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July Introduction

Jan Shoenberger, MD and Stuart Swadron, MD, FRCPC
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13:47
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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05:09

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EM:RAP 2019 July Written Summary 289 KB - PDF

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Daniel S., MD -

Going to go on a rant here about the piece that Jessica Mason and Jason Woods did. Why are we giving D25 and D50 to children (or the bigger kids)? Our body uses 6 mg / kg / min (this would be 0.006 g / kg / min or 0.36 grams / kg / hour) of glucose but we want to give the pediatric patient 25 grams of D50 as a slug. This "medication" has a serum osm of around 2500 with a pH between 3.5 and 6.5 along with the concerns for direct toxic effects with extravasation and potential neurotoxic effects of hyperglycemia. Why in the world do we continue to use a "medication" that has a lot of potential harm to patients as compared to D10 that has a serum osm around 500 with a neutral pH. And remember ... we are giving them 25 grams (this is the same amount of glucose a 70 kg individual uses per hour) over a 2 - 4 minute interval ... maybe a little longer depending on how it is pushed.

This medicine should go into one of the medical "well this is how we have always done it" treatments and we should get rid of D50 all together. So many of our prehospital colleagues have made the switch from using D50 to D10 and this was even discussed in the 2015 epmonthly by Paul Rostykus (https://epmonthly.com/article/d10-may-be-better-than-d50-for-acute-hypoglycemia/) along with some articles in the prehospital emergency care and prehospital disaster medicine journals.

Jason Woods -

Hi Daniel!

You bring up a good point of clarification here. The rule of 50s is a quick way to calculate how to give 25 grams of glucose to a hypoglycemic or metabolically ill child. The main point was supposed to be showing a way to calculate this so that you can use it no matter what glucose containing fluid might be available, rather than to endorse D50. We could have worded that more clearly. In my clinical practice I never use D50 (for the reasons you outlined above) but in some situations this is all that is available. You note that many prehospital colleagues have switched to D10, but not all have. We strongly prefer that D50 is diluted before administering, though the same dose of glucose would be given. Not all agencies permit this. As far as 25 gms of glucose being the dose choice and whether or not it is too high, that is a wider ranging debate but I think it it beyond the bounds of this piece.

I do want to note that while your calculations and mentions of normal glucose utilization are correct, I do not think that point specifically applies here. We are discussing patients who may be hypoglycemic or severely energy deplete due to an inborn error of metabolism, and need to be repleted (and likely overcorrected) to stabilize them until we can figure out what is going on.

~Jason

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EM:RAP 2019 July Full episode audio for MD edition 192:37 min - 268 MB - M4AEM:RAP 2019 July German Edition Deutsche 103:01 min - 142 MB - MP3EM:RAP 2019 July Aussie Edition Australian 10:50 min - 15 MB - MP3EM:RAP 2019 July Farsi Edition Farsi 164:39 min - 226 MB - MP3EM:RAP 2019 July Canadian Edition Canadian 20:02 min - 28 MB - MP3EM:RAP 2019 July Spanish Edition Español 61:20 min - 84 MB - MP3EM:RAP 2019 July French Edition Français 24:38 min - 34 MB - MP3EM:RAP 2019 July Board Review Answers 237 KB - PDFEM:RAP 2019 July Board Review Questions 111 KB - PDFEMRAP 2019 July Individual MP3 250 MB - ZIPEM:RAP 2019 July Written Summary 289 KB - PDF

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