In pts with poor peripheral perfusion (ie. sepsis) can we do a blood sugar reading on pts ear? Recently had call where pt was severely septic and we gave glucagon and then dextrose and pts blood sugar kept going down. ER doctor took blood sugar on pts ear where perfusion was better then peripherally and sugar levels were well above normal.

I have a question in regards to the hypoglycemia directive. We were dispatched to a patient who suffered a fall, with history of diabetes. Upon assessment the patient was GCS 15, answering questions appropriately and oriented to person, place, time and event, however the patient was unable to move their limbs, and had loss of sensation in portions of the arms, torso, and legs, as well as a depressed skull fracture. The patient was hypovolemic and hypoglycemic at 3.2, stating he has not been eating or drinking fluids all day. Due to a complaint of back pain and paralysis, the a c-dollar was applied and scoop was used to extricate. Because the patient was secured to the stretcher supine, treating with oral gel was not an option, and transport was a priority. Some of the symptoms exhibited by the patient are concurrent with typical signs of hypoglycemia. In this situation where the patient is NOT altered, but hypoglycemic, with sufficient suspicion to suspect that low blood sugar may be causing some of the symptoms, would it be reasonable to treat the patient with IV dextrose? How do we proceed in situations where patients may be hypoglycemic, are not altered (GCS less than 15) but are unable to tolerate oral glucose or carbs? I can see this being the case for traumas.

If you attend to an unresponsive patient with diabetes paraphernalia (glucometer kit, dexcom, empty bag of candy, etc) on them and your glucometer is malfunctioning, do you have sufficient cause to administer dextrose or glucagon?

Hello and thank you for your time everyone. Module 2 point 2 reinforces the concept that high quality CPR is the primary focus for care of an opioid overdose VSA patient. However, It also highlights that naloxone may be administered as long as AHA guidelines for cardiopulmonary resuscitation are adequately being met. Given this point; is it o.k. for paramedics to administer naloxone for these type of VSA patients? The directive book and phone application Medical Cardiac Arrest directive continues to state, “There is no clear role for routine administration of naloxone in confirmed cardiac arrest”. I found it a little unclear whether this segment was reinforcing the concept to not administering naloxone for a VSA patient, or providing guidance that it is acceptable as long as other aspects of care are effectively delivered.

What is our responsibilities once a patient has been arrested under the mental health act? Is it considered implied consent? Are we responsible for vital taking, blood sugar and treatment if the BG is below four? Can the patient refused treatment with a decreased BG and a GCS of 14(confusion)?

Question: Could you please give clarification – On a VSA of a suspected opioid overdose, can we leave after the 1st analysis? Half my co-workers say yes and the other half says no, that you must stay to complete 4 analysis. I understand that early transport can be considered in medication overdose/toxicology. Where we are having difficulty with the interpretation of the protocol is “In cardiac arrest associated with opioid overdose, continue standard medical cardiac arrest directive. There is no clear role for routine administration of naloxone in confirmed cardiac arrest”. Some medics are saying that the “continue standard medical arrest directive ” means to complete 4 analysis. My interpretation is, no narcan and continue protocol, which is to consider early departure. Thanks

I am an PCP IV certified paramedic, working with a non IV medic. If we have a hypoglycemic patient do I need to attend & consider D10/D50 or can my non IV partner treat the patient with Glucagon instead? Same question for Gravol; do they need to get it IV or can non IV certified medic give it IM?

Do we really need to get a blood glucose on an actively seizing patient?

I was told during my I.V. course that it is O.K. to give dextrose immediately after Glucagon if an I.V. was achieved after Glucagon administration (failed I.V. attempts – give Glucagon – try another I.V. and succeed – give dextrose). Is this true? If so, would I have to record a new sugar reading prior to dextrose administration even if Im prepared to give dextrose immediately after glucagon? Would there be any changes to the number of max doses of either drug I could administer in this case.

Question: Im a recent graduate from the paramedic program and was wondering if I can get some feedback regarding the hypoglycemia treatment. The new protocol that came into play that now includes D10, I was curious what the reasoning was for choosing D10 over D50? Is there anything specific separating the 2 options of treatment?

Question: Can we draw up D10 in a 50cc syringe and administer it that way instead of going through the Buretrol?

Question: A couple questions with regards to D10. We have used D10 a few times now to treat hypoglycemia and have noticed some issues. It seems that for anyone with a BLG that is very low (say less than 2.0 for argument sake) the max dose of 10g will not get them over 4.0 mmol/L. Is there plans in the future to increase the dose? Perhaps something like if the patient is < 2.0 mmol/L then a 20g max or 4ml/kg loading dose followed by a 10g or 2ml/kg maintenance dose if necessary?

Second, with regards to Buretrol administration of D10, the process is very slow. Both the setup of the Buretrol and the infusion take quite a bit of time obviously more so if a second dose is required. Is there any reason a 60ml syringe can’t be used (draw up and push 60cc and follow up with 40cc) as a push administration instead of the Buretrol? For most situations the slow drip is okay but in the case of an agitated or aggressive patient the quicker option would be nice. I realize the benefits of D10 over D50 in not sky rocketing BGL but the way it is laid out now seems that we have gone too far the other way in not raising BGL enough.

Question: If we are presented with a hypoglycemic patient that demonstrates signs and symptoms of a TIA/CVA (slurred speech, inability to hold arms/legs up or due to confusion a grip test) and once the hypoglycemia is reversed with treatment and those signs and symptoms are gone, can we now deliver Ibuprofen/Acetaminophen or Ketorolac if the patient complains of CA related pain or muscle strain as per the Adult Analgesic Protocol?

Question: This question is in regards to hypoglycemia mimicking a stroke. You arrive on scene and the patient is presenting with the classic signs of a stroke such as facial droop, arm drift etc. Patient is out of the stroke protocol since GCS was <10, and the patient was terminally ill due to cancer, with a valid DNR. I obtain a BGL and the BS comes back as a 3.0mmol, so I correct the hypoglycemic event. Moments later a second BS was taken and it comes back as 4.1mmol. Another stroke assessment was done, with no signs and or symptoms of a stroke. Patient then complains of severe cancer related pain in her abdomen. My question is now, would I have been save in not giving the patient any NSAIDS since one of the contraindications was "CVA or TBI within previous 24 hours?" I ended up giving Acetaminophen since I thought doing something is better than nothing for the patients abdomen pain. Along with that, I didn't know if the patient experienced both a CVA and a Hypoglycemic event together at the same time, or if the patient experienced a stroke hidden in with the hypoglycemic event. What are your thoughts?

Question: In a situation where we are unable to get a blood glucose reading from the patient’s finger due to patient being combative/handcuffed, are we allowed to get it from the toes of the patient?

Question: If a patient is presenting with signs and symptoms of hypoglycemia (confusion, diaphoresis, pallor, tachycardia, etc.) and you find them with a BG of 4.5mmol/L, but family on scene states their normal BG is over 12mmol/L, and that they are presenting as they typically do when their blood sugar is low, AND you cannot identify from assessment/history any other reason for their current presentation, is it advised to give them oral glucose at this point if they are able to swallow?

Question: After the recent introduction of Narcan for PCPs, I’m still a little confused about the role of Narcan in an arrest. The 2010 AHA Guidelines state there is no role for Naloxone in cardiac arrest but the 2015 Guidelines are less prohibitive, leaving some room for interpretation. I understand that where there is question whether the patient is pulseless or not, there is a role for naloxone in the setting of presumed opioid overdose but what is the direction of base hospital for the use of naloxone where there is definite absence of vital signs in the setting of a PCP-only arrest. Is it the expectation of the base hospital that PCPs attempt to administer naloxone at some point during that call? If so, when during the cardiac arrest protocol? On scene or en route to hospital?

Question: In which instance should a transdermal patch be removed in the pre-hospital setting? Example 1: Hypotensive patient with a Nitro patch on. Example 2: VSA with a narcotic patch on. Example 3: Suspected OD with a narcotic patch on (or several).

Question: I have a question about postictal patients and cardiac monitoring. I have been told two things by several other partners in past few weeks. Assume you are a regular seizure patient whom you have seen many times and he/she is in their normal postictal state and you are not suspecting brain trauma. Is there any clinical reason/need to put cardiac monitor (e.g. limb leads) on? Also assuming you have a 1 min transport time. I was told as per BLS standard you “must” but in the postictal section it mentions that the paramedic may consider enroute. Thanks.

Question: Whilst completing my pre-course recertification material, we were asked a question with regards to blood glucose testing. Following administration of med for hypoglycemia, the question asked when next should you do a blood glucose test. I had guessed after 5 min although re-dosing would not be for 10 or 20 min depending on drug used. I guessed wrong apparently.

The other choices would have been:
a) With EVERY vitals post treatment (what about a long off load, we might do 3 or 4 more sets of vitals!)
b) After no improvement (no time noted and they might not show no improvement for a few minutes and sticking them after just two would be unnecessary)
c) Once at the hospital (that would disallow the re-administration of a second dose of treatment.)

Question: What is the Medical Director’s direction on doing repeated blood sugars after treatment for hypoglycemia? I recently had a patient who complained of chest pain after a fall. He was a diabetic with a GCS of 14 on initial assessment. His blood sugar was 3.8 and I treated him with oral glucose. He felt better and his GCS became 15. I got a comment back from an auditor who felt I should have done a follow up blood sugar after treating him. I was always taught that it was unnecessary to do a blood glucose if the patient had a GCS of 15. Has there been a change in thinking?

Question: This question is regarding not giving Narcan to a DNR patient. Obviously, if there is not an underlining medical issue (e.g. terminal CA) and a patient ODs, even with a DNR, we attempt to reverse any issues. However, if the patient does have a medical issue with a DNR, has decided to OD to commit suicide and is in a pre-arrest / arrested state, is it reasonable to assume that since they are breaking the law, that the DNR can no longer be valid?

Question: With regards to the administration of D50W. I was just curious if it has ever been to considered for us to titrate this drug for effect. By this I mean, if you are pushing the 10ml of D50 then flushing and repeating this until the entire 50ml is given it is assumed that you will likely notice positive effects of the drug before it is all given. So would we be better off to stop the infusion and re-check a blood sugar at this point to see if we have achieved a blood glucose above 4 or within normal range as opposed to giving the whole dose and pushing their blood sugars usually above 10.

Question: I have noticed a number of paramedics do blood glucose testing based on the hx of an event and not how the patient is presenting at the time of assessment. For example – hx of fainting, period of unresponsiveness, diabetic with N/V, etc. If the patient is not presenting with any of the indicators outlined in the hypoglycemia protocol should we be testing the patients blood glucose levels?

Question: I’m curious if it is recommended to take blood sugar readings on VSA patients? If a blood sugar is taken on a VSA patient, and the reading is < 4mmol/L (which may be quite common due to the sample being capillary and CPR not perfusing sugar to the extremities), do we treat with Glucagon or D50? What if we suspect the patient is VSA due to a diabetic event? Does the answer change whether I'm a PCP or an ACP? Thanks!

Question: This question was addressed at the end of January but I’m still unclear on the answer. In our protocol is discusses DKA and the patch point for pts from 2 to 12 for obvious reasons to me. It does not discuss any patient greater than 12. In the past if pt was DKA and showing signs of dehydration we could do a 10ml/kg bolus, then it was changed so that we had to patch for this bolus.

The previous question was weather or not we were doing boluses for adults and it was not addressed. There is no talk of it in our latest protocols. Can we go ahead and bolus an adult in DKA who is showing signs of dehydration without a patch or even with a patch?

Question: Why do we have a mandatory patch point for pediatric patients (> 2 but less than 12) with a blood sugar over 25 mmol/l and suspected to be in DKA for a fluid bolus but there is no patch point for adult patients.

Question: My question is regarding fluid bolus for DKA. Past practice has been to initiate a BHP patch for direction to administer a fluid bolus. The most recent Provincial Protocol states that a patch is only necessary for DKA in patients under 12. Are we still required to patch for a fluid bolus for adults in DKA?