• When Should You Test for and Treat Hypoglycemia in Prehospital Seizure Patients?

    by Alan Batt. Last modified: 02/03/14

    glucose

    Summary

    • Retrospective review of clinical database
    • 76,584 calls identified as seizure-related
      • 53,505 (69.9%) had blood glucose monitored
      • 638 (1.2%) had blood glucose <60mg/dL (~3.3mmol/l)
      • Benzodiazepine was administered to 73 (11.4%) of 638
    • Obtaining a blood glucose measurement prior to benzodiazepine administration (compared to  either measurement or  measurement after benzodiazepine administration) was associated with a 2.1 minute delay in benzodiazapine administration.
    • Rates of hypoglycemia were very low in patients treated by EMS for seizure in this study
    • Measurement of blood glucose prior to treating a seizure with a benzodiazepine is not supported by this study.

    An interesting paper that looks at the accepted view of hypoglycaemia being a common cause of seizures encountered in the prehospital arena. This study is limited in its usefulness based on a number of factors:

    • Retrospective review of a clinical database.
    • Bias of diagnoses possible as decision on seizure presentation made by prehospital care providers – this means that some seizure presentations may not be included because the provider decided it was not a seizure presentation.
    • No patient outcome data available.
    • Not all confounding factors taken into account such as patients not actively seizing on EMS arrival (which would lead to a documented “delay” in benzodiazapine administration), and those patients who did not have a blood glucose measurement performed (may have led to higher or lower levels of hypoglycaemia presentations).

     
    Beskind DL, Rhodes SM, Stolz U, Birrer B, Mayfield TR, Bourn S, Denninghoff K. When Should You Test for and Treat Hypoglycemia in Prehospital Seizure Patients? Prehosp Emerg Care. 2014 Jan 24. PMID: 24459993.

    Abstract

    Objectives

    Seizure is a frequent reason for activating the Emergency Medical System (EMS). Little is known about the frequency of seizure caused by hypoglycemia, yet many EMS protocols require glucose testing prior to treatment. We hypothesized that hypoglycemia is rare among EMS seizure patients and glucose testing results in delayed administration of benzodiazepines.

    Methods

    This was a retrospective study of a national ambulance service database encompassing 140 ALS capable EMS systems spanning 40 states and Washington DC. All prehospital calls from August 1, 2010 through December 31, 2012 with a primary or secondary impression of seizure that resulted in patient treatment or transport were included. Median regression with robust and cluster (EMS agency) adjusted standard errors was used to determine if time to benzodiazepine administration was significantly related to blood glucose testing.

    Results

    Of 2,052,534 total calls, 76,584 (3.7%) were for seizure with 53,505 (69.9%) of these having a glucose measurement recorded. Hypoglycemia (blood glucose <60 mg/dL) was present in 638 (1.2%; CI: 1.1, 1.3) patients and 478 (0.9%; CI: 0.8, 1.0) were treated with a glucose product. A benzodiazepine was administered to 73 (11.4%; CI: 9.0, 13.9) of the 638 hypoglycemic patients. Treatment of seizure patients with a benzodiazepine occurred in 6,389 (8.3%; CI: 8.1, 8.5) cases and treatment with a glucose product occurred in 975 (1.3%; CI: 1.2, 1.4) cases. Multivariable median regression showed that obtaining a blood glucose measurement prior to benzodiazepine administration compared to no glucose measurement or glucose measurement after benzodiazepine administration was independently associated with a 2.1 minute (CI: 1.5, 2.8) and 5.9 minute (CI: 5.3, 6.6) delay to benzodiazepine administration by EMS, respectively.

    Conclusions

    Rates of hypoglycemia were very low in patients treated by EMS for seizure. Glucose testing prior to benzodiazepine administration significantly increased the median time to benzodiazepine administration. Given the importance of rapid treatment of seizure in actively seizing patients, measurement of blood glucose prior to treating a seizure with a benzodiazepine is not supported by our study. EMS seizure protocols should be revisited.

    References

     
    1.

    Beskind DL, Rhodes SM, Stolz U, Birrer B, Mayfield TR, Bourn S, Denninghoff K. When Should You Test for and Treat Hypoglycemia in Prehospital Seizure Patients? Prehosp Emerg Care. 2014 Jan 24. PMID: 24459993.

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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