Dextrose

Vitamin

May 3, 2024

Welcome back to UH EMS-I’s Pharmacy Phriday. May is National Stroke Awareness Month, and in honor of that topic, we will direct the focus of this forum to the “Stroke/CVA” algorithm of the UH EMS Protocols for the next few weeks. In this installment, we will focus on Dextrose as it is referenced in the protocols.

During a suspected stroke emergency, the EMS provider has many important considerations to address, including but not limited to:

airway management and oxygenation
determining the last known well
completing the Cincinnati Prehospital Stroke Scale (CPSS)
completing a VAN + assessment if there were positive findings from the CPSS
limiting on-scene times to less than 15 minutes
if the patient is using anticoagulants
where the patient should be transported
relaying the results of the stroke exam to the receiving hospital and activating a “Stroke Alert,” “Brain Attack Team” (BAT) call, or “Code Brain Attack,” etc.

All of the above considerations are important steps in limiting the damage to brain tissue and meeting the time frames for the use of thrombolytics or possible mechanical thrombectomy.

Dextrose can play an important role in the assessment of the suspected stroke patient, as hypoglycemia can often mimic an acute stroke and can easily be diagnosed. In cases where glucose values are low, Dextrose is the answer. The condition must be corrected quickly or permanent brain damage and/or death can occur.

It should be understood that Dextrose should not be given to the stroke patient unless warranted by low glucose values (<70 mg/dl). Unwarranted Dextrose given to the stroke patient can cause lactic acidosis, damage to the penumbra, extend the infarct, and worsen the patient’s outcomes.

When warranted, Dextrose is provided for the advanced and paramedic-level EMS provider to administer in various concentrations. Administration of a D10 concentration is the first line of treatment under UH’s protocols when considering IV Dextrose. D50 remains a treatment option when the D10 concentration is not available.

Per UH protocols, the dosing of Dextrose in the adult hypoglycemic patient is based on the glucometer readings obtained during your initial assessment. Dosing will vary if the readings are <40 mg/dl (25 grams is called for) or in the range of 40-70 mg/dl (12.5 grams is called for).

In the case of the hypoglycemic pediatric patient, dosing is weight-based (see chart below). Remember that D10 is the only option for the neonate patient, while D25 can be mixed and used in other pediatric patients when D10 is not available. D50 should not be used in any pediatric patient.

When administering Dextrose to the hypoglycemic patient, choose a large vein and assure the patency of the IV. The IV push should be a slow push, watching carefully for any signs of extravasation or leaking into surrounding tissues. Dextrose is a hypertonic agent, even at concentrations of 10%, and can cause tissue necrosis if extravasation occurs. IO administration is referred to in the protocols but realize that this route of administration should only be used for situations of arrest or pre-arrest patients.

An additional use of Dextrose within the UH protocol is for cases of aspirin overdose. In such cases, glucose levels available to the central nervous system can be lowered even when serum glucose concentrations are normal. In accordance with the “Toxic Ingestion / Exposure / Overdose” algorithm, 12.5 grams of D10 are indicated if the patient has an altered mental status regardless of blood glucose readings.

Other items worth noting regarding the administration of Dextrose include:

Remember the need to administer thiamine in the potential alcoholic or malnourished patient.
Remember that any form of Dextrose is unlikely to maintain blood sugar for long after administration to a hypoglycemic patient. If not transported, the patient will need to eat.
Be sure to document glucometer readings before and after Dextrose administration.
Use Dextrose with caution if a patient is suspected of a head injury.
Shut off wearable insulin pumps, if present, when the patient is hypoglycemic.
Dextrose can be administered after glucagon if an IV is later established and the patient remains symptomatic.
5% Dextrose solution is provided in the drug boxes as a base solution for mixing drips in the field, not for treating hypoglycemia.

For more on stroke care in the pre-hospital setting, check out the Prehospital Paradigm episode from 2023. Have a great weekend and stay safe!

Sincerely,

The UH EMS-I Team

University Hospitals

November 3, 2023

Welcome back to UH EMS-I’s Pharmacy Phriday. As we continue our recognition of National Diabetes Month, we remain focused on diabetic emergencies. This week, we review the use of IV Dextrose for those emergencies.

Glucose is a simple sugar that is the primary carbohydrate used by the cells for energy. Low glucose levels in the blood mean hypoglycemia, cell dysfunction, and a potentially life-threatening event. The condition must be corrected quickly or permanent brain damage and/or death can occur. Dextrose is the answer! And a rapid answer! One should see the effects of the medication within minutes. As discussed before, for those patients who are conscious and still able to protect their airway and swallow, Oral Glucose is the first choice of treatment. But often, our patients are not able to take the oral glucose and require an IV and administration of IV Dextrose.

Dextrose is provided for the Advanced and Paramedic level EMS provider to administer in cases of hypoglycemia in various concentrations. Administration of a D10 concentration is the first line of treatment under UH’s protocols when considering IV Dextrose. D50 remains a treatment option when the D10 concentration is not available. Shortages have existed over the last year and can happen at any time, so it is wise to stay current on all possibilities.

Per UH protocols, the dosing of Dextrose in the adult hypoglycemic patient is based on the glucometry readings obtained during your initial assessment. Dosing will vary if the readings were <40 mg/dl (25 grams is called for) or in the range of 40-70 mg/dl (12.5 grams is called for). In cases where glucometry cannot be obtained, and the EMS provider is treating the patient based on signs and symptoms only, dosing can be titrated to a desired effect or relief of symptoms.

When administering Dextrose to the hypoglycemic patient, choose a large vein and ensure the patency of the IV. The IV push should be a slow push, watching carefully for any signs of extravasation or leaking into surrounding tissues. Dextrose is a hypertonic agent, even at concentrations of 10%, and can cause tissue necrosis if extravasation occurs. IO administration is referred to in the protocols, but realize that this route of administration should only be used for situations of arrest or pre-arrest patients.

An additional use of Dextrose included in the 2023 version of the UH protocol is for cases of Aspirin overdose. In such cases, glucose levels available to the central nervous system can be lowered even when serum glucose concentrations are normal. In accordance with the new/updated “Toxic Ingestion / Exposure / Overdose” algorithm, 12.5 grams of D10 are indicated if the patient has an altered mental status regardless of blood glucose readings.

Other items worth noting regarding the administration of Dextrose include:

Remember the need to administer thiamine in the potential alcoholic or malnourished patient.
As discussed in the previous article on Oral Glucose, remember that any form of Dextrose is unlikely to maintain a blood sugar for long after administration to a hypoglycemic patient. If not transported, the patient will need to eat.
Be sure to document glucometer readings before and after administration.
Use Dextrose with caution for patients suspected of having a stroke or head injury.
Shut off wearable insulin pumps if present when the patient is hypoglycemic.
Dextrose can be administered after glucagon if an IV is later established and the patient remains symptomatic.
A 5% Dextrose solution is provided in the drug boxes as a base solution for mixing drips in the field.

Have a great week and stay safe!!

Sincerely,

The UH EMS-I Team

University Hospitals