changed to D10 years ago
 
MrBrown said:
I don't know, I'm not a doctor ..... yet.

Surpised you are still using D50 we changed to D10 years ago
Click to expand...

How many grams do you give? Or you just run a D10 drip? I've had several patients this year who required more than 1 dose of 25g D50...that would have been a LOT of D10.
 
MrBrown said:
We give 100ml of 10% glucose as standard
Click to expand...

100ml?!?! Standard? So you has to give 500ml to give as much dextrose as I give in 50ml.

So, based on that, since I have had pts that required 100ml of D50 over the course of a transport, you would have to give 1000ml in that same time? What if you had a diabetic with CHF? You would drown them. :blink:

Or am I way off here? :unsure:
 
lightsandsirens5 said:
100ml?!?! Standard? So you has to give 500ml to give as much dextrose as I give in 50ml.

So, based on that, since I have had pts that required 100ml of D50 over the course of a transport, you would have to give 1000ml in that same time? What if you had a diabetic with CHF? You would drown them. :blink:

Or am I way off here? :unsure:
Click to expand...

Even most chronicly ill folks can handle a liter of fluid without too much of a problem. Many times the first line in hospital treatment of cardiogenic shock is a fluid bolus.

The general idea behind D10 is that 1: very few patients need 50gms of dextrose and 2: D10 is MUCH easier on the pt's vasculature.

How long was your transport? His temp looks to be slightly elevated. If the pt was in a hypermetabolic state, he may have simply been burning off the dextrose. It's not a paticularly long acting med, and why we advise pt's to eat before not transporting hypoglycemic pt's.
 
With the BGL still tanking and the low grade fever leads me to believe it was probably an infection. Certain infections can consume most of the body's glucose. had a call similiar to this once, unfortunately we only carry two amps of D50. I wonder whats his labs looked like and if he had any other signs of infection.
 
usalsfyre said:
Even most chronicly ill folks can handle a liter of fluid without too much of a problem. Many times the first line in hospital treatment of cardiogenic shock is a fluid bolus.
Click to expand...

1/2 of all patients on dialysis in this country are there because of diabetes. For those on hemodialysis 1 liter a day is a common recommendation for their MAX fluid intake (including fluid in foods, like soup or watermelon). I wouldn't want to be dumping a liter into them.
 
Aidey said:
1/2 of all patients on dialysis in this country are there because of diabetes. For those on hemodialysis 1 liter a day is a common recommendation for their MAX fluid intake (including fluid in foods, like soup or watermelon). I wouldn't want to be dumping a liter into them.
Click to expand...

Who said anything about "dumping" a liter of fluid into these patients. Fluid should be given in a controlled manner with frequent reassessment to everyone.

In addition, max daily fluid intakes are based on a chronic, day in, day out basis with a set time between dyalisis. Acute injury or illness will by nature change the body's requirements, and fluid balance should be adjusted accordingly, in either direction.
 
Hypoglycemia does not really constitute an injury or illness that increases the body's need for fluid by that much.

Here is the issue I see with using D10 exclusively. You've got someone who is hypoglycemic, and the first reaction of EMS is to fix it, and fix it quickly. Not everyone is going to dump in the 1000mls as fast as they can, but plenty of people would. Sure, it could be addressed through protocols, but people would still push the fluid in as fast as they can.

My use of "dumping" is a reflection of how I know it would be administered by people who are thinking about the amount of sugar, and not fluid.
 
You must log in or register to reply here.
Back
Top