Skinny little 72-year-old man, sent in by his nursing home for "aggressive behavior/altered mental status." Apparently he had been throwing food and dishes at breakfast and was cursing at the other residents and staff. He cursed at and didn't recognize his daughter when she came to visit, either.
It took two of us to get him into bed, and three of us to get vital signs--he was fighting and kicking and biting and cursing. The daughter was very distraught--"He's never been like this! He's a sweet guy!" No history of Alzheimer's, no psych history, just some cardiac issues and arthritis.
I immediately thought he was hypoxic, but his color was good, and his oxygen saturation (when we could get it!) was 96% on room air. That was good, because there was no way he would keep a mask on. I was finishing up my triage when I realized in all the hubub, I hadn't gotten a blood glucose level. The patient wasn't diabetic, but we get a glucose level on all patients who are altered.
It was 26 mg/dL. Normal is 70-120 or so. (I was shocked that he was even AWAKE, let alone fighting and kicking!) So five of us held him down, started a line, and gave him 2 amps of 50% dextrose solution. After the first one, he calmed down. After the second, he sat up in bed and said, "Hello ladies! What's all the fuss?" Completely back to normal. We got him started on a little D5W and gave him something to eat.
What I'm wondering is how his blood sugar got that way. Perhaps he took someone else's oral antidiabetic medication by accident?
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14 comments:
GAH!
I really hope if I start flipping out, you know, more than normal, they fly me to wherever the hell your hospital is.
What would the likely course of action have been without that little nugglet of bgl info been?
they probably would have sedated him!
I didn't think even oral anti-diabetics could make a person drop that far. I wonder if he got insulin by accident? Or if he hadn't been eating well for a long time. That's weird. Glad it was an easy fix though.
Actually, there should always be a high suspicion of hypoglycemia when an elderly individual presents with altered mental status...so good catch GG! Of course, other common causes may include metabolic dysfunction (thyroid, for example), polypharmacy, and drug reactions (older folks often don't react well to Benadryl, for example).
I do hope they gave the gentleman a complete metabolic workup to identify potential causes of his hypoglycemia. It could be that he just hasn't been eating, but you'd probably expect to see ketones with a BS that low. He could have an underlying disease process at work (such as acute liver failure) or even sepsis (Yes, sepsis can actually cause the BS to go down in some cases). In all likelihood, the med tech a t the nursing home made a medication error and gave this guy someone else's oral meds. But were it me, I'd run the standard labs just to be sure.
Regardless, way to stay on your toes GG!
Brian
I would not be surprised to find out that a nurse gave him insulin.
I have asked for information from the nurse taking care of patients and simple questions are sometimes not answered.
Is he diabetic?
I think so.
Insulin dependent?
I don't know.
Well, do you give him insulin when he eats?
How do you graduate nursing school, work as a nurse in a setting where you administer these medications several times a day - and not know what you are doing?
But some do.
Most are confined to inflicting their care on nursing home patients, but there are some who do not know their limitations.
Any chance there was a cockroach in his vagina?
:-)
I don't think a blood sugar of 120 is considered normal.
Great catch though.
A blood sugar of 120 would certainly be wnl in the post-prandial period. ;-)
Brian
26 mg/dL! I wonder how Skinny Little 72-yr-old Man's roommate is doing back at the nursing home without his insulin? ha.
This situation sounds terribly interesting, but I recently heard a story about an inflatable "object" being "lodged" in a "hard to reach place" that beats this one hands down!
Screw House MD and ER. THIS is where the action's at.
You go girl!
Nice catch!
Off topic, this morning I heard some new Eric Clapton and Steve Winwood music. Flashbacks to the 70's. Very nice. I immediately thought of GGRN.
I've seen totally unconscious with a BS that low, but not aggression. Wethought they were stroking until we found the blood sugar result. Good catch!
I went on a call once where it took 6 very manly firefighters to hold down a one legged, one armed retired man with a cbg of 38 so that I could get an IV and some D50 on board. And even then, we ended up with a sticky mess all over the back of the ambulance.
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