Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Comment on Irresponsibility and Intubation – The EMS Standard Of Care

 

I wrote about the petition to protect paramedic incompetence in Irresponsibility and Intubation – The EMS Standard Of Care

Nathan Boone responded with the following comment
 

You’re forgetting about the rural medic out there.

 

No. I am not.

Are you suggesting that bad airway management for a longer period of time is less harmful than bad airway management for a shorter period of time?
 


 

Where we are with our patients for more then a hour, not 5 mintues.

 

The harm from incompetent airway management does not depend on distance from the hospital. Intubation even kills patients in the hospital.

You may believe that the efficacy of voodoo is directly related to the distance from the hospital, but it appears to be only your belief that increases.

Voodoo does not work, regardless of the distance from the hospital.

If the paramedic cannot manage an airway, the paramedic should not be permitted to intubate.
 

Sometimes air- craft isn’t available if its raining or on another call.. You want us to use a bvm and take chance of filling the patients stomic up for over a hour.. Yes we can be extremely careful and do everything in our power not to fill the stomic but there’s some patients out there who have difficult airways where bagging can be extremely difficult and or impossible.

 

Give incompetent paramedics dangerous tools to try to manage difficult airways because of distance? Wouldn’t it be better to try to make them competent – or to limit intubation to competent paramedics?

Intubation and BVM (Bag Valve Mask) are not the only forms of ventilation.
 

Rsi does save patients in rural areas, we need intubations..

 

Maybe. Maybe not. Maybe RSI kills more patients than it saves.

Actually, what I mean to write is, Maybe paramedics using RSI kill more patients than they save.

If you want to claim otherwise, prove it with high-quality research.

Unless you can provide high-quality research, your plastic airway religion is just another alt-med scam.

If your patients are important, then you need to demand that we find out what is best for the patients.
 

Do I believe that Rsi is risky and their is some medics out there who would rather make the patient more hypoxic then before until they give up and go to a secondary airway..absolutely.. But to take it away from Rural Medics when we can have anything to burn patients to anaphylactic reactions and to take our ONLY definitive airway;away from us..

 

You seem to think that RSI (Rapid Sequence Induction of anesthesia) becomes less risky the farther you are from the hospital.

Why?

Incompetence for a longer period will be expected to cause more harm.

Sometimes the incompetence of the paramedic doesn’t kill the patient.
 

Trauma patients were significantly more likely to have misplaced ETTs than medical patients (37% versus 14%, P<.01). With one exception, all the patients found to have esophageal tube placement exhibited the absence of ETCO2 on patient arrival. In the exception, the patient was found to be breathing spontaneously despite a nasotracheal tube placed in the esophagus.[1]

 

The patient clearly did not need intubation.

As with the crash of Trooper 2 in Maryland, the survival of the patient for hours in the woods, in the rain, following the helicopter crash that killed all of the other healthy people on board, was clear evidence that there was no reason to send this patient to the trauma center by air.

The same argument was provided by people, including Dr. Thomas Scalea, the head of Shock Trauma – If you don’t let us have our toys, people will die![2]

The rate of helicopter transport of trauma patients was dramatically cut.

That was almost a decade ago and we are still waiting for the dead bodies.

I expect that the same failure of prophesy will occur, when incompetent paramedics are prevented from intubating.

I expect that the fatality rate will decrease, when incompetent paramedics are prevented from intubating.
 

I think you’re out of your mind.

 

Many religious fanatics do.
 

In the city, I can maybe defend you. But the studies need to be done out in the sticks as well. I believe that we should have to go outpatient surgery every year or 2 or have number set of how many we need in that time period successfully to keep our skills sharp..

 

Every year or two?

WTF?

You don’t want to be taken seriously, do you?

This is something that requires a lot of skill and practice, so I get just a tiny bit, every other year. Trust me with your life.
 

After a Rsi and I have no one in the back but myself for over an hour.., I can place the patient on a vent and care for my patient. If RSI is taken away. I loose the capability to monitor my patient, and would be more focused on bagging my patient, or making sure the secondary away isn’t failing and I’m filling the stomic on the vent, because it can happen.

 

It is just a staffing issue.

That is different.

Competence isn’t needed when you are in the back by yourself.

Why are you opposed to competence?

Where is a single reasonable argument that intubation improves outcomes?

Where is a single reasonable argument that rural paramedics have an intubation success rate that is above 95%?

Even 95% means that some of your patients don’t end up with a properly placed endotracheal tube. What do you think happens to them?

Does your EMS agency have a better than 95% intubation success rate?

If you can’t manage at least 95%, why do you believe you can manage intubation?

Is each intubation on video, or do they just believe whatever you tell them?

If you want to be taken seriously, these are just some of the essential points to address.
 

This is not a new topic. You might also read the series below:

In Defense of Intubation Incompetence – Part I

In Defense of Intubation Incompetence – Part II

In Defense of Intubation Incompetence – Part III

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part I

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part II

Footnotes:

[1] Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.
Katz SH, Falk JL.
Ann Emerg Med. 2001 Jan;37(1):32-7.
PMID: 11145768 [PubMed – indexed for MEDLINE]

Free Full Text PDF

[2] Helicopters and Bad Science
Thu, 09 Oct 2008
Rogue Medic
Article

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Acute coronary syndrome on Friday the 13th: a case for re-organising services?

ResearchBlogging.orgAcute coronary syndrome on Friday the 13th - a case for re-organising services 1
 
There has been a bunch of research on the likelihood of bad things happening on Friday the 13th. These researchers thought that the big problem with all of the available research is that the populations studied have been too small. The authors took information on over 56,000 patients with acute coronary syndromes, broke them down into 217 day/date combinations (Friday the 1st, Saturday the 1st, . . . ,Wednesday the 31st, Thursday the 31st), and compared the outcomes of those 216 groups with their Friday the 13th group.

Cut to the conclusion –
 

Conclusion: On most days, there was no difference in the 13-year mortality rate for patients admitted with their first ACS from that for “unlucky” Friday the 13th. However, patients admitted on five day/number combinations were 20-30% more likely to survive at 13 years. These findings could be explained by subgroup analysis inflation of the type I error, although supernatural causes merit further investigation.[1]

 

No. Supernatural causes do not merit further investigation, at least, not based on anything in this paper.

The authors used Friday the 13th as their normal date for comparison with every other date, but the outcomes from Friday the 13th are not the true statistical mean. The outcomes on Friday the 13th were just chosen because of the superstition being investigated. Friday the 13th is so close to the statistical mean that this mistake is easy to make.
 

Surprisingly, however, we also identified five potentially “lucky” days on which mortality rates were significantly lower, by 20-30%.[1]

 

When analyzing 217 samples, it is not surprising that some of the data deviate from average by an amount that is expected to produce no more than one significant deviation out of every twenty comparisons. The authors had over 200 comparisons, so we should not have been surprised by up to 11 day/date combinations with p values of less than 0.05. There were only 5. Should anyone go looking for supernatural explanations for statistically normal outcomes?

While Friday the 13th was not the statistical mean, it was very close. Look at the five potentially “lucky” days and how close the ranges are to 1.00. If the range crosses (includes) 1.00, the results are not statistically significant according to the prospectively determined criteria of the authors. Crossing 1.00 is just another way of expressing P <0.05. Sunday the 1st and Monday the 29th each produced outcomes 29% worse than Friday the 13th. Saturday the 31st produced outcomes that were 36% worse. If we compared these with the actual statistical mean, Monday the 29th and Saturday the 31st become significantly “unlucky” using a p value of less than 0.05 and all of the significantly “lucky” days become insignificant.

As we should expect, the most extreme benefit and harm both fall on the 31st. Only 7/12 (58.3%) of months have 31 days, so these days have much smaller sample sizes. With smaller samples, the appearance of deviance is expected to be greater. The actual deviation is less important, because the sample size is smaller.

Friday the 13th is only slightly different from the statistical mean, using the data in this paper, which may be the largest examination of a possible Friday the 13th effect.

Once again, the biggest problem with Friday the 13th is that we end up listening to people promoting superstition.
 

I have also written about this kind of superstition here –

The Magical Nonsense of Friday the 13th – Fri, 13 May 2016

Happy Friday the 13th – New and Improved with Space Debris – Fri, 13 Nov 2015

Friday the 13th and full-moon – the ‘worst case scenario’ or only superstition? – Fri, 13 Jun 2014

Blue Moon 2012 – Except parts of Oceanea – Fri, 31 Aug 2012

2009’s Top Threat To Science In Medicine – Fri, 01 Jan 2010

T G I Friday the 13th – Fri, 13 Nov 2009

Happy Equinox! – Thu, 20 Mar 2008

Footnotes:

[1] Acute coronary syndrome on Friday the 13th: a case for re-organising services?
Protty MB, Jaafar M, Hannoodee S, Freeman P.
Med J Aust. 2016 Dec 12;205(11):523-525.
PMID: 27927150

Protty, M., Jaafar, M., Hannoodee, S., & Freeman, P. (2016). Acute coronary syndrome on Friday the 13th: a case for re-organising services? The Medical Journal of Australia, 205 (11), 523-525 DOI: 10.5694/mja16.00870

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2016 – Amiodarone is Useless, but Ketamine Gets Another Use

amiodarone-edit-1
 

I didn’t write a lot in 2016, but 2016 may have been the year we put the final nail in the coffin of amiodarone. Two major studies were published and both were very negative for amiodarone.

If we give enough amiodarone to have an effect on ventricular tachycardia, it will usually be a negative effect.[1]

Only 38% of ventricular tachycardia patients improved after amiodarone, but 48% had major adverse cardiac events after amiodarone.

There are better drugs, including adenosine, sotalol, procainamide, and ketamine for ventricular tachycardia. Sedation and cardioversion is a much better choice. Cardioversion is actually expected after giving amiodarone.

For cardiac arrest, amiodarone is not any better than placebo or lidocaine. What ever happened to the study of amiodarone that was showing such wonderful results over a decade ago? It still hasn’t been published, so it is reasonable to conclude that the results were negative for amiodarone. It is time to make room in the drug bag for something that works.[2],[3]

On the other hand, now that we have improved the quality of CPR by focusing on compressions, rather than drugs, more patients are waking up while chest compressions are being performed, but without spontaneous circulation, so ketamine has another promising use. And ketamine is still good for sedation for intubation, for getting a patient to tolerate high flow oxygen, for agitated delirium, for pain management, . . . .[4],[5]

Masimo’s RAD 57 still doesn’t have any evidence that it works well on real patients.[6]

When intubating, breathe. Breathing is good. Isn’t inability to breathe the reason for intubation?[7]

Footnotes:

[1] The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia
Wed, 17 Aug 2016
Rogue Medic
Article

[2] Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest
Mon, 04 Apr 2016
Rogue Medic
Article

[3] Dr. Kudenchuk is Misrepresenting ALPS as ‘Significant’
Tue, 12 Apr 2016
Rogue Medic
Article

[4] What do you do when a patient wakes up during CPR?
Tue, 08 Mar 2016
Rogue Medic
Article

[5] Ketamine For Anger Management
Sun, 06 Mar 2016
Rogue Medic
Article

[6] The RAD-57 – Still Unsafe?
Wed, 03 Feb 2016
Rogue Medic
Article

[7] Should you hold your breath while intubating?
Tue, 19 Jan 2016
Rogue Medic
Article

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Should you hold your breath while intubating?

 

This is one of the ancient bits of street wisdom common sense about intubating. If you hold your breath while intubating, you will know when the patient needs to take a breath.

As with much of common sense, it is based on mythology.
 

Never take more than 30 seconds per attempt at each intubation!
Hint: Hold your breath while intubating – when you need to take a breath, so does the patient!
[1]

 

60 pct of the time, it works every time 1
Typical intubation instructor?
 

Obviously, this idea came about long before apneic oxygenation. No, . . . . Wait, it could be that apneic oxygenation came first, since papers were being written about apneic oxygenation long before paramedics were sent out to spread the word of the benefits of unrecognized esophageal intubation close enough for prehospital intubation.[2],[3],[4]

It could be that some anesthesiologists thought breath holding while intubating was a good idea, but I did not find any papers.

Apneic oxygenation can prevent desaturation for much longer than 30 seconds, yet many of us still emphasize fast and bloody, rather than slow and benign.

If the patient can hold her breath for as long as I can, she may be breathing as well as I am breathing, and may not need to be intubated. How do I really know when my patient needs to take a breath?

If I can only hold my breath for as long as a patient who needs to be intubated, then I may be breathing as badly as she is, and I may need intubation more than she does. How long can a paramedic hold his breath before becoming hypoxic and/or confused? How good am I at recognizing this change when I am focused on putting the little plastic tube in the slightly larger cartilage and flesh tube?

If the patient does not need to be intubated, why intubate? If I need to be intubated, should I be the one intubating anyone else? If I can hold my breath longer than the average paramedic, should I take up smoking to make this technique work for me? Should we be testing paramedics on how long a breath can be held as part of the hiring process?

I am shocked that such a simple one size fits all approach fails to consider even one of the many variables that would affect its use. How could that possibly happen in EMS?

Footnotes:

[1] Widely circulated, unwritten paper
The Mythbuilders of EMS
Trust us.
We know what we’re doing.

[2] Oxygen uptake in human lungs without spontaneous or artificial pulmonary ventilation.
ENGHOFF H, HOLMDAHL MH, RISHOLM L.
Acta Chir Scand. 1952 Jul 14;103(4):293-301. No abstract available.
PMID: 12985091

[3] Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea.
HOLMDAHL MH.
Acta Chir Scand Suppl. 1956;212:1-128. No abstract available.
PMID: 13326155

[4] Apneic oxygenation in man.
FRUMIN MJ, EPSTEIN RM, COHEN G.
Anesthesiology. 1959 Nov-Dec;20:789-98. No abstract available.
PMID: 13825447

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Why EMS Should Limit the Use of Rigid Cervical Collars

 
Well, should EMS limit the use of rigid cervical collars?

As with the rest of anecdote-based medicine, or hunch-based medicine, we have been doing this for decades without any evidence of benefit. Do we know what we are doing?

But you have to prove that this is harmful, otherwise we cannot withhold the standard of ignorance.
 


Image credit.     Regardless of brand. A perfect fit – every time. Right?
 

Where does the burden of proof rest? In medicine, it is supposed to be the responsibility of the person treating to convince the patient that the treatment is more likely to be beneficial than harmful. This is informed consent. Informed consent is often overlooked and replaced with a blanket consent for the doctor (or designee, such as nurse, EMT, medic, . . . ) to do whatever the doctor thinks is a good idea.

Is there any valid evidence that a backboard, or KED (Kendrick Extrication Device), or rigid cervical collar will improve any outcome?

Not for the backboard or KED, but we know that the rigid cervical collar is beneficial because it stabilizes the neck and we would not use it if it didn’t work.

That is the same excuse made for using a backboards, or a KED, without evidence. Is there any valid evidence?

Can I get back to you on that?
 

Even though there should be no need to go further in criticizing rigid cervical collars, in the medical fields, we like to believe that what we have been doing is good and not harmful, because we don’t want to think of ourselves as harming our patients. Ironically, this attitude stops us from eliminating harmful treatments. We harm our patients to protect ourselves from having to admit that we were harming our patients.

For those who insist on evidence of harm, Dr. Bryan Bledsoe and Dr. Dale Carrison have provided us with a thorough evidence-based explanation of the ways that rigid EMS collars can harm our patients.
 

Interestingly, one of the first protocols that significantly changed spinal immobilization practices came out of several EMS agencies in Northern California. In a rather sweeping protocol change, they elected to forgo rigid C-collars and use soft collars.[1]

 

Do rigid cervical collars decrease manipulation of the neck/spine? Do rigid cervical collars protect patients from disability?

Read the article for a discussion of the evidence and of what we assume.

The argument in favor of backboards and collars is similar to the argument in favor of mandatory vaccination for school. It is a minor inconvenience for many, that protects against death/disability of some.

There is plenty of evidence for the vaccine argument. Vaccines are safe. Vaccines save lives. Vaccines are worth it. What about rigid EMS collars? Do they protect against death/disability?
 

Go read the article and find out.
 

Dr. Bledsoe and Dr. Carrison provide plenty of evidence to support their conclusions. What do the supporters of rigid cervical collars have?

Footnotes:

[1] Why EMS Should Limit the Use of Rigid Cervical Collars
Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P and Dale Carrison, DO, FACEP
Monday, January 26, 2015
JEMS
Article

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If We Pretend that Anecdotes are Not Anecdotes, Do We Change Reality?

 

The following comment was written by Duke Powell in response to Where is the Evidence for Traction Splints?
 

I’ve been an urban paramedic for 34 years and, prior to that, a volunteer EMT for 9 years. For those who can’t add, ….that’s a long time.

How many times have I used a traction splint? …… I dunno, let’s guess 10 times.

 

That works out to an average of over four years between uses of the traction splint. That is plenty of time to have the memory of each use reconstructed many times, so that the memory and the reality may not have much in common. Each time we remember something, we recreate and modify the memory.
 

Several years ago, after several years of not even thinking about traction splinting, I found myself using it 3 times in 2 weeks.

Did it help? Yep, clinically, in my opinion, it helped.

 

Maybe it helped the patients. Maybe it harmed the patients. Maybe it helped some patients and harmed other patients. Maybe it helped the pain, but caused longer term harm. We do not know.

Without valid evidence, especially evidence of something more than the superficial appearance of improvement, we have no idea. We can use our imaginations and generate opinions, but we are merely discussing opinions.
 

Will Rogue Medic call my experience “anecdotal” and not worthy of consideration? Yes, he will.

Don’t care what the Rogue Medic thinks.

I care about what my patients and my Medical Director thinks.

 


Image credit.
 

Does calling an anecdote by a different name make it not an anecdote? It does not matter what you call it. A story is an anecdote. More than one story is just more than one anecdote.

What kind of follow up was there on the patients? What kind of comparison of the other variables was there?

Blood-letting looks like an excellent treatment – if we stick to anecdotes about blood-letting.
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.[1]

 

How many patients did we kill with blood-letting? Thousands? Tens of thousands? Hundreds of thousands?

The opinions of medical directors have been in favor of many harmful treatments. Do you remember nifedipine?

Anecdotes do not become evidence of good patient care by telling the stories with style. Reality does not work that way, no matter how much we want to change reality. EMS shows us people who are having reality ignore their opinions about how the world should work. If reality is not going to change for a parent who wants their dead child back, how little is reality going to change for a paramedic who wants to put a positive spin on a treatment that he likes?

Reality does not care about our opinions.

Reality does not even care about the opinions of medical directors.

Science is the way we learn the difference between what is real and what is just a pleasing mirage.
 

What do you think science is? There is nothing magical about science. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results. So which part of that exactly do you disagree with? Do you disagree with being thorough? Using careful observation? Being systematic? Or using consistent logic? – Dr. Steven Novella.

Anecdotes are not thorough observations. Anecdotes do not use consistent logic. Anecdotes do not have anything to do with systematic evaluation.

Footnotes:

[1] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507

.

Where is the Evidence for Traction Splints?

 

We eliminated tourniquets from ambulances because of anecdotes and some strong opinions, but not because of valid research. Valid research shows that tourniquets work. Tourniquets are back.

We added traction splints because of anecdotes and some strong opinions, but not because of any valid research. Will research result in the same reversal of opinion-based practice.

With so little evidence, devices that are frequently misused, and no apparent need for these Rube Goldberg devices, should we continue to use traction splints?
 


Image credit.
 

Does a traction splint work?

That depends on what we mean by the word work. If work means that it pulls on the leg, then it does work, but if work means that it improves outcomes, then the traction splint is about as effective as eye of newt. Maybe the eye of newt is more effective.

If your have a lot of patients who have no other major injuries, then you may be able to set up a study of traction splints. A ski resort might be a good place for a study. On the other hand, if you are not an isolated femur fracture magnet, then your patients would probably be much better off if you focused on pain management, rather than pulling on their broken bones.
 

The fact is, there were no definitive studies demonstrating efficacy or decreased morbidity or mortality from prehospital use of traction splints 10 years ago, nor are there any now.3 So our use of traction splints is purely anecdotal.[1]

 

What is an anecdote?

An anecdote is misinformation from a know-it-all who doesn’t know what matters.

Anecdotes are just rumors. We believe some things because we want to believe, not because they are true. If we want to know the truth, we look for unbiased information. Unbiased information is the opposite of anecdotes and rumors.

There I was, standing on the corner, minding my own business, when all of a sudden . . .

He was dying and we gave the special sauce and he got better and ran a marathon last year.

These are examples of anecdotes. Anecdotes are what sells alternative medicine.

Footnotes:

[1] Sacred Cow Slaughterhouse: The Traction Splint
By William E. “Gene” Gandy, JD, LP and Steven “Kelly” Grayson, NREMT-P, CCEMT-P
Jul 31, 2014
EMS World
Article

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Dextrose 10% in the Treatment of Out-of-Hospital Hypoglycemia

ResearchBlogging.org
 

Is 50% dextrose as good as 10% dextrose for treating symptomatic hypoglycemia?

If the patient is disoriented, but becomes oriented before the full dose of dextrose is given, is it appropriate to continue to treat the patient as if the patient were still disoriented? If your protocols require you to keep giving dextrose, do the same protocols require you to keep giving opioids after the pain is relieved? Is there really any difference?

50% dextrose has problems.
 

Animal models have demonstrated the toxic effect of glucose infusions in the settings of cardiac arrest and stroke.2 Experimental data suggests that hyperglycemia is neurotoxic to patients in the setting of acute illness.1,3 [1]

 

Furthermore, extravasation can cause necrosis.
 


Image credit.[2]
 

I expect juries to look at this kind of image and say, Somebody has to take one for the 50% dextrose team. We can’t expect EMS to change.

Is 10% dextrose practical?
 

Won’t giving less concentrated dextrose delay treatment?
 

The median initial field blood glucose was 38 mg/dL (IQR = 28 mg/dL – 47 mg/dL), with subsequent blood glucose median of 98 mg/dL (IQR = 70 mg/dL – 135 mg/dL). Elapsed time after D10 administration before recheck was not uniform, with a median time to recheck of eight minutes (IQR = 5 minutes – 12 minutes).[1]

 

If that is going to slow your system down, is it because you are transporting patients before they wake up?

Did anyone require more than 10 grams of 10% dextrose, as opposed to 25 grams of 50% dextrose?
 

Of 164 patients, 29 (18%) received an additional dose of intravenous D10 solution in the field due to persistent or recurrent hypoglycemia, and one patient required a third dose.[1]

 

18% received a second dose, which is 20 grams of dextrose and still less than the total dose of 25 grams of dextrose given according to EMS protocols that still use 50% dextrose.

Only one patient, out of 164 patients, required a third dose. That is 30 grams of dextrose.

Only one patient, out of 164 patients, received as much as we would give according to the typical EMS protocol, which should be a thing of the past. If we are routinely giving too much to our patients, is that a good thing? Why?
 

Maybe the blood sugars were not that low to begin with.
 


 

The average was 38 mg/dL, which is not high.
 

Maybe the change in blood sugar was small after just 10 grams of dextrose, rather than 25 grams.
 


 

The average (mean) change was 67 mg/dL, which is enough to get a patient with a blood sugar of 3 up to 70.
 

Maybe the blood sugar was not high enough after just 10 grams of dextrose, rather than 25 grams.
 


 

The average (mean) repeat blood sugar was 106 mg/dL, which is more than enough.
 

Maybe it took a long time to treat patients this way.
 


 

The average (mean) time was 9 minutes, which is not a lot of time.
 

Is this perfect?
 

Three patients had a drop in blood glucose after D10 administration: one patient had a drop of 1 mg/dL; one patient had a drop of 10 mg/dL; and one patient had a drop of 19 mg/dL.[1]

 

All patients, even the three with initial drops in blood sugar (one had an insulin pump still pumping while being treated) had normal blood sugars at the end of EMS contact.

10% dextrose is cheaper, just as fast, probably less likely to cause hyperglycemia, probably less likely to cause rebound hypoglycemia, probably less likely to cause problems with extravasation, less of a problem with drug shortages, . . . .

Why are we still resisting switching to 10% dextrose?
 

Other articles on 10% dextrose.

Footnotes:

[1] Dextrose 10% in the treatment of out-of-hospital hypoglycemia.
Kiefer MV, Gene Hern H, Alter HJ, Barger JB.
Prehosp Disaster Med. 2014 Apr;29(2):190-4. doi: 10.1017/S1049023X14000284. Epub 2014 Apr 15.
PMID: 24735872 [PubMed – indexed for MEDLINE]

[2] Images in emergency medicine. Dextrose extravasation causing skin necrosis.
Levy SB, Rosh AJ.
Ann Emerg Med. 2006 Sep;48(3):236, 239. Epub 2006 Feb 17. No abstract available.
PMID: 16934641 [PubMed – indexed for MEDLINE]

Kiefer MV, Gene Hern H, Alter HJ, & Barger JB (2014). Dextrose 10% in the treatment of out-of-hospital hypoglycemia. Prehospital and disaster medicine, 29 (2), 190-4 PMID: 24735872

Levy SB, & Rosh AJ (2006). Images in emergency medicine. Dextrose extravasation causing skin necrosis. Annals of emergency medicine, 48 (3) PMID: 16934641

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