Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Chapter 19 Diabetic Emergencies and Altered Mental Status

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory U.S. DOT Objectives Directory U.S. DOT Objectives are covered and/or supported by the PowerPoint™ Slide Program and Notes for Emergency Care, 11th Ed. Please see the Chapter 19 correlation below. *KNOWLEDGE AND ATTITUDE Identify the patient taking diabetic medications with altered mental status and the implications of a diabetes history. Slides 9, 14-15, State the steps in the emergency medical care of the patient taking diabetic medicine with an altered mental status and a history of diabetes. Slides Establish the relationship between airway management and the patient with altered mental status. Slides 14, 20-21, 28-29, 42, 45, 53, 59, State the generic and trade names, medication forms, dose, administration, action, and contraindications for oral glucose. Slides Evaluate the need for medical direction in the emergency medical care of the diabetic patient. Slide Explain the rationale for administering oral glucose. Slides (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory U.S. DOT Objectives Directory *SKILLS Demonstrate the steps in the emergency medical care for the patient taking diabetic medicine with an altered mental status and a history of diabetes Demonstrate the steps in the administration of oral glucose Demonstrate the assessment and documentation of patient response to oral glucose Demonstrate how to complete a prehospital care report for patients with diabetic emergencies.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Diabetes Mellitus

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory The condition brought about by decreased insulin production, or the inability of the body cells to use insulin properly (which prevents the body’s cells from taking the simple sugar called glucose from the bloodstream) Diabetes Mellitus

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Insulin Allows Sugar to Pass from the Bloodstream to the Body’s Cells

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Diabetes and Insulin Click here to view an animation on diabetes and insulin.here

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Normal Glucose Regulation

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Diabetes Is Treated with Injections of Insulin or Oral Medication

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Diabetic Emergencies

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Hypoglycemia Hyperglycemia Two Types of Diabetic Emergencies

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Hypoglycemia (low blood sugar) is a life-threatening emergency for people with diabetes. It is the most common emergency for the diabetic patient. Hypoglycemia

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory After taking too much insulin Vomiting After unusual amount of exercise Reduced sugar intake caused by not eating Causes of Hypoglycemia

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Rapid onset Intoxicated appearance, staggering, slurred speech, unconsciousness Cold, clammy skin Rapid heart rate Seizures (severe cases) Signs and Symptoms of Hypoglycemia (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Unusual or bizarre behavior Anxiety Refusal to cooperate or combativeness Signs and Symptoms of Hypoglycemia

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Hyperglycemia (high blood sugar) is a slow-onset condition from decreased insulin levels in people with diabetes. Hyperglycemia

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Forgotten or insufficient insulin dose Infection Stress Increased dietary intake Causes of Hyperglycemia

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Slow onset Nausea/vomiting Acetone odor on breath Increased urination/hunger/thirst Signs and Symptoms of Hyperglycemia

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Distinguishing the Difference Slow onset Skin is warm, red, or dry. Acetone odor on breath Increased urination/hunger/ thirst Abdominal cramps Hyperglycemia Rapid onset Skin is cold, pale, moist, or “clammy.” No breath odors Hypoglycemia

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Perform initial assessment. Perform focused history and physical exam. Get SAMPLE history. – Note any medical alert tags. Take baseline vital signs. Assessing Diabetic Emergencies

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Perform initial assessment. – Maintain airway. – Administer oxygen. Assessing and Treating Diabetic Emergencies (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory – When and how did it start? – How long did it last? – Complaints of other symptoms? – Any trauma involved? Perform focused history and physical exam. Assessing and Treating Diabetic Emergencies (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory – Any medical alert tags? – Has the patient seized? – Fever? – Interruptions in episode? Perform focused history and physical exam. Assessing and Treating Diabetic Emergencies

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Diabetic Patients Often Test Their Blood Glucose at Home

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Get a SAMPLE history. If the patient has a history of diabetes: – – When did patient last eat? – Any medications? Last taken? – Any other illnesses? – Can the patient swallow? Assessing and Treating Diabetic Emergencies (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Take baseline vital signs. – In some areas, protocols direct the EMT to treat the patient before getting vital signs. FOLLOW YOUR LOCAL PROTOCOL! Assessing and Treating Diabetic Emergencies (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory – History of diabetes – Altered mental status – Patient can swallow Give oral glucose if all of these conditions are met: Assessing and Treating Diabetic Emergencies (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Reassess patient. If patient becomes unconscious, stop glucose administration immediately and secure the airway! If no improvement, consult medical direction. Assessing and Treating Diabetic Emergencies (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory If patient is not awake enough to swallow: – – Secure airway. – Administer oxygen. – Position appropriately. – Request ALS and transport. Assessing and Treating Diabetic Emergencies

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Blood Glucose Meters

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Using Blood Glucose Meter and Test Strip

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 80–120 mg/dlNormal 60–80 mg/dlModerate hypoglycemia Below 50 mg/dlSevere hypoglycemia Above 120 mg/dlHyperglycemia Question results that are inconsistent with patient’s condition. Blood Glucose Readings

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Meter not calibrated Low batteries in meter Improperly stored or expired test strip Insufficient blood on test strip Causes of Inaccurate Reading

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Administration of Oral Glucose

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Squeeze Glucose onto Tongue Depressor

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Insert Tongue Depressor between the Patient’s Cheek and Gum

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Indications: – Altered mental status – Ability to swallow Contraindications: – Unconsciousness – Diabetic who has not taken insulin for days – Inability to swallow Oral Glucose (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Dosage: one tube Oral Glucose (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Administration: – Assure altered mental status with history of diabetes. – Assure patient is conscious. Oral Glucose (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Oral Glucose (cont.) Administration: – Administer glucose on tongue depressor between cheek and gum, or let patient self-administer. – Perform ongoing assessment.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Oral Glucose Actions: – Increases blood sugar Side effects: – None when given properly – May be aspirated if given to patient without gag reflex (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Oral Glucose Reassessment strategies: – If patient seizes or loses consciousness, remove tongue depressor and secure airway.

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Altered Mental Status

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Hypoglycemia Poisoning (including alcohol and drugs) Infection Head trauma Hypoxia Causes of Altered Mental Status

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Evaluate potential causes. Transport. Ventilate and suction as needed. Secure airway. Emergency Care of Altered Mental Status (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Treat patient as trauma patient if injury cannot be ruled out. Emergency Care of Altered Mental Status

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Sudden change in sensation, behavior, or movement caused by irregular electrical activity of the brain Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Toxin (including drugs and alcohol) Brain tumor Congenital brain defects Trauma Infection/fever (#1 cause in pediatric patients 6 months to 3 years old) Causes of Seizures (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Epilepsy Stroke Hypoglycemia Eclampsia (complication of pregnancy) Hypoxia Unknown Causes of Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory What was the patient doing before the seizure? What movements were exhibited? Loss of bladder or bowel control? What did the patient do after the seizure? Length of episode? Information to Obtain

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Protect patient from injury; do not hold patient still or place anything in mouth. Remove harmful objects. Loosen restrictive clothing. Position patient on side. Place patient on floor. Emergency Care During Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory After seizure subsides: – Protect airway with positioning and suction. – If cyanotic, ventilate with oxygen. – Treat injuries. – Transport. Emergency Care of Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory In a simple partial seizure (also called focal motor, focal sensory, or Jacksonian), there is tingling, stiffening, or jerking in just one part of the body. Simple Partial Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory This type of seizure (also called psychomotor or temporal lobe) is characterized by abnormal behavior that varies widely from person to person. Complex Partial Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory In a tonic-clonic (also called grand mal) seizure, there is often no aura or other warning. This type of seizure is characterized by unconsciousness and major motor activity. Generalized Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory An absence seizure (also called petit mal) is brief. There is no dramatic motor activity and the person usually does not slump or fall. Instead there is a temporary loss of concentration or awareness. Absence Seizures

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory A life-threatening condition in which the patient has two or more convulsive seizures without regaining consciousness or lasting more than 5 minutes Status Epilepticus

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Transport immediately. Request ALS. Ventilate with 100% oxygen. Secure the airway. Emergency Care of Status Epilepticus

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Stroke

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Death or injury of brain tissue that is deprived of oxygen Caused by a blockage (ischemic) or bleeding (hemorrhagic) of a blood vessel in the brain Stroke

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Intoxicated appearance, slurred speech, unconsciousness Severe headache, vision changes One-sided weakness on body Confusion Signs and Symptoms of Stroke (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Loss of bladder/bowel control Unequal pupils High blood pressure Signs and Symptoms of Stroke

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory “Mini-stroke” Signs and symptoms of a stroke Often resolved before EMS arrival Symptoms resolve without treatment in less than 24 hours Significant risk of having a “full” stroke Transient Ischemic Attack (ITA)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Maintain airway; administer oxygen. Identify potential stroke patients and notify the hospital. Prompt transport is critical. Treatment of Stroke

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Have patient attempt to smile. Cincinnati Prehospital Stroke Scale (cont.) © Michal Heron Photography

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Have patient attempt to hold arms straight in front of her for 10 seconds. Cincinnati Prehospital Stroke Scale (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Evaluate patient’s speech. Cincinnati Prehospital Stroke Scale

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Syncope is a brief loss of consciousness. It can occur at any age; more common in elderly. It may be an indicator of a serious medical problem. Dizziness and Syncope

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Hypovolemia – Trauma – Dehydration Metabolic – Hypoglycemia – Stroke – Seizure Causes of Dizziness and Syncope (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Environmental/toxicological – Alcohol/drugs – Carbon monoxide – Panic/anxiety Causes of Dizziness and Syncope (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Cardiovascular – Fast or slow heart rates – Electrical system disturbance – Vagus nerve stimulation Causes of Dizziness and Syncope

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Obtain a SAMPLE history. Ask about onset time, activities. Length of episode? Any previous episodes? Assessment of Dizziness and Syncope

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Any medications for this condition? Any nausea/vomiting/bowel changes? Treatment of Dizziness and Syncope (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Request ALS and transport. Treat any associated injuries. Lay patient flat and elevate legs (if no suspected spinal injury). Loosen restrictive clothing. Administer high-concentration oxygen. Treatment of Dizziness and Syncope

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 1. List the signs and symptoms of a diabetic emergency. 2. Explain how you can determine a medical history of diabetes. 3. Explain what treatment may be given by an EMT for a diabetic emergency and the criteria for giving it. Review Questions (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 4. Tell whether treatment for a diabetic emergency should be given before or after baseline vital signs are taken. 5. Explain the care that should be given to a patient who has had a seizure. Review Questions (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory 6. Explain the care that should be given to a conscious and to an unconscious patient with suspected stroke. 7. Explain the care that should be given to a patient who has experienced dizziness or syncope. Review Questions

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Does this patient need a thorough assessment? What is the first concern when starting to assess this patient? Street Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory What types of underlying medical problems might make a patient appear to be drunk? Does your assessment plan change at this point? Street Scenes (cont.)

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory How will you get a SAMPLE history if the patient is alone? What is the priority level of this patient? Is there a need for ALS assistance? Street Scenes

Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Sample Documentation