Basic Outline Ch 19
I.
Diabetes (pp. 448–458)
A.
Diabetes mellitus, “sugar diabetes,” or just “diabetes”
1.
Decreased insulin production or inability (commonly older patients) to use
insulin properly, resulting in high bloodsugar (p. 449)
a.
B.
Person suffering from this condition is a diabetic
Diabetic emergencies (p. 450)
1.
Hypoglycemia (low blood sugar)
a.
b.
c.
d.
Caused by the following
i.
Takes too much insulin (or oral medication used to treat
diabetes)
ii.
Reduces sugar intake by not eating
iii.
Overexercises or overexerts himself
iv.
Vomits a meal, emptying stomach of sugar as well as other
food
Children are more at risk for hypoglycemia than diabetic adults.
i.
Children can exhaust blood sugar levels by playing hard.
ii.
Children are less likely to be disciplined about eating
correctly and on time.
Signs
i.
Rapid onset
ii.
Abnormal behavior
iii.
Very sweaty skin
Treatment
i.
Quick administration of glucose
(1)
2.
Patient must be conscious and be able to swallow if
oral glucose used
Hyperglycemia (high blood sugar)
a.
Caused by a decrease in insulin, which leaves sugar in the
bloodstream rather than allowing it to enter the cells
b.
Unlike hypoglycemia, generally has a slower onset
i.
Patient experiences increased urination, thirst, and hunger
(1)
C.
May be nauseated and have an acetone-like odor
on his or her breath
Patient assessment (p. 450)
1.
Diabetic emergencies
a.
To access patient
i.
Perform initial assessment (identify altered mental status).
ii.
Perform a focused history and physical exam.
(1)
History of present episode from patient or
bystanders
(2)
SAMPLE history
(3)
b.
(a)
Look for medical identification bracelet or
wallet card.
(b)
Look for medications (insulin and
medication to treat diabetes).
Perform glucose monitoring if permitted by local
protocol.
iii.
Determine if patient is alert enough to swallow.
iv.
Determine baseline vital signs.
Signs and symptoms associated with diabetic emergency
i.
Onset of altered mental status
(1)
After a meal on day patient took prescribed insulin
(2)
Vomiting a meal on a day took prescribed insulin
(3)
After unusual amount of physical exercise or work
(4)
No identifiable predisposing factor
D.
ii.
Intoxicated appearance, staggering, slurred speech, to
unconscious
iii.
Cold, clammy skin
iv.
Elevated heart rate
v.
Hunger
vi.
Uncharacteristic behavior
vii.
Anxiety
viii.
Combativeness
ix.
Seizures
Blood glucose meters (pp. 451–455) (Scan 19-2, p. 453)
1.
Calibrated and stored according to manufacturer’s recommendations
2.
Steps to follow
a.
Take Standard Precautions.
b.
Prepare device, including test strip and lancet.
c.
Cleanse finger with alcohol prep.
d.
Stick the finger and wipe away the first drop of blood.
e.
Apply second drop of blood to strip.
f.
Meter analyzes the sample and provides a reading.
g.
Less than 60 to 80 milligrams per deciliter in a symptomatic
diabetic is typical of hypoglycemia and indicates need for prompt
administration of glucose.
i.
Value less than 50 milligrams per deciliter will usually
indicate significant altered mental status.
ii.
Reading over 120 to 140 milligrams per deciliter indicates
hyperglycemia.
iii.
A reading inconsistent with patient’s symptoms should
have EMT question the result.
(1)
Consider insufficient blood sample, expired strip,
not stored properly, meter needs calibration, or
device not used properly.
E.
Calibration and testing on a regular basis are
essential.
(3)
The blood glucose monitor is just one tool and
should never be done before a thorough initial
assessment.
Patient care (p. 455)
1.
II.
(2)
Diabetic emergencies
a.
Determine all of the following criteria for administration of oral
glucose are present: history of diabetes, altered mental status,
and is awake enough to swallow
b.
If criteria met, then administer oral glucose.
c.
Reassess patient and consult medical direction about
administering more oral glucose.
d.
If patient not awake enough to swallow, treat him or her like any
other patient with altered mental status.
i.
Secure airway, provide artificial ventilations if necessary,
and be prepared to perform CPR.
ii.
Position the patient appropriately.
iii.
Request an ALS intercept if available.
Additional Information on Diabetes (pp. 457–458)
A.
B.
Types of diabetes
1.
Type I is usually insulin-dependent
2.
Type II is non-insulin-dependent (usually associated with obesity)
Hyperglycemia (p. 449)
1.
High blood sugar
a.
Occurs when the diabetic does not produce enough natural insulin
to take sugar out of blood and into cells
i.
Usually occurs due to one of the following:
(1)
Diabetic hasn’t taken enough insulin
(2)
Diabetic has forgotten to take insulin
ii.
C.
Diabetic has overeaten
(4)
Diabetic has an infection that has upset his
insulin/glucose balance
Body uses other alternate forms of food energies,
particularly stored fats, which results in ketones in the
blood turning the blood acidic
(1)
Person will drink large quantities of water to make
up for fluid loss through excess urination
(2)
Leads to a serious condition known as diabetic
ketoacidosis
Hypoglycemia and hyperglycemia compared (p. 449)
1.
Onset—hyperglycemia usually slower
2.
Skin
3.
a.
Hyperglycemic patient often warm, red, and dry
b.
Hypoglycemic patient cold, pale, moist, or “clammy”
Breath
a.
Hyperglycemic patient often has acetone breath and
hypoglycemic patient does not
4.
Hyperglycemic patient frequently breathes very deeply and rapidly with a
dry mouth, intense thirst, abdominal pain, and vomiting
5.
Distinguishing some of the differences in the field may be difficult.
a.
6.
III.
(3)
Consult medical direction if questions or concerns.
“Sugar (glucose) for everyone”
Other Causes of Altered Mental Status (pp. 458–469) (Fig. 19-4, p. 460) (Scan 19-4,
p. 464)
A.
Seizure disorders
1.
Common causes (pp. 458–461)
a.
Adults—failure to take prescribed antiseizure medications
b.
Infants/children (3 months to 3 years)—febrile seizures
2.
3.
Categories (pp. 458–459)
a.
Toxic—drug or alcohol use, abuse, or withdrawal
b.
Brain tumor
c.
Congenital brain defects—defects in the brain
d.
Infection—swelling and inflammation in the brain
e.
Metabolic—irregularities in brain body chemistry
f.
Trauma—head injury
g.
Idiopathic—spontaneously with unknown cause
h.
Epilepsy
i.
Stroke
j.
Measles, mumps, and other childhood diseases
k.
Hypoglycemia
l.
Eclampsia
m.
Hypoxia (lack of oxygen)
n.
Heat stroke (resulting from exposure to high temperature)
Patient assessment
a.
Seizure disorders
i.
Ask the following questions (usually from bystanders):
(1)
What was the person doing before the seizure
started?
(2)
Exactly what did the person do during the seizure—
movement by movement—was there loss of
bladder or bowel control?
(3)
How long did the seizure last?
(a)
Two or more convulsive seizures without
regaining full consciousness and lasting 5 to
10 minutes or more is known as status
epilepticus.
(4)
4.
What did the person do after the seizure? Was he
asleep? Was he awake? Was he able to answer
questions? (If not sure, use AVPU scale to assess
mental status.)
Patient care
a.
Seizure disorders
i.
Present during the seizure
(1)
Place patient on floor/ground.
(a)
ii.
5.
IV.
If no possibility of spine injury, position
patient on side.
(2)
Loosen restrictive clothing.
(3)
Remove objects that may harm the patient.
(4)
Protect the patient from injury, but do not try to hold
the patient still during convulsions.
After convulsions have ended
(1)
Protect the airway.
(2)
If patient is cyanotic, ensure an open airway and
provide artificial ventilations with supplemental
oxygen.
(3)
Treat any injuries the patient may have sustained
during the convulsions, or rule out trauma
(immobilize the neck and spine if trauma
suspected).
(4)
Transport to a medical facility, monitoring vital signs
and respirations closely.
If patient refuses transportation, try to encourage patient to go to
hospital—if he or she still won’t go, then patient should not be left alone
and should not drive.
Types of Seizure (p. 461)
A.
Partial seizures
1.
Also called focal motor, focal sensory, or Jacksonian
a.
Simple seizure
b.
B.
ii.
May be an aura (sensation such as smell, bright lights,
or burst of color)
Complex partial seizure (also called psychomotor or temporal
lobe)
i.
Patient confusion, glassy stare, aimless moving about,
lip smacking, and chewing or fidgeting with clothing
ii.
May appear to be drunk or on drugs
iii.
Not violent but may struggle or fight restraint
iv.
No loss of consciousness
v.
May be confusion and no memory of episode
vi.
Rarely develops into a tonic-clonic seizure
Tonic-clonic (also called grand mal) seizure
a.
Three distinct phases
i.
Tonic phase—body becomes rigid and stiffens for no more
than 30 seconds; breathing may stop; patient may bite
tongue; bladder and bowel control lost
ii.
Clonic phase—body jerks about violently, usually no more
than 1 to 2 minutes; patient may foam at mouth and drool;
face and lips become cyanotic
iii.
Postictal phase—begins when convulsions stop; patient
may regain consciousness immediately and enter a state
of drowsiness and confusion or may remain unconscious;
headache is common
Absence seizure (also called petit mal)
1.
Brief only lasts 1 to 10 seconds
a.
D.
Patient tingling, stiffening, or jerking in just one part of the
body
Generalized seizures (p. 461)
1.
C.
i.
No dramatic motor activity
Stroke (pp. 462–466)
1.
Death or injury to brain tissue that is deprived of oxygen
a.
b.
c.
Causes
i.
Blockage of artery that supplies the brain (called ischemic
stroke)
ii.
Bleeding from a ruptured blood vessel in the brain (called
hemorrhagic stroke)
Signs
i.
One-sided weakness (hemiparesis)—body weakness is
opposite from the side of the brain that is affected
ii.
Headacheiii. Inability to speak or use words (aphasia is a
general term that refers to difficulty in communication)
Transient ischemic attack (TIA)
i.
Patient is confused, weak on one side, and having difficulty
speaking but may be acting normal when EMS arrives.
(1)
d.
Initially may look like a stroke
ii.
Patient is at risk for a full-blown stroke.
iii.
If patient refuses transport, should be encouraged to be
evaluated as soon as possible.
Patient assessment (pp. 464–465)
i.
Cincinnati Stroke Scale
(1)
(2)
(3)
Ask patient to grimace or smile (ask that they show
their teeth).
(a)
Normal is to move both sides of face equally
(b)
Abnormal is unequal movement or no
movement
Ask patient to close eyes and extend arms straight
out in front for 10 seconds.
(a)
Normal is patient moves both arms at the
same time
(b)
Abnormal is one arm drifts down or does not
move at all
Ask patient to say something like “The sky is blue in
Cincinnati.”
ii.
e.
(a)
Normal is clear speech.
(b)
Abnormal response is slurred speech,
wrong words, or no speech at all.
Other signs and symptoms
(1)
Confusion
(2)
Dizziness
(3)
Numbness, weakness, or paralysis (usually onesided)
(4)
Loss of bowel or bladder control
(5)
Impaired vision
(6)
High blood pressure
(7)
Difficult respiration or snoring
(8)
Nausea or vomiting
(9)
Seizures
(10)
Unequal pupils
(11)
Headaches
(12)
Loss of vision in one eye
(13)
Unconsciousness (uncommon)
Patient care (pp. 465–466)
i.
ii.
For conscious patient
(1)
Maintain and monitor airway.
(2)
Administer high-concentration oxygen.
(3)
Calm and reassure patient.
(4)
Transport in a semisitting position.
For unconscious patient
(1)
Open airway if patient can’t maintain on own.
iii.
E.
(2)
Provide high-concentration oxygen.
(3)
Transport with patient lying on the affected side.
Follow any special protocols.
Dizziness and syncope (pp. 466–469) (Fig. 19-6, p. 467)
1.
Dizziness can be described in many ways by patients: loss of strength,
spinning, lightheadedness, weakness
2.
Syncope is a brief loss of consciousness with spontaneous recovery
a.
3.
May have some symptoms as a warning before an episode
i.
Lightheadedness
ii.
Dizziness
iii.
Nausea
iv.
Weakness
v.
Vision changes
vi.
Sudden pallor (loss of normal skin color)
vii.
Sweating
viii.
Occasionally incontinence
ix.
Patient may describe palpitations, racing heart, slow heart
rate, or a headache.
Causes of dizziness and syncope (pp. 467–469)
a.
b.
Hypovolemia
i.
Low fluid/blood volume (dehydration)
ii.
Women of childbearing age may have ruptured ectopic
pregnancy
iii.
Slow leaking abdominal aortic aneurysm
iv.
Gastrointestinal bleeding
Metabolic
i.
Hypoglycemia
c.
d.
Environmental/toxicological
i.
Alcohol/drugs
ii.
Carbon monoxide poisoning
iii.
Panic attacks
Cardiovascular
i.
ii.
e.
4.
Dysrhythmias
(1)
Bradycardia
(2)
Tachycardia
Vasovagal syncope
Other causes
Patient assessment (p. 469)
a.
Questions for focused history and physical exam
i.
What do you mean by dizziness? weakness? a spinning
sensation? lightheadedness?
ii.
Did you have any warning? If so, what was it like?
iii.
When did it start?
iv.
How long did it last?
v.
What position were you in when the episode occurred?
vi.
Have you had any similar episodes in the past? If so, what
cause was found?
vii.
Are you on medication for this kind of problem?
viii.
Did you have any other signs or symptoms? Nausea?
Vomiting (what did it look like)? Black tarry stools?
ix.
Did you witness any unpleasant sight or experience
a strong emotion?
x.
Did you hurt yourself?
xi.
Did anyone witness involuntary movments of the
extremities (like seizures)?
5.
Patient care (p. 469)
a.
Administer high-concentration oxygen.
b.
Loosen any tight clothing around the neck.
c.
Get the patient flat and elevate the legs if there is no reason not to
do so.
d.
Call ALS if it is available in your area.
e.
Treat any associated injuries the patient may have incurred from
the fall.
f.
Transport in the position of comfort.