Blood Glucose Measuring in the
Pre-Hospital Setting
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Purpose
1. To prepare Certified First Responders (CFR) and EMTBasics (EMT-Bs) with current certification to utilize a
blood glucose measuring device (glucometry) when
operating under NY State – approved BLS protocols
for Altered Mental Status (AMS), in accordance with:
• NYS DOH Policy Statements 05-04, 12-01
• Revised NYS BLS Protocol for AMS (M-2)
• Suffolk County EMS Medical Director / Suffolk REMAC Standard of Care
2. To provide a review of diabetic and neurologic (CVA/TIA
and Seizure) emergencies.
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Education & Training Objectives
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•
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Indications to perform glucose test
How to obtain blood sample
Instruction on glucometer operation
What to do with test result
Proper disposal of sharps / contaminants
Proper action for blood borne pathogen
exposure
• Proper documentation
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Note
Information within this presentation should be
tailored to the specific glucometer used by the
ambulance service and should include a review
of the manufacturer’s instructions.
Documentation of successful completion of this
training, by signing the Attestation of
Completion Form and completing the hands-on
skills review, is required for authorization to
perform blood glucose monitoring in the field
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Agency Responsibility
• Ensure compliance with Suffolk County EMS
Policy and NY State EMS BLS Protocol
• Provide information to the agency’s inclusion
in the CLIA Permit-Waiver**
• Procure equipment
• Provide training and re-training as needed
• Establish an agency policy for equipment
calibration and maintenance, per
manufacturer’s recommendations
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What is CLIA and why do we need a
Permit-Waiver?
•
The use of blood glucometry equipment and the measurement of a patient’s
blood sugar constitutes use of laboratory-acquired specimen data to
diagnose and treat a patient
•
NY State DOH regulations contained in the Clinical Laboratories Evaluation
Program (CLEP) require that laboratories, including ambulance services,
meet State DOH standards for “laboratories” as a function of the Clinical
Laboratories Improvement Amendments (CLIA).
•
Blood glucometry is a permit-waived test as defined as a simple laboratory
examination and procedure that has an insignificant risk of an erroneous
result
•
Suffolk County EMS holds the Multi-Site Permit-waiver for the entire EMS
System with each ambulance service listed as an “off-site” laboratory
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What is CLIA and why do we need a
Permit-Waiver?
•
The permit-waiver application and fee is submitted bi-annually by Suffolk County
EMS.
•
The permit expires every 2 years, current permit effective until April 19, 2015.
•
If you are affiliated with an ambulance service in Suffolk County operating at the
ALS level, your agency already has the proper permit-waiver in place.
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If you are affiliated with an ambulance service in Suffolk County operating at the
BLS level, or if you are in a BLS-First Response (BLS-FR) agency, your
administration has been asked to provide site specific information so we can add
your BLS agency to the list of off-site laboratories. Failure to comply will result in
your agency being unable to perform blood glucometry.
•
The CLIA Permit-waiver requires that the agency comply with manufacturer's
recommendations for glucometer maintenance and calibration/control testing and
documentation.
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Changes in protocol
• As approved by the NY State Commissioner of
Health, and adopted by the NYS DOH Bureau
of EMS, the Suffolk County EMS Medical
Director, in conjunction with the Suffolk
REMAC, has authorized the implementation of
the revised NY State AMS protocol, which
includes 2 new skills for BLS providers:
– obtaining blood sugar readings to assist in the
identification of hypoglycemia; and the
– administration of intranasal naloxone to patients
with opiate/opioid overdose.
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Glucometry Devices
• Typical glucometer used to check blood
sugar levels.
• Many different types and models.
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• Per NY State DOH requirements, the use
of “dextrostix” are prohibited. A glucometer
must be used.
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Indications for BG Measuring
Patient signs and / or symptoms consistent with
• Acute Stroke
– weakness, facial droop, slurred speech
– Aphasia (inability to speak), dysarthria (difficulty
pronouncing words) and hemiparesis (one-sided
weakness), hemiplegia (inability to move one side of
body)
• Altered Mental Status
– confusion, disorientation
• Diabetic Emergencies
• Opiate/Opioid Overdose
• Seizure/Post-Seizure
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Use of Glucometer
• Equipment needed:
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Exam gloves
Alcohol prep pads
Glucometer
Test strips
Cotton balls or gauze
pads
– Band-aid
– Lancets
– Sharps container and
proper waste disposal
container
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Device Variations
• Some glucometers turn on automatically when the test
strip is inserted.
• Know the features of the glucometer your agency
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uses.
Manufacturer-Specific Maintenance
• Set up requires identification of:
– Proper batch number for test strips
– Routine control testing
– Calibration when necessary
– Documentation of control testing and
calibrating
– Follow manufacturer’s directions
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Care of the Blood Glucometer
• Handle with care!
• Do NOT expose to excessive heat,
humidity, cold, dust, or dirt
• Clean as directed by manufacturer
• Store the glucometer and supplies in the
case provided by the manufacturer
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Blood Glucometer Errors
Can result from:
• Improper calibration of glucometer
• Lack of glucometer maintenance and cleaning
• Battery failure
• Test strip failure
• Codes on strip container and glucometer don’t
match
* Proper care and maintenance of
glucometers can help prevent
these errors
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NY State EMS
BASIC LIFE SUPPORT PROTOCOL
Suffolk County EMS
BLOOD GLUCOMETRY POLICY
• NOTE: The use of blood glucometry may be of clinical
benefit in cases of known history of diabetes controlled
by medication with suspected diabetic emergencies,
seizure, stroke/CVA, opiate/opioid overdose and
behavioral emergencies, and may provide agencies with
information necessary to help determine the appropriate
treatment and hospital destination for patients with s/s of
stroke/CVA.
• BLS providers should refer to the most current New York
State BLS Altered Mental Status protocol (M-2) ; M-2
revision has been officially published and referred under
NYS Policy Statement 13-10
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Suffolk County EMS
BLS Blood Glucometry Policy
• Request Advanced Life Support (ALS) but do not delay
transport to the hospital waiting for ALS, or to perform blood
glucometry
• It is understood that the applicable New York State DOH
Basic Life Support (BLS) Protocols are always to be initiated
in conjunction with this policy, particularly for AMS,
suspected stroke/CVA, seizure, overdose, and behavioral
emergencies.
• Assess the situation for potential or actual danger. If the
scene/situation is not safe, retreat to a safe location, create
a safe zone, and obtain additional assistance from a police
agency.
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Suffolk County EMS
BLS Blood Glucometry Policy
• Persons suspected of a behavioral emergency must be
presumed to have an underlying medical or traumatic
condition causing the AMS. All suicidal or violent threats
or gestures must be taken seriously.
• These patients should be in police custody if they pose a
danger to themselves or to others. If the patient poses a
danger to themselves or others and police are not
present, summon police for assistance.
• Consider the use of soft restraints per current policy to
protect the patient and yourself
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Suffolk County EMS
BLS Blood Glucometry Policy
•
Perform patient assessment. This protocol is intended for use for
any adult patient presenting with the Signs and/or Symptoms of :
– stroke
– seizure activity;
– syncopal episode;
– opiate/opioid overdose
– previously diagnosed history of diabetes and whose complaints
are consistent with signs and symptoms of hypoglycemia.
•
NOTE: Altered Mental Status denotes a change in the patient’s
mentation from their usual status as defined by anyone who is
familiar with the patient……OR……..
•
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the EMS provider reasonably believes the patient’s GCS is usually 15
and the patient presents with a GCS less than 15.
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Suffolk County EMS
BLS Blood Glucometry Policy
• Obtain blood sample via finger stick, perform blood
glucose testing and document on the PCR. Be prepared
to pass this information along to responding ALS
personnel. If blood glucose is less than (<) 65 mg/dl
AND the patient is conscious with an intact gag reflex:
• Administer 1 Tube Oral Glucose (24 grams) between
the patient’s cheek and gum or on patient’s tongue. Use
caution and avoid creating a choking hazard. If
necessary, the patient may self-administer Oral Glucose.
• Begin transport to the hospital
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Suffolk County EMS
BLS Blood Glucometry Policy
• Reassess blood glucose after five (5) minutes. If blood glucose
remains less than (<) 65mg/dL, AND AMS is present AND the
patient is conscious with an intact gag reflex:
• Administer a second tube of Oral Glucose(24 grams) between
the patient’s cheek and gum or on patient’s tongue. Use caution
to avoid creating a choking hazard. If necessary, the patient may
self-administer Oral Glucose.
– if the BG is less than (<) 65 but the AMS resolves or the patient goes back
to baseline, withhold further oral glucose
• If needed…..reassess blood glucose after another five (5)
minutes. If blood glucose remains less than 65mg/dL, AND AMS
is not resolved the patient is conscious with an intact gag reflex:
• Administer a third tube Oral Glucose (24 grams), per above
procedure
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Suffolk County EMS
BLS Blood Glucometry Policy
• Contact Medical Control to discuss cancellation of
responding ALS ambulance or for hospital destination
decision if blood glucose is greater than 65mg/dL and ALL of
the following conditions exist:
– The patient is alert with a GCS of 15 -OR - For cases where
the patient’s usual GCS is less than 15, the patient’s usual
level of mentation has been restored;
– The patient has a diagnosed history of diabetes; AND
– The patient does not present with any complaints that require
ALS intervention.
– If the patient chooses to RMA after administration of glucose
– Provide post-call signal 34 to Suffolk County Medical Control
to register your call with the system.
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N
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Fingerstick Procedure
For Accurate Glucose Results
Credit to: Duke University
Choose the finger carefully
•
Best locations for a finger
stick is the 3rd and 4th
fingers of the nondominant hand.
•
Avoid the 2nd and 5th
fingers if possible.
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Perform the stick off to
side of the center of the
finger.
•
NEVER use the tip or
center of the finger.
Credit to: Duke University
Massage or Warm the site
• Avoid fingers that are cold,
cyanotic, swollen, scarred
or covered with a rash.
• Massage to warm the
finger and increase blood
flow by gently squeezing
from hand to fingertip 5-6
times.
Credit to: Duke University
Clean and Dry the site



Cleanse fingertip with
70% isopropyl alcohol
Wipe dry with clean
gauze or allow to air
dry.
Caution: Alcohol can
falsely elevate or lower
blood glucose results.
Credit to: Duke University
Finger Stick location
•
Using a sterile lancet,
make a skin puncture
just off the center of the
finger pad.
•
Wipe away the first drop
of blood (which tends to
contain excess tissue
fluid).
Credit to: Duke University
Do not milk finger
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If necessary, apply light pressure to
the surrounding tissue until another
drop of blood appears.
•
Avoid "milking." The drop of blood
must be big enough to fill the strip
completely.
•
NOTE: Do NOT squeeze or apply strong
repetitive pressure to the site. This may
result in hemolysis or increase tissue
fluid in the blood causing incorrect
glucose results.
•
Caution: Free flowing blood is
necessary to obtain reliable results.
Increased pressure beyond that
necessary to hold the finger can result in
inaccurate results.
Credit to: Duke University
BG Procedure
•The glucometer reading indicates the amount of
glucose in the patient’s blood stream.
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What are we measuring?
•
The amount of
glucose in the blood.
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Blood Sugar Level
Yields high blood –sugar levels
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Hyperglycemia and
Hypoglycemia
• Both lead to diabetic emergencies.
• Hyperglycemia: Blood glucose is above
normal.
– Result of lack of insulin
– Untreated, results in DKA
Hyperglycemia and
Hypoglycemia
• Hypoglycemia: Blood glucose is below
normal.
– Untreated, results in unresponsiveness and
hypoglycemic crisis
• Signs and symptoms of hyperglycemia
and hypoglycemia are similar.
Hyperglycemia and
Hypoglycemia
What Now?
Properly dispose of sharp
Treat the Patient
Document Results
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Administering Glucose
• If the blood glucose reading is less than (<) 65
mg/dl and the patient is awake w/ intact gag reflex,
let patient them squeeze oral glucose into his/her
mouth
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Administering Glucose w/
Tongue Depressor
• If patient awake w/
intact gag reflex, open
the patient’s mouth.
• Place the tongue
depressor on the
mucous membranes
between the cheek and
the gum (bucchal) with
the gel side next to the
cheek.
• Repeat as needed, per
protocol and policy.
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Differential
Pre-hospital Impressions
• Since many of the signs and symptoms of hypoglycemia mimic
those of other illnesses / events , it has become the standard of care
to use blood glucometry in assisting the provider in determining both
a hospital destination and what further intervention during transport
is warranted. Some common conditions that hypoglycemia might
mimic:
– Overdose (Especially Alcohol and Opiates/Opioids)
– TIA/CVA (including aphasia, dysarthria and hemiparesis)
– Postictal state
• In essence, all of these can manifest in “AMS”
– Therefore, the modification to the NYS AMS Protocol, to include:
• Nasal Narcan administration at the BLS level
• Glucometry
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Hypoglycemia versus
Opioid Overdose
• If the patient’s blood glucose is greater than
(>) 65 mg /dl, the patient is not
“hypoglycemic” and other causes of AMS
should be explored
• Given the new treatment options of
inhalation narcan, consider opioid overdose
if the patient has AMS and respiratory
depression with pinpoint pupils
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Hypoglycemia versus Stroke/CVA
• If patient’s blood glucose is greater than
(>) 65 mg/dl and their respiratory rate is
normal and there is no evidence of opioid
overdose….consider stroke/CVA
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Hypoglycemia versus Stroke/CVA
•
•
•
Perform initial assessment
– Mental status
– ABC
– Vital Signs
Obtain relevant history
– OPQRSTI
– Time symptom onset / last seen normal
– Sz activity?
– Recent illness, injury, surgery
Focused Physical Examination
– Glasgow Coma Score
– Cincinnati Prehospital Stroke Screen
– Blood glucose
– Signs of trauma
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Opioid Overdose
The signs and symptoms of opioid overdose and the
administration of inhalation narcan are covered in the
required on-line video review and skills affirmation process
Congratulations, you have successfully completed the
education phase of blood glucometry
The next step
• All CFRs and EMT-Bs
will be required to
participate in the BG
practical skill at the
agency level
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Case Study 1
You are treating a 59 year old male patient, with a sudden onset of altered mental status and lethargy per
bystanders. History includes bone cancer, Type II diabetes, high blood pressure. He is on glucophage for
his diabetes, wears a fentanyl patch for pain management, and takes labetalol for his hypertension.
Physical exam reveals that the patient responds to painful stimuli by groaning, his pupils are bilaterally
constricted, respiratory rate is 4 breath per minute, B/P is 110/70 and heart rate is 66 regular and strong.
You perform a blood sugar via finger stick, the glucometer shows 100 mg / dl.
Your field impression is:
1. Hypoglycemia
2. Stroke / CVA
3. Opioid Overdose
4. Hypertensive Crisis
What is the appropriate treatment for this patient?
1.
Oral Glucose
2.
Inhalation narcan
3. Oxygen an 6 lpm via nasal cannula
4. Allow the family to give him his glucophage
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Case Study 2
You are treating a 56 year old female patient, with a sudden onset of altered mental status, with difficulty in
speaking. History includes heart disease with several TIAs. Patient’s daughter states that the patient was
fine all morning, and went into the room when she “heard a sound of breaking glass.” Daughter also states
that the patient returned from an overseas airline flight several days ago. Patient takes no medications on a
regular basis. Physical exam reveals that the patient’s eyes are opened spontaneously, pupils are normal
in size, equal and reactive, respiratory rate is 14 breath per minute, B/P is 140/90 and heart rate is 72
regular and strong. Because of the AMS, you perform a blood sugar via finger stick, the glucometer shows
88 mg / dl. Cincinnati Prehospital Stroke Screen reveals that the patient has pronator drift with concurrent
facial droop and cannot speak normally.
Your field impression is:
1.
2.
Hypoglycemia
Stroke / CVA
3. Opioid Overdose
4. Acute Myocardial Infarction
What is the appropriate treatment for this patient?
1.
2.
Oral Glucose
Follow NYS BLS Stroke/CVA Protocol
3. Assist the patient with her prescribed nitroglycerine
4. Inhalation Narcan
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Case Study 3
You are treating a 26 year old male patient, with a sudden onset of altered mental status, which you are
told progressed to “unconsciousness” prior to your arrival on a construction site. The supervisor states
that the job needed to be finished so he ordered the crew to work through lunch. He states that he “thinks
the patient has sugar problems” and “just returned to work several days ago after recovering from an onthe-job back injury.” Physical exam reveals that the patient is A&O x 3, speaking well, pupils are normal in
size, equal and reactive, respiratory rate is 18 breath per minute, B/P is 126/84 and heart rate is 80 regular
and strong. Because of the AMS, you perform a blood sugar via finger stick, the glucometer shows 50 mg
/ dl.
Your field impression is:
1.
2.
Hypoglycemia
Stroke / CVA
3. Opioid Overdose
4. Complications from Back Injury
What is the appropriate treatment for this patient?
1.
2.
Oral Glucose
Low Dose Aspirin
3. Oxygen, and transport to the closest Trauma Center
4. Inhalation narcan
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Post-Use Reporting Requirements
• All cases of INH narcan must be reported by making a post-call
signal 34 to Medical Control at 444-3600 as soon as feasible after
the call to register the call with the system.
• All cases of INH narcan must be reported to Suffolk County EMS
by sending the post-use data form and a copy of the PCR, within
24 hours of use, either by FAX (852-5028) or EMAIL to
marty.matuza@suffolkcountyny.gov
• These cases are to be reported whether or not you perform a
blood sugar, as required by NYS DOH policy.
• It is the responsibility of the BLS Provider administering the51
form to report its use.
Post-Use Reporting Requirements
• There is no requirement to report obtaining a
blood glucose determination in cases where
you may obtain a blood sugar reading but you
DO NOT administer inhalation narcan
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The next step
Now that you have completed the educational
portion of blood glucometry, contact your
agency training officer for the required skills
review
Complete the on-line video and required skills
review for inhalation narcan
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The next step
• Documentation for successful completion
includes your:
•  Attestation of Training form for blood
glucometry
•  Skills affirmation checklist for blood glucometry
•  On-line certificate for inhalation narcan video
•  Skills affirmation checklist for inhalation narcan
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END OF PRESENTATION
Thank you for your continued support of
the Suffolk County EMS System and for
taking the time necessary to improve the
level of care that you can provide
to your patients.
Don’t forget to complete the Attestation
of Training and Skills Affirmation Forms.
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