Emergency Medical Services. Группа авторов
Treatment should be aimed at restoring glucose levels to a normal range, continued monitoring of glucose levels, and transport to an ED for continued monitoring and care. Unrecognized profound hypoglycemia carries a significant risk of hypoglycemic encephalopathy, causing lifelong cerebral dysfunction [41]. Recurrent hypoglycemia has been reported for 2‐3 days in patients with massive overdoses [42–44].
Disposition
The disposition of diabetic prehospital patients with successfully corrected hypoglycemia has been controversial. The concern for adverse outcomes, recurrent hypoglycemia, poor access to care, and possible litigation has fueled the discussion. A retrospective analysis, relying on 2013 data from the National EMS Information System and additional national surveys, found that approximately 20% of prehospital patients treated for hypoglycemia are not transported from the scene [45]. The practice of releasing treated hypoglycemic patients appears to be safe, particularly in the context of structured “treat and release” protocols [1,46–48].
A study of the reasons for EMS nontransport after a 9‐1‐1 call demonstrated that diabetic calls represent approximately 9% of nontransports. Previous studies had reported diabetes accounting for 2%‐7% of nontransports [49]. Studies examining the outcomes of patients who refuse transport reveal that they are no more likely than transported patients to experience recurrence of hypoglycemia or to require later care. Through these studies, a set of reasonable guidelines have been derived for refusal of care instructions. A patient should be able to eat, have a responsible adult who will remain with him or her, and not have any condition that would predispose the patient to a repeat episode, such as persistent vomiting. Additionally, the patient should receive written instructions directing physician follow‐up [1, 50, 51]. Research has shown that patients prefer a protocol that allows discharge of hypoglycemic patients without transport to the ED [52]. The burden of hypoglycemia to the health care system could potentially be reduced with implementation and appropriate use of EMS treat‐and‐release protocols, along with programs to educate patients on hypoglycemia risk factors and emergency preparedness [45]. EMS systems should develop specific guidelines for patient refusal after hypoglycemia treatment. The most important elements for these prehospital guidelines are summarized in Table 20.3.
Table 20.2 Pediatric dextrose administration
Source: Courtesy of The Office of the Medical Director, Austin/Travis County EMS System.
| Dose 1.0 g/kgConcentration is 1 g/10 mL in 250 mL bag sterile water (D10W)Must use volume control device (IV burette) for infusionTitrate to patient’s condition and response | ||||||||
|---|---|---|---|---|---|---|---|---|
| Patient weight | 3 kg | 5 kg | 7 kg | 9 kg | 11 kg | 13 kg | 15 kg | 17 kg |
| Desired dose | 1 G | 1 G | 1 G | 1 G | 1 G | 1 G | 1 G | 1 G |
| Grams Dextrose | 3 g | 5 g | 7 g | 9 g | 11 g | 13 g | 15 g | 17 g |
| mL D10w | 30 mL | 50 mL | 70 mL | 90 mL | 110 mL | 130 mL | 150 mL | 170 mL |
| Patient weight | 19 kg | 21 kg | 23 kg | 25 kg | 27 kg | 30 kg | 33 kg | 35 kg |
| Desired dose | 1 G | 1 G | 1 G | 1 G | 1 G | 1 G | 1 G | 1 G |
| Grams Dextrose | 19 g | 21 g | 23 g | 25 g | 25 g | 25 g | 25 g | 25 g |
| mL D10w | 190 mL | 210 mL | 230 mL | 250 mL | 250 mL | 250 mL | 250 mL | 250 mL |
Table 20.3 Key elements for safe discharge after treatment for hypoglycemia
| History of insulin‐dependent diabetes mellitus.Return of normal mental state within 10 minutes of dextrose administration.Pretreatment blood glucose less than 80 mg/dL.Posttreatment blood glucose greater than 80 mg/dL.Ability to tolerate food by mouth.Absence of comorbid conditions or complicating factors.The patient has follow‐up with a primary care physician.No use of sulfonylurea medications.Normal vital signs after treatment.Patient understands discharge instructions.Patient has a responsible adult to monitor him/her. |
Protocols
EMS protocols should clearly provide appropriate assessment and treatment guidelines. Symptomatic hyperglycemia mandates administration of IV fluid and transport to a hospital. When hypoglycemia is encountered, treatment protocols should include administration of dextrose in some form (D50W, D25W, or D10W) if IV access can be obtained, or the administration of glucagon when IV access cannot be obtained. Policies concerning treat‐and‐release protocols or transport refusal in patients successfully treated in the field should be very clear and well understood by all personnel. A robust quality management program is necessary to monitor compliance with clinical standards, evaluate appropriateness of clinical decision making, and identify opportunities for improvement.
Summary
Diabetes mellitus is a highly prevalent chronic disease in the United States, responsible for large expenditures of health care dollars. Diabetic emergencies are frequently encountered by EMS clinicians, with hypoglycemia being the most common. It is imperative for EMS clinicians to be adequately prepared and trained to manage such conditions. The primary evaluation starts with the 9‐1‐1 call taker, who may be able to gather crucial