2You Are the Emergency Medical Responder Lesson 23: Medical EmergenciesYou Are the Emergency Medical ResponderYou are the emergency medical responder (EMR) responding to a scene on a downtown street involving a male who appears to be about 60 years old. He is confused and appears agitated. Several bystanders state that they saw the man wandering aimlessly and that he appeared to be lost. Upon interviewing the patient all you can learn is that his name is Earl. He does not seem to know where he is or where he is going. During your physical exam you note that the patient is sweating profusely but, other than his diminished level of consciousness (LOC), his vital signs are normal. More advanced medical personnel have been called. As an EMR, you want to provide proper care for the patient.
3Medical EmergenciesMedical emergencies are sometimes like solving a medical mystery!You are not there to diagnose, just provide appropriate careEMRs need to think about:What is the possible problem?What are the possible causes?When did the condition begin to develop?Acute – Diabetes, heart attackChronic – Diabetes, COPD (respiratory distress), hypothermia?
4General Medical Complaints Guidelines for care are the same as for any emergency.Size-up the scenePerform a primary assessmentConduct a SAMPLE/OPQRST history and secondary assessmentSummon more advanced medical personnelHelp the patient restKeep the patient safe and comfortableProvide reassurance
5Altered Mental Status One of the most common medical emergencies Sudden or gradual change in a person’s LOCDrowsiness or confusionPartial or complete loss of consciousnessSyncopeUnpleasant sightSmells
6Causes of Altered Mental Status in Adults Conditions leading to decreased blood flow or oxygen to the brainCardiac or diabetic emergenciesShockStrokeBehavioral illnessSeizuresFever or infectionPoisoning or overdoseBlood sugar/endocrine problemsHead injuryInadequate oxygenation or ventilation
7Causes of Altered Mental Status in Children Respiratory failureHypoxemiaShockHypoglycemiaBrain injurySeizuresPoisoning or intentional overdoseSepsis – blood poisoningMeningitisHyperthermia or hypothermia
8Care for Altered Mental Status Conduct primary and secondary assessments and SAMPLE / OPQRST historyPerform ongoing assessmentEnsure an open airway; place in a recovery positionGive nothing to eat or drinkTake spinal precautions if trauma is suspectedLoosen restrictive clothingElevate legs 8-12” if you suspect no spinal injury
9SeizuresA seizure is temporary abnormal electrical activity in the brain caused by injury, disease, fever, infection, metabolic disturbances or conditions that decrease oxygen levelsEpilepsy is neurologic disorders involving recurrent seizuresStatus epilepticus – any epileptic seizure lasting longer than 5 minutes without slowing down – true medical emergency
10Types of Seizures Generalized tonic-clonic (grand mal) Most recognized Characterized by an aura, LOC, muscle rigidity (tonic phase lasting 2-5 minutes), LOBF (clonic phase), & mental confusion, followed by deep sleep, headache, and muscle soreness (postictal)PartialSimple – patient remains awareComplex – last about 1-2 min; awareness impairedAbsence (petit mal) – blank stare, occur in childrenFebrile - < 5 years of age; increase in temperature
11ScenarioYou arrive at the scene of a motor-vehicle crash and begin to provide care to two patients who are both alert and conscious with minor lacerations. They are sitting on the curb. Suddenly one of them falls to the side and begins to have a tonic-clonic seizure.
12Care for Seizures Active seizure DO NOT restrain; Remove objects that are harmful to the patient;Loosen restrictive clothing;Turn the victims head to the side if possible;DO NOT force anything into the mouth;Protect the patient, but DO NOT try to holdPost seizureProtect the airway, place in the recovery position if possible;If the patient is cyanotic, open the airway & ventilate;Treat any injuries that may have occurred, immobilize the C-spine if you suspect injury;Monitor vitals and summons more advanced help
13Diabetes Two major types: Type 1 – insulin dependent Type 2 – adult-onsetHyperglycemia (glucose high; insulin low)Hypoglycemia (glucose low; insulin high)Gestational – usually goes away after birth
14Diabetic Emergencies Signs and Symptoms Change in LOCIrregular breathingAbnormal pulse (rapid or weak)Looking or feeling illAbnormal skin characteristics
15Diabetic Emergency Hyperglycemia When sugar is used, its by products are water and carbon dioxide, which can be eliminated via the kidneys and lungsWhen fats are used, an organic acid (keto-acid) is created, creating a condition known as DKAThese ketones are exhaled on our breath usually like a sweat smelling smell (juicy fruit)As the ketones build up, acid levels in the blood increase, increasing the rate and depth of respirationsThis is occurring at the same time that the level of circulating glucose is increasing frequency of urinationThis increased urination increases the loss of fluids (dehydration) and increases the complaints of stomachaches and cramps.DKA is a build-up of keto-acids in the blood, and occurs in individuals who are dependent on insulin supplements and only when they have no taken sufficient amounts of the hormone. May be a life-threatening condition if not treated.
16Diabetic Emergency Signs of Hyperglycemia - Diabetic Coma Gradual onset;Frequent urination;Extreme thirst;Fruity breath odor (ketones);Heavy breathing;Vomiting;Drowsiness;Flushed, dry, warm skin;Eventual LOCOccurs when the body has TOO much sugar in the blood.MOIInsufficient insulin to covert sugar (e.g. too much sugar production), overeating, inactivity, illness, stress or a combination of these factors.An unconscious diabetic who is hyperglycemic is said to be in a diabetic coma
17Diabetic Emergency Hypoglycemia When the circulating glucose level falls the body reacts by allowing the adrenal glands to release adrenaline into the bloodThis stimulates the release of stored sugar, however, it also stimulates the heart, makes a person sweaty, shaky and agitatedThese are also signs of shock, therefore, the term insulin shock is used
18Diabetic Emergency Signs of Hypoglycemia Usually a sudden onset;AMS (lack of glucose);Poor coordination, confusion, combativeness, anxietyIntoxicated appearance, staggering;Cold, clammy;Sudden hunger;Excessive sweating;Trembling;Seizure (low blood sugar);Eventual LOCHypoglycemia occurs when a patient does the following:Takes to much insulin, thereby putting too much sugar into the cells and leaving too little sugar in the blood stream;Reduces sugar intake by noting eating;Over exercises or overeats himself, this using sugar faster than normal;Vomits a meal, emptying the stomach of sugar as well as other food sources;Experiences great emotional upsetExcessive insulin = insulin shock = To much insulin not enough sugarInsufficient insulin = diabetic coma = not enough insulin, too much sugarSeizures may also occur because the brain is not getting enough fuel.(“Insulin Reaction” or “Low-Blood Sugar”)
19Care for Diabetic Emergencies Perform a primary assessment and care for life-threatening conditionsConduct a physical exam and SAMPLE history (if patient is conscious); note medical ID tag or braceletConscious patient:Give sugar (glucose tablets, fruit juice, nondiet soft drink, table sugar or commercial sugar source)Unconscious patient:Monitor patient’s condition, prevent chilling or overheating, summon more advanced medical personnel and administer emergency oxygen, if available
20Stroke Cerebrovascular accident or brain attack Causes Blood clots blocking blood flow to brainRupture and bleeding of arteries in the brainTransient ischemic attack (TIA): “mini-stroke”
21Stroke: Signs and Symptoms Looking or feeling ill (common)Weakness or numbness (face, arm or leg)Facial drooping or droolingSpeech difficulties - aphasiaVisual disturbances or lossDizziness, confusion, agitation or loss of consciousnessLoss of balance or coordinationIncontinence
22Stroke Assessment Scales Cincinnati Stroke ScaleFacial DroopHave the person smile or show teethArm DriftClose eyes and hold arms out straightSpeechYou can’t teach an old dog new tricksTime
23Stroke Assessment Scales Cincinnati Stroke Scale – 89% SpecificityTime is Brain!Last time they were well?Were they watching TV programs?Los Angeles Prehospital Stroke Scale - LAPSS
24Care for Stroke Ensure an open airway Care for life-threatening conditionsPosition the patient on side to allow fluids to drainMonitor the patient’s conditionOffer comfort and reassurance (if conscious)Do not give anything by mouthTime, Time, Time
25Abdominal Pain Can be life-threatening; require immediate care Sudden onset: Acute abdomenIntensity of pain not necessarily an indicator of the seriousness of the conditionSigns and symptoms:Abdominal tendernessAnxietyNausea or vomitingRigid, tense or distended stomachRapid pulse / blood pressure changes
26Abdominal Pain Care: Ensure an open airway; call for transport Watch for signs of potential aspiration due to vomitingDo not give anything by mouthWatch for signs of shock
27Hemodialysis: Special Considerations Information on past dialysis and complications; current dialysis session; patient’s dry weight; amount of fluid removedFluid status, mental status, cardiac rhythm and shunt location (and whether active or non-functional)Any associated medical problemsShuntsEvidence of possible hypovolemia or hypervolemiaSigns and symptoms of altered mental statusCardiac rhythm
28You Are the Emergency Medical Responder As you continue monitoring the patient, he becomes even more confused and agitated. You begin to notice signs of shock.
29Enrichment Basic Pharmacology: Drug Names Chemical – based on chemical propertiesGeneric – non-proprietary, shorter nameTrade or brand – used for marketing
31Drug Administration Five Rights Right patient Right medication Right routeRight doseRight dateAdminister only by routes EMR has been licensed or authorized to administerAssess effectsDocument reason for administration
32Enrichment Blood Glucose Monitoring Testing a drop of blood on a test strip using a glucometerNormal levels:90 to 130 mg/dL before mealsLess than 180 mg/dL after mealsHypoglycemia: less than 70 mg/dL
33Care for Hypoglycemia If conscious: Give two to five glucose tablets or about 12 ounces fruit juice or nondiet soft drinkRecheck Blood Glucose Level (BGL) in 15 minutesIf unconscious:Summon more advanced medical personnel