2. PCP March 9, 2012

3. You are dispatched Code 3 for a Diabetic, at 0730….You arrive at a Gold River townhouse and are led by the parents to the upstairs. They state their son is a insulin dependent diabetic and has been sick for two days with flu like symptoms. This morning they could not wake him and he sleep thru his alarm and they called for a Ambulance. You find a 13 year old male, lying supine in bed……… Case Study

4. Lets discus the symptoms... What do you expect? Break out Groups Case Study

5. The parents also tell you he went to bed early last night, and skipped his bedtime snack. Last night his blood sugar was 4.1 mmol/l. On Exam: No evidence of trauma Loc—Groans to painful stimulus Airway—Inadequate, snoring-will not take an airway positioned ¾ prone—airway clears Breathing—Adequate Circulation—Easily felt radial pulse/rapid RBS—unremarkable

6. What do you think now? Break out Groups Case Study

7. Should you initiate your Diabetic emergencies Protocol or should you load and go? What are the 5 things you must have done to initiate your protocol?

8. On further Exam: IDDM since the age of 8 years old, sick for 2 days, infrequent episodes of hypoglycemia that are usually resolved with food. The patient has never required an ambulance before. Vitals—108/64, Pulse 96 regular and easily felt, respirations are 20 regular and adequate, skin is pale, cool and clammy, GCS 1,2,4 = 7, O2 sat on high flow o2 is 99% Blood glucose is 1.7 mmol/l

9. What do you need to know? Break out Groups Case Study

10. Patient takes Humulin N and R on a sliding scale in the morning and evening. He has also been taking Ibuprofen for the last 2 days. The Patient has no drug allergies. No other medical conditions.

11. You start administering gluco-gel….. A blood glucose of what indicates using D10W and not Normal saline? What is our first choice, IV dextrose (D10W) or glucagon? If a line is established how much D10W do we administer? What else do we give with the first 100 ml of D10W? Over what time frame to we give this? If you miss the IV what do you do? Do we do the above steps on scene or en route to the hospital?

12.  So back to the patient:  Were having a bad day and miss our IV attempts:

13. What do you do now? Break out Groups Case Study

14. Drug Monograph: Glucagon Classification: Hyperglycemic Agent (antihypoglycemic) Mechanism: Pancreatic Hormone, which acts on the glycogen in the liver, converting it to glucose. Producing a temporary rise in blood glucose. (Glycogenolysis) Indication: Hypoglycemia (if unable to establish an IV for ACP and PCP and hypoglycemia when patient is unable to obey commands) Contraindications: Known allergy to Glucagon Pheochromocytoma (an adrenal gland tumor, can cause sudden and marked increase in BP)

15. Glucagon Drug Monograph: Glucagon Route and Method: SC/IM (ACP, PCP) Onset/Duration: IM 8-15 minutes, 10-30 minutes SC—similar to IM (a little slower) Elimination: rapidly degraded by the liver, kidneys and in the plasma. Half life 3-6 minutes in plasma

16. Dose: Patients > 20 kg—1.0 mg Patients < 20 kg—0.5 mg Side Effects: Nausea and Vomiting (common) (infrequent) Hypokalemia, Generalized allergic reaction Hypertension, Hypotension Diarrhea Increased pulse and BP (rare)Hypoglycemia

17. How much Glucagon do we give to this patient? What are the doses and weight guidelines?

18. We give the glucagon—What routes can we use? What do we do next? We initiate transport, it has been about 5 minutes after Glucagon administration, we do another set of Vitals and find: BP-105/68Pulse-92 Resp-20 Skin-Pale, cool, clammyGCS-1,2,4 = 7 Pt is unable to follow instructions, O2 saturation is 99% on high flow O2

19. SC injection Where?

20. Another 5 minutes goes by: Current Vitals: 110/70, pulse 88, resp 18, skin is pale cool and dry, GCS is now 4,4,6 = 14, o2 sat 99% Blood glucose is now 3.9 mmol/l Patient is now able to follow instructions, what do you do now?

21. So back to the patient: You have given gluco-gel and you are well on the way to the hospital…current vitals are now: BP-110/72 Pulse-82 Resp-18 Skin-Normal, Cool, Dry GCS- 4,5,6 = 15, O2 sat 99 % on high flow The patient is able to follow instructions, things are looking pretty good! The rest of the trip to the hospital is uneventful….

22. Can glucagon be repeated if the patient doesn’t respond to the first dose? Do we give thiamine after administering Glucagon? What are the chances of an overdose? If a patient doesn’t respond to IV glucose do we give Glucagon? Can Glucagon or IV dextrose be used in the NYD protocol? Case Study

23. Glucagon is only effective if the patient has adequate stores of glycogen, what conditions cause depleted glycogen stores? What else is in the glucagon solution that we are giving? Will glucagon be effective if a patient has had a hypoglycemic reaction in the last 24-48 hours? Case Study

24. IINDICATIONS Known diabetic patients with decreased LOC whose history suggests hyperglycemia or hypoglycemia Diabetic Protocol

25. Before initiating the Diabetic Emergencies protocol, you must have done or obtained the following: (5) AA primary survey AA history of diabetes CCritical History AA baseline set of vital signs SSigns and symptoms sufficient to suggest hypoglycemia or hyperglycemia

26. What do you think now? Break out Groups Case Study

27. CONTRAINDICATIONS (2)  Peripheral IVs are contraindicated in patients under 12 years.  Glucagon is contraindicated in persons known to be allergic to Glucagon

28. PROTOCOL Blood Glucose > 4.0mmol/L Blood Glucose < 4.0mmol/L Initiate transport Administer oral glucose Initiate IV N/S en route Initiate IV D10W administer 100ml rapid infusion & 50mg Thiamine IV before D10W infusion is complete Administer IV N/S at maintenance rate Continue with further assessment & tmt If IV is contraindicated or if IV cannot be obtained, administer 1mg SC Glucagon (>20kg) or 0.5mg SC (<20kg) Initiate transport Continue with assessment & tmt en route LOC improves Administer IV D10W at 100ml/hr Continue with assessment & tmt No Improvement Administer second 100ml D10W rapid infusion -Maintain IV D10W at 100ml/hr -Continue with assessment & tmt -Repeat Glucometer testing If no improvement consider causes of unconsciousness Contact Emergency Physician for further orders

29. Hypoglycemia versus Hyperglyemia Hypoglycemia  Onset Sudden  Skin cold, pale, moist  Normal  Weak, rapid pulse  Weakness/ uncoordinated  Headache  Irritable/Nervous Behavior Hyperglycemia  Slower onset  Skin warm, red, dry  Acidic Breath  Kussmaul’s Respirations  Rapid Pulse  Polyuria, polydypsia, polyphagia  Nausea/Vomiting  Falling Blood Pressure