A common question is how much should we expect the blood glucose concentration to increase after dextrose 50% (D50) administration. Fortunately, there is an answer from 3 studies.
- Balentine JR, Gaeta TJ, Kessler D, Bagiella E, Lee T. Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers. Acad Emerg Med. 1998;5(7):691-694. doi:10.1111/j.1553-2712.1998.tb02487.x PMID 9678393
- Population: Healthy volunteers in the ED
- Intervention: 25 gm (1 ampule of D50)
- Result: Mean increase of 162 mg/dL at 5 min. Glucose concentrations returned to baseline by 30 minutes.
- Murthy MS, Duby JJ, Parker PL, Durbin-Johnson BP, Roach DM, Louie EL. Blood glucose response to rescue dextrose in hypoglycemic, critically ill patients receiving an insulin infusion. Ann Pharmacother. 2015;49(8):892-896. doi:10.1177/1060028015585574. PMID 25986006
- Population: Critically ill patients experiencing hypoglycemia while on insulin infusions
- Intervention: D50
- Result: Median increase of 4 mg/dL per gm of D50 administered
- Adler PM. Serum glucose changes after administration of 50% dextrose solution: pre- and in-hospital calculations. Am J Emerg Med. 1986;4(6):504-506. doi:10.1016/S0735-6757(86)80004-3. PMID 3778594
- Population: ED patients with altered mental status (23 with diabetes, 28 without diabetes)
- Intervention: 25 gm (50 mL of D50)
- Result: Mean increase of 166 mg/dL
Take Home Points
- Glucose concentrations increase 4-6 mg/dL per gm of dextrose administered
- 50 mL of D50 = 25 gm = expected 100-150 mg/dL glucose rise
- D50 rescue glucose is short-lived (30 minutes)
- If the blood glucose does not respond as anticipated, investigate further (e.g., IV decannulation)
Want to learn more about EM Pharmacology?
Resuscitation before intubation is a critical construct in modern emergency medicine. The prevention of peri-intubation arrest by correcting pre-intubation hypoxia, hypotension, and acidosis is often easier said than done. Worse yet, the intubation process itself, especially if difficult, can worsen hypoxia and hypotension which is often unrecoverable [1, 2] Supraglottic devices, such as a King Airway or laryngeal mask airway, can be placed quickly, and they effectively oxygenate and ventilate patients with a high degree of success . Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. Ideally the King could be blindly changed over a tube exchanger however it is quite easy to lose the airway completely during this process. We describe a potentially safer and more effective alternative.
Trick of the Trade
After a patient is stabilized after initial resuscitation, the supraglottic King airway device should be exchanged. A disposable, single-patient-use bronchoscope can serve as a bougie-like guide.
- Disposable bronchoscope
- Endotracheal tube
- 50 mL syringe
- Laryngoscope (video or direct)
- Trauma shears
Description of the Trick
- Insert a disposable bronchoscope through the airway port of the King airway
- Guide the bronchoscope to exit through the side port of the King and into the trachea until you approach the carina
- Cut the disposable bronchoscope at the level of the handle, leaving a “fiberbougie” in the trachea above the carina
- Remove the King airway over the cut fiberscope in a modified Seldinger technique while suctioning airway
- Insert the endotracheal tube over the “fiberbougie”
- Use video or direct laryngoscopy to visualize the tube sliding over the “fiberbougie” into cords
- Confirm placement with capnography and/or with direct visualization and x-ray
Video Tutorial of the Fiberbougie Technique to Exchange a King Tube
- April MD, Arana A, Reynolds JC, et al. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;162:403-411. doi:10.1016/j.resuscitation.2021.02.039. PMID 33684505
- Russotto V, Tassistro E, Myatra SN, et al. Peri-intubation Cardiovascular Collapse in Critically Ill Patients: Insights from the INTUBE Study [published online ahead of print, 2022 May 10]. Am J Respir Crit Care Med. 2022. doi:10.1164/rccm.202111-2575OC. PMID 35536310
- Burns JB Jr, Branson R, Barnes SL, Tsuei BJ. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010;25(1):92-95. doi:10.1017/s1049023x00007743. PMID 20405470
What is the correct antidote for a patient who is poisoned with the pictured substance?
- Digoxin Specific Fab
- Hydroxocobalamin/Sodium Thiosulfate
(photo used with permission courtesy of Maureen Dallhoff, MD)
Ultrasound-guided IVs require hand-eye coordination and fine movements of probe in Goldilocks fashion. Apply too much pressure, and the vein in question is compressed. Slide a little to the right, and now it’s out of the window. Something that practitioners don’t think about is the tension from the cord. If left to its own devices, the cord will tug on the probe, making the probe harder to steer and handle, especially for those tiny veins.
Trick of the Trade: Reduce cord tension
Have the patient grasp the cord!
This makes them an active participant. Usually, if they are awake and good-humored, tell them “audience participation is required.” Doing so will give you enough slack to effectively visualize and troubleshoot the ultrasound-guided IV.
What if the patient is intubated, or altered, doesn’t quite grasp, or can’t handle the situation?
Tape the cord to the gurney side rail. Use a 2×2 gauze as a buffer between the tape and the rail so the tape doesn’t damage the cord itself.
Want to learn other tricks?
Read other articles in the Tricks of the Trade series.