Another hazard of hypertonic dextrose

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In this study, at least 1 year of working on rescue proved to increase confidence, although the paramedics did not recognize this fact. The majority (54%) stated that being a parent was the most beneficial training, whereas additional courses (IS%), teaching (4%), outside employment (3%), and general exposure to children (10%) were also listed as beneficial. These results differ from the study by Gausche in Los Angeles that found that parenting and years of paramedic experience had little effect on paramedic comfort.” Because pediatric rescue runs were quite infrequent in this survey, additional clinical hours might have helped their contidence. Sessions performed in a pediatric setting in which large volumes of children could be assessed in a relatively short period could be helpful and were indeed requested by survey respondents and their chiefs. Time spent with an intravenous team, emergency department nurses and physicians could greatly enhance the practice of paramedics. The PALS course, adapted for paramedics, significantly improved paramedics’ comfort and perceived skill when treating children in medical and trauma emergencies. Additional research would be useful if paramedics were surveyed before and after PALS to study the effects more decisively; scores on the written and skill tests given at PALS could be compared with comfort levels and analyzed. It would be beneficial to collect data on rescue runs to determine if paramedics’ performance matched their subjective comfort/skill levels. comfortable.

CAROL LAFAYETTEROACH, RN Department of Emergency Medicine Miami Children’s Hospital Miami, FL FRANCISCOA. MEDINA. MD Director, Emergency Pediatrics Baptist Hospital of Miami, Miami, FL

References 1. Seidel JS: Emergency medical services and the pediatric patient: Are the needs being met? Il. Training and equipping emergency medical services provides for pediatric emergencies. Pediatrics 1986;78:808-812 2. American Academy of Pediatrics and American Heart Association Textbook of Pediatric Advanced Life Support, ed 2. Chicago, IL, American Heart Association, 1990, pp 1-4, 109-l 11 3. Seidel JS: Pediatric prehospital areas. Pediatrics 1988;4:681-689

care in urban and rural

4. Gausche M, Henderson D, Seidel JS: Vital signs as part of the prehospital assessment of the pediatric patient: A survey of paramedics. Ann Emerg Med 1990;19(2):173-178

ANOTHER HAZARD OF HYPERTONIC DEXTROSE To the Editor:-A case of persistent hypoglycemia and local tissue necrosis from inadvertent infiltration of a 50% dextrose solution is reported. The case highlights the need to evaluate intravenous sites when faced with an apparent medication failure. Paramedics responded to a private residence for a reported case of “low blood sugar.” On arrival, they found an obese 55-year-old man lying in a supine position on the bed, unresponsive to painful stimuli. The wife stated a bedside glucose reagent strip that she had performed measured 24 mg/dL. His medical history was remarkable for congestive heart failure and non-insulindependent diabetes mellitus. Medications were bumetanide, gemtibrozil, and glyburide. The patient’s wife believed that the patient had taken all his medications as had been prescribed. Initial field vital signs were systolic blood pressure (BP), 200 torr; pulse rate, 76 beats/mitt; and respirations, 12 breathslmin, shallow and sonorous. A 20-gauge intrave-

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nous (IV) line was placed near the right wrist after four attempts and 25 gm of 50% dextrose solution (50 ml) was injected intravenously. When no response occurred, a second dextrose bolus was injected, again without apparent effect. The patient was transported to the emergency department (ED). On arrival, the patient had no spontaneous respirations and was intubated orotracheally. Vital sings were BP, 176/70 torr; pulse rate, 82 beats/mitt; and temperature, 36.I”C rectally. Physical examination showed anasarca with cool, moist skin. Bedside blood glucose reagent strip was again 24 mg/dL, and 50 gm of 50% dextrose (100 mL) was injected through the paramedic-placed IV in two aliquots. with no change in the level of responsiveness. Serum glucose on blood obtained immediately after arrival in the ED was 26 mg/dL. Ten minutes after the initial 50 gm of glucose injected in the ED, bedside glucose level registered 15 mg/dL. The IV site was noted to be “positional” but flowed adequately by gravity. An additional 25 gm bolus of 50% dextrose was injected. At this point, the IV was noted to be infiltrated and restarted more proximally on the forearm. A sixth bolus of 25 gm 50% dextrose was injected in this new site with rapid improvement in the patient’s level of responsiveness. Within minutes, he was awake and was extubated. Bedside glucose level was 118 mg/dL. While arrangements were being made to admit the patient to the intensive care unit (ICU), he became agitated and repeat bedside glucose was 53 mg/dL. An additional 25 gm of 50% dextrose was injected; however. infiltration was quickly noted, and the forearm IV was discontinued. A right internal jugular central venous catheter was placed, and 25 gm 50% dextrose was injected with resolution of the patient’s symptoms. Within several hours the patient’s right forearm began to swell and become painful. Limb elevation and warm compresses were instituted. Within 6 hours, large bullae began to form circumferentially on the forearm. The digits and upper arm were spared. Surgical consultation was obtained, and the bullae was superficially debrided and fluid drained under local anesthesia on the evening of admission. The underlying skin was noted to be intact and sensitive to pain. The patient made an uneventful recovery with no further episodes of hypoglycemia. Dressing changes and elevation were continued at home after the patient was discharged on day 3. Follow-up appointments during a 6-week period showed gradual healing of the forearm with no observed sequelae. Phlebitis, pain, or local tissue inflammation are common adverse effects of hypertonic glucose when injected into an intact peripheral vein.’ The pH range of dextrose solutions is 3.5 to 6.5 and the osmolarity of D,, is 2,525 mOsm/L.’ Some references recommend injecting hypertonic dextrose only into large, free-flowing veins, preferably central veins.2.3 Caroline specifically recommends an IV catheter of at least 18 gauge and a test bolus of 10 to 20 mL of 5% dextrose, as a means of avoiding intravenous infiltration of the dose of D,,.4 In this case, approximately 150 gm (300 mL) of dextrose may have been injected inadvertently into the soft tissues of the forearm. Infiltration of intravenous catheters is usually detected by swelling of the insertion site, resistance to injection, and lack of flow by gravity.’ The paramedics and ED staff may have been mislead in their detection of infiltration by the patient’s anasarca, obesity, and the observation that the IV appeared to run freely, albeit intermittently. Recurrent and persistent hypoglycemia has occurred with oral hypoglycemic agents.6 However, it is very unusual for such an event to require an initial dose greater than 25 to 50 gm of dextrose.6 In the absence of hypothermia, lack of patient response to the initial injection should trigger reassessment of the cause of unconsciousness.’ Collier et al reports a rapid rise (median time, 4 minutes) in serum glucose levels after IV administration of glucose.’ Lack of bedside blood glucose response to repeated injections suggests that medication dosage or administration error has occurred. Avoidance of similar errors in the future will require the combined efforts of prehospital, nursing, and physician personnel. Guidelines

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for prehospital use of hypertonic dextrose might include a minimal IV catheter size and use of an isotonic test dose. Repeated IV insertion attempts should alert the medical control physician that the intravenous line may be tenuous, and other options, such as glucagon, may be preferable. Once in the ED, staff must recognize that prehospital IV lines are often inserted under adverse conditions and are subject to dislodgement in transport. Care must be taken to ensure that IV sites are checked frequently, particularly if sclerosing or irritating solutions are being injected. If infiltration is suspected, the IV must be immediately discontinued’ and an alternative site, preferably on another extremity, should be used or a different medication route employed. There is no specific antidote to hypertonic glucose tissue toxicity. Treatment consists of local wound care such as loose dressings, elevation, and in severe cases, surgical debrideROBERTA. DELORENZO, MD JEFF P. VISTA, MD Department of Emergency Medicine Wright State University School of Medicine Dayton, OH

References 1. McEvoy GK, Litvak K, Welsh OH, et al: American Hospital Formulary Service Drug Information. Bethesda, MD, American Society of Hospital Pharmacists, Inc, 1992, pp 1527-1529 2. Rutherford C: Fluid and electrolyte therapy: Considerations for patient care. J Intravenous Nurs 1989;12:173-183 3. Nursing 91 Drug Handbook. Springhouse, PA, Springhouse Corp, 1991, pp 921-922 4. Caroline NL: Emergency Care in the Streets, ed 4. Boston, MA, Little, Brown, 1991, pp 567-579, 885 5. Malseed FIT, Harrigan GS: Textbook of Pharmacology and Nursing Care. Philadelphia, PA, Lippincott, 1989, pp 95-125 6. Seltzer HS: Drug induced hypoglycemia: A review of 1418 cases. Endocrinol Metab Clin North Am 1989;18:163-183 7. Peterson J: Coma, In Rosen P, Barkin RM, Braen GR, et al (eds): Emergency Medicine: Concepts and Clinical Practice, ed 3. St Louis, MO, Mosby, 1992, pp 1728-1751 8. Collier A, Steedman DJ, Patrick AW, et al: Comparison of introvenous glucagon and dextrose in treatment of severe hypoglycemia in an accident and emergency department. Diabetes Care 1987;l 0:712-l 75