Transcript Start Traige

Seattle/King County EMT-B Class
Topics
1
Diabetic Emergencies: Chapter 15
2
Allergic Reactions: Chapter 16
3
Substance Abuse and Poisoning: Chapter 17
1
Diabetic Emergencies
1
Defining Diabetes
Diabetes mellitus
• Metabolic disorder in which the body
cannot metabolize glucose.
• Usually due to a lack of insulin
1
Defining Diabetes, cont'd
Glucose
• One of the basic sugars in the body
• Along with oxygen, it is a primary fuel
for cellular metabolism.
Insulin
• Hormone produced by the pancreas
• Enables glucose to enter the cells
• Without insulin, cells starve.
1
Type I Diabetes
• Insulin-dependent diabetes
• Patient does not produce any insulin.
• Insulin injected daily
• Onset usually in childhood
1
Type II Diabetes
• Non-insulin-dependent diabetes
• Patient produces inadequate amounts of
insulin.
• Disease may be controlled by diet or oral
medication.
1
Role of Glucose and Insulin
• Glucose is the major source of energy
for the body.
• Constant supply of glucose needed for
the brain
• Insulin acts as the key for glucose to
enter cells.
1
Hyperglycemia
• Lack of insulin causes glucose to buildup in blood in extremely high levels.
• Kidneys excrete glucose.
• This requires a large amount of water.
• Without glucose, body uses fat for fuel.
• Ketones are formed.
• Ketones can produce diabetic
ketoacidosis.
1
Diabetic Ketoacidosis
•
•
•
•
Vomiting
Abdominal pain
Kussmaul respirations
Unconsciousness
1
Blood Glucose Monitors
• Glucometer
• Normal range:
80-120 mg/dL
1
Blood Glucose Level
1
Signs of Diabetic Coma
•
•
•
•
•
•
Kussmaul respirations
Dehydration
“Fruity” breath odor
Rapid, weak pulse
Normal or slightly low blood pressure
Varying degrees of unresponsiveness
1
Signs of Insulin Shock
• Altered mental
status
• Aggressive or confused
behavior
• Normal or rapid
respirations
• Hunger
• Pale, moist skin
• Sweating
• Dizziness,
headache
• Rapid pulse
• Fainting, seizure, or
coma
• Weakness on one side
of the body
1
Scene Size-up
1. Scene Size-up
• Scene safety remains a
priority.
• Beware of used syringes.
• Ensure that needed
resources are requested.
• Consider spinal
immobilization based on
MOI.
1
Initial Assessment
1. Scene Size-up
2. Initial
Assessment
• Decide SICK/NOT SICK.
• Does the patient appear
anxious, restless, or
listless?
• Is the patient apathetic or
irritable?
• If the patient has an
altered mental status,
summon ALS immediately.
1
Focused History/Physical Exam
1. Scene Size-up
• Unresponsive patients
receive a rapid physical
2. Initial
exam.
Assessment
• Ask patients with known
diabetes the following
3. Focused History/
questions:
Physical Exam
1
Focused History/Physical Exam
1. Scene Size-up
• Do you take insulin or any
 Patients who have eaten
taken
pillsbut
thatnot
lower
your blood
2. Initial
insulin are more likely sugar?
to have developed
Assessment
diabetic ketoacidosis.
• Have you taken your usual
Patients who have taken
insulin
but (or
have
not
dose
of insulin
pills)
3. Focused
History/
eaten are more likely to
be in insulin shock.
today?
Physical Exam
 The patient will often
knowyou
what
is wrong.
• Have
eaten
normally
 Do not assume that diabetes
today? is the cause of
the problem.
• Have you had any illness,
unusual amount of activity,
or stress today?
1
Detailed Physical Exam
1. Scene Size-up
• Focus on the patient's
ability to swallow.
2. Initial
• The patient may have
Assessment
sustained trauma or may
have another metabolic
3. Focused History/
problem; do not make
Physical Exam
assumptions.
4. Detailed Physical • Perform a careful physical
Exam
exam if time permits.
1
Ongoing Assessment
1. Scene Size-up
• Is the patient’s mental
status improving?
2. Initial
• Reassess ABCs, vital
Assessment
signs.
3. Focused History/ • If patient deteriorates,
provide more glucose.
Physical Exam
• Carefully document your
4. Detailed Physical
assessment findings.
Exam
• Follow local protocols for
refusals.
5. Ongoing
Assessment
1
Airway and Breathing
Breathing:
• If adequate or patient has an altered
mental status, provide oxygen via
nonrebreathing mask at 10 to 15 L/min.
• If inadequate, ensure ventilations with
100% oxygen.
A hyperglycemic patient may have rapid,
deep respirations (Kussmaul respirations)
and sweet, fruity breath odor.
1
Circulation
• Warm, dry skin = diabetic coma
• Moist, pale skin = insulin shock
• Rapid, weak pulse = insulin shock
1
Transport Decision
• Depends on LOC and ability to swallow.
• Patients with altered mental status and
impaired ability to swallow should be
transported promptly.
• Patients who can swallow and maintain
own airway may be further evaluated and
interventions performed.
1
Hypoglycemia Vital Signs
Hypoglycemia
• Altered mental state
• Respirations = normal to rapid
• Pulse = normal to rapid (bounding)
• Skin = pale and clammy
• Blood pressure = normal to high
1
Hyperglycemia Vital Signs
Hyperglycemia
• Respirations = deep and rapid
• Pulse = normal to fast (weak)
• Skin = warm and dry
• Blood pressure = normal to low
1
Interventions
Conscious patient
• If able to swallow without risk of
aspiration, encourage him or her to drink
juice or another drink that contains sugar.
• Or administer oral glucose.
Unconscious patient
• Will need IV glucose.
When in doubt, consult medical control.
1
Administering Glucose
• Names:
– Glutose
– Insta-Glucose
• Dose equals one tube.
• Glucose should be given to a diabetic patient
with a decreased level of consciousness.
• DO NOT give glucose to a patient with the
inability to swallow or who is unconscious.
1
Administering Glucose, cont'd
• Make sure the tube
is intact and has not
expired.
• Squeeze a generous
amount onto a bite
stick.
1
Administering Glucose, cont'd
• Open the patient’s
mouth.
• Place the bite stick on
the mucous
membranes between
the cheek and the
gum with the gel side
next to the cheek.
• Repeat.
1
Complications of Diabetes
•
•
•
•
•
•
•
•
Heart disease
Visual disturbances
Renal failure
Stroke
Ulcers
Infections of the feet and toes
Seizures
Altered mental status
1
Seizures
• Consider hypoglycemia as the cause.
• Use appropriate BLS measures for
airway management.
• Provide prompt transport.
1
Altered Mental Status
• Altered mental status is often caused by
complications of diabetes.
• Ensure that airway is clear.
• Be prepared to ventilate and suction.
• Provide prompt transport.
1
Alcoholism
• Patients may appear intoxicated.
• Suspect hypoglycemia with any altered
mental status.
• Be aware of the similarity in symptoms
of acute alcohol intoxication and
diabetic emergencies.
1
Airway Management
•
•
•
Patients may lose their gag reflex,
causing them to be unable to guard
their airway.
Be ready to manage the airway.
Place patient in lateral recumbent
position and have suction available.
2
Allergic Reactions
2
Allergic Reactions
Allergic reaction
• Exaggerated immune response to
any substance
2
Anaphylaxis
• Severe allergic reaction
• Involves multiple organs
• Can rapidly result in death
2
Anaphylaxis, continued
Most common signs:
1. Wheezing
2. Urticaria (hives)
2
Five General Allergen Categories
• Insect bites and stings
• Medications
• Plants
• Food
• Chemicals
2
Insect Bites and Stings
• Death from insect stings outnumber
those from snakebites.
• Venom is injected through stinging
organ.
• Some insects and ants can sting
repeatedly.
2
Signs and Symptoms
• Sudden pain, swelling, and redness at
site
• Itching and sometimes a wheal
• Sometimes dramatic swelling
2
Removing Stingers
2
Anaphylactic Reactions to Stings
• 5% of all people are allergic to bee,
hornet, yellow jacket, and wasp stings.
• Anaphylaxis accounts for approximately
200 deaths a year.
• Most deaths occur within half an hour of
being stung.
2
Signs/Symptoms of Allergic Reaction
•
•
•
•
Itching and burning
Widespread urticaria
Wheals
Swelling of the lips
and tongue
• Bronchospasm and
wheezing
• Chest tightness and
coughing
• Dyspnea
• Anxiety
• Abdominal cramps
• Hypotension
2
Scene Size-up
1. Scene Size-up
• Remember crew safety.
• Check environment for
source of the reaction—
insects, foods,
medications.
• Call ALS immediately if
reaction is serious, as in
this case.
2
Initial Assessment
1. Scene Size-up
2. Initial
Assessment
• Decide SICK/NOT SICK.
• Check carefully for medical
identification tags.
• See what treatment has
been administered prior to
your arrival.
2
Focused History/Physical Exam
1. Scene Size-up
• Unresponsive patients
receive a rapid physical
2. Initial
exam.
SAMPLE history helps determine:
Assessment
• For responsive patients,
obtain a SAMPLE history.
 History
of History/
specific allergies
3.
Focused
 If
patient Exam
carries medication for an allergy
Physical
 If reaction is related to food or environment
2
Focused History/Physical Exam
1. Scene Size-up
• Evaluate respiratory
system, circulatory system,
2. Initial
mental status, and skin.
Assessment
• Be alert for altered mental
status.
3. Focused History/
• Thoroughly assess
Physical Exam
breathing and auscultate.
• Check for wheezing and
stridor.
2
Detailed Physical Exam
1. Scene Size-up
Consider if:
• Complaint or history is
2. Initial
confusing.
Assessment
• There is extended
transport time.
3. Focused History/
Physical Exam
• You need to clarify
findings.
4. Detailed Physical
Exam
In severe reactions, exam
may be omitted.
2
Ongoing Assessment
1. Scene Size-up
• Monitor with vigilance;
deterioration can be rapid
2. Initial
and fatal.
Assessment
• Note the effect of
epinephrine. Consider
3. Focused History/
second dose.
Physical Exam
• Document the patient’s
4. Detailed Physical
response.
Exam
5. Ongoing
Assessment
2
Airway and Breathing
• You may only have a few minutes to
assess the airway and provide lifesaving
measures.
• Place conscious patient in tripod
position.
• Quickly listen to lungs for wheezing.
• Provide high-concentration oxygen via
nonrebreathing mask, but be prepared
to assist with ventilations if necessary.
2
Circulation
• Look for indications of circulatory
distress.
• If unresponsive without a pulse, begin
CPR and AED resuscitation.
• Rapid heart rate; cool, moist skin; and
delayed capillary refill times indicate
hypoperfusion.
2
Transport Decision
• Transport promptly.
• Take patient medications and autoinjectors with you.
• Treat respiratory distress and shock,
then transport immediately.
2
Signs and Symptoms
•
•
•
•
•
•
•
•
•
Sneezing or itchy, runny nose
Tightness in chest or throat
Irritating, persistent dry cough
Hoarseness
Rapid, labored, or noisy respirations
Wheezing and/or stridor
Decreased blood pressure
Increased pulse
Pale skin, dizziness
2
Signs and Symptoms, cont'd
• Loss of
consciousness, coma
• Flushing, itching, or
burning skin
• Urticaria
• Swelling
• Warm, tingling feeling
in the face, mouth,
chest, feet, hands
•
•
•
•
•
Anxiety
Abdominal cramps
Headache
Itchy, watery eyes
Decreasing mental
2
Baseline Vital Signs
• Assess pulse, respirations, blood
pressure, skin, and pupils.
• Watch for shock.
• Fast pulses and hypotension are
ominous signs.
• Skin signs may be unreliable due to
rashes or swelling.
2
Interventions
• Severe reactions require epinephrine
and ventilatory support.
• Milder reactions may only require
oxygen.
• In either case, transport.
2
Emergency Medical Care
• In addition to providing oxygen, be
prepared to maintain airway or give CPR.
• Placing ice over injury site may slow
absorption of toxin, but may also freeze
skin and cause more damage.
• Adult dose is 0.3 mg; pediatric dose is
0.15 mg.
2
Using an Epi-Pen
• Follow local protocols.
• Follow BSI
precautions.
• Make sure the
medication is not
discolored or expired.
2
Administering an Auto-Injector
• Remove safety cap.
• Place tip of injector against lateral side of
patient’s thigh (ideally injector tip to skin).
• Push injector firmly and hold until all
medication is injected (10 seconds).
• Remove injector.
• Massages the site (10 seconds).
• Record time and dose.
• Reassess and record vital signs.
3
Substance Abuse and Poisoning
3
Poison
Any substance whose chemical action
can damage body structures or
impair body functions.
3
Substance Abuse
Knowing misuse of any substance to
produce a desired effect.
3
Identify the Patient and the Poison
If you suspect poisoning, ask the patient
the following questions:
• What substance did you take?
• When did you take it or (become
exposed to it)?
• How much did you ingest?
• What actions have been taken?
• How much do you weigh?
3
Determine the Nature of the Poison
Take suspicious materials, containers, vomitus
to the hospital.
Provides key information on:
• Name and concentration of the drug
• Specific ingredients
• Number of pills originally in bottle
• Name of manufacturer
• Dose that was prescribed
3
Inhaled Poisons
Wide range of effects:
• Some inhaled agents cause progressive
lung damage.
Move to fresh air immediately.
All patients require immediate transport.
3
Absorbed Poisons
• If substance is in the eyes, they should be
irrigated.
• Do not irrigate with water if substance is
reactive.
3
Ingested Poison
• Poison enters the body by mouth.
• Accounts for 80% of poisonings
• May be accidental or deliberate
• Activated charcoal will bind to poison in
stomach and carry it out of the body.
• Assess ABCs.
3
Injected Poisons
• Usually result of drug overdose
• Impossible to remove or dilute poison
once injected
• Prompt transport
3
Scene Size-up
1. Scene Size-up
• Look for clues of poisons
or substances.
• Medicine bottles may be
an indication of overdose
• Alcoholic beverages/bottles
• Syringes or drug
paraphernalia
• Unpleasant or odd odor in
room
• Ensure your safety.
3
Initial Assessment
1. Scene Size-up
2. Initial
Assessment
General impression
(SICK/NOT SICK)
• Do not be fooled into
thinking a conscious, alert,
oriented patient is stable.
• Systemic reactions may
take time to develop.
• Signs of distress and
altered mental status
suggest a systemic
reaction.
3
Focused History/Physical Exam
1. Scene Size-up
SAMPLE history questions:
• What is the substance
2. Initial
involved?
Assessment
• When did the patient ingest
or become exposed?
3. Focused History/
Physical Exam
• How much was ingested?
• Over what period of time?
• Have any interventions
helped? Made it worse?
• How much does the patient
weigh?
3
Focused History/Physical Exam
1.
Scene
• or
Evaluate
Focus
on Size-up
area of body
routerespiratory
of exposure.
system, circulatory system,
2. Initial
mental status, and skin.
Treatment
is
based
on:
Assessment
• Be alert for altered mental
• What they were exposed to
status.
3. Focused
History/
• When they were exposed to it
• Thoroughly assess
Physical
Exam
• Signs and symptoms
breathing and auscultate.
• Check for wheezing and
Contact medical controlstridor.
or poison control
center to discuss options.
3
Focused History/Physical Exam
1. Scene Size-up
• Evaluate respiratory
system, circulatory system,
2. Initial
mental status, and skin.
Assessment
• Be alert for altered mental
status.
3. Focused History/
• Thoroughly assess
Physical Exam
breathing and auscultate.
• Check for wheezing and
stridor.
3
Detailed Physical Exam
1. Scene Size-up
Perform, at a minimum, on
patients:
2. Initial
• With extensive
Assessment
chemical burns
• With other significant
3. Focused History/
trauma
Physical Exam
• Who are unresponsive
4. Detailed Physical
ABCs are the priority.
Exam
3
Ongoing Assessment
1. Scene Size-up
• Patient conditions can
change quickly.
2. Initial
• Continually reassess
Assessment
ABCs.
3. Focused History/ • Repeat vital signs.
Physical Exam
• Communicate as much as
possible to receiving
4. Detailed Physical
hospital.
Exam
• Take MSDS with you or
have faxed en route.
5. Ongoing
Assessment
3
Airway and Breathing
• Open airway; provide adequate
ventilation.
• If patient is unresponsive, use airway
adjunct.
• Suctioning is critical; poisoned patients
may vomit.
• BVM may be needed.
• Take spinal precautions.
3
Circulation
• Circulatory status can vary.
• Assess pulse, skin color.
• Some poisons are stimulants, others
depressants.
• Some cause vasoconstriction, others
vasodilation.
• Bleeding may not be obvious.
3
Transport Decision
• Alterations to ABCs and a poor general
impression require immediate transport.
• Check industrial settings for specific
decontamination sites/antidotes.
• Consider decontamination before
transport.
3
Interventions
• Depends on poison.
• Support ABCs.
• Some poisons can be easily diluted or
decontaminated before transport.
• Dilute airborne exposures with oxygen.
• Remove contact exposures with water unless
contraindicated.
• Consider activated charcoal for ingested
poisons.
• Contact medical control to discuss options.
3
Emergency Medical Care
• External decontamination is important.
• Care focuses on support: assessing and
maintaining ABCs.
• You may be permitted to give activated
charcoal for ingested poisons.
3
Activated Charcoal
Charcoal is not indicated for:
• Ingestion of an acid, alkali, or
petroleum
• Patients with decreased level of
consciousness
• Patients who are unable to swallow
Usual dosage is 25 to 50 g for adults and
12.5 to 25 g for pediatric patients.
3
Activated Charcoal, cont'd
•
•
•
•
Obtain approval from medical control.
Shake bottle vigorously.
Ask patient to drink with a straw.
Record the time you administered the
activated charcoal.
• Be prepared for vomiting.
3
Specific Poisons
Tolerance
• Need for increased amount of drug to
have same desired effect
Addiction
• Overwhelming desire or need to
continue using an agent
3
Alcohol
• Most commonly abused drug in the US
• Kills more than 200,000 people a year
• Alcohol is a powerful CNS depressant.
• Acts as a sedative and hypnotic
• A person that appears intoxicated may
have a medical problem.
3
Alcohol, continued
• Intoxicated patients should be
transported and seen by a physician.
• If patient shows signs of serious CNS
depression, provide respiratory support.
• A patient with alcohol withdrawal may
experience delirium tremors (DTs).
3
Alcohol, continued
Patients with DTs may experience:
•
•
•
•
•
•
Agitation and restlessness
Fever
Sweating
Confusion and/or disorientation
Delusions and/or hallucinations
Seizures
3
Opioids
• Drugs containing opium
• Most of these, such as Codeine, Darvon,
and Percocet, have medicinal purposes.
• The exception is heroin, which is illegal.
• Opioids are CNS depressants causing
severe respiratory distress.
3
Opioids, continued
• Care includes supporting airway and
breathing.
• You may try to wake patients by talking
loudly or shaking them gently.
• Always give supplemental oxygen and
prepare for vomiting.
3
Sedative-Hypnotic Drugs
• These drugs are CNS depressants and
alter level of consciousness.
• Patients may have severe respiratory
depression and even coma.
• The main concern is respiratory
depression and airway clearance,
ventilatory support, and transport.
3
Abused Inhalants
• "Huffing"
• Common household
products inhaled by
teenagers for a high
• Effects range from
mild drowsiness to
coma
• May often cause
seizures
3
Abused Inhalants, continued
• Patient is at high risk for sudden cardiac
arrest.
• Try to keep the patients from struggling
or exerting themselves.
• Give oxygen and use a stretcher to
move patient.
• Prompt transport is essential.
3
Sympathomimetics
• CNS stimulants cause hypertension,
tachycardia, and dilated pupils.
• Amphetamine and methamphetamine are
commonly taken by mouth.
• Cocaine can be taken in may different
ways.
– Can lead to seizures and cardiac
disorders
• Be aware of personal safety.
3
Marijuana
• Smoked by 20 million people daily in
the US
• Produces euphoria, relaxation, and
drowsiness
• Impairs short-term memory and ability
to work
• Transport to hospital is rarely needed.
• Marijuana can be used as vehicle for
other drugs, ie, it can be covered with
PCP or crack.
3
Hallucinogens
• Alter an individual’s sense of perception
• LSD and PCP are potent hallucinogens.
• Sometimes, people experience a “bad
trip.”
• Patient typically are hypertensive,
tachycardic, anxious, and paranoid.
3
Hallucinogens, continued
• Use a calm, professional manner and
provide emotional support.
• Only restrain if danger of injury exists.
• Watch the patient carefully during
transport.
3
Anticholinergics
• “Hot as a hare, blind as a bat, dry as a bone,
red as a beet, and mad as a hatter”
• Block the parasympathetic nerves
• Patient may go from “normal” to seizure to
death within 30 minutes.
• Consider ALS backup.
3
Cholinergic Agents
• Commonly used as nerve agents for
warfare
• Overstimulate body functions controlled
by the parasympathetic nervous system
• Organophosphate insecticide or wild
mushrooms are also cholinergic agents.
3
Signs/Symptoms of Cholinergic Poisoning
D Defecation
U Urination
M Miosis
B Bronchorrhea
E Emesis
L Lacrimation
S Salivation
S
L
U
D
G
E
Salivation
Lacrimation
Urination
Defecation
GI irritation
Eye constriction/Emesis
3
Care for Cholinergic Poisoning
• Main concern is to avoid exposure
• May require field decontamination
• Priority after decontamination is to
decrease the secretions in the mouth and
trachea.
• Provide airway support.
• May be treated as a HazMat incident
3
Aspirin
Signs and symptoms
• Nausea/vomiting
• Hyperventilation
• Ringing in ears
• Confusion
• Seizures
Patients should be transported
quickly to the hospital.
3
Acetaminophen
• Overdosing is common.
• Generally not very toxic
• Symptoms may not appear until it is too
late.
• Liver failure may not be apparent for a full
week.
• Gathering information at the scene is very
important.
3
Other Alcohols
• Methyl alcohol and ethylene glycol are
more toxic than ethyl alcohol.
• May be taken by chronic alcoholics who
cannot obtain drinking alcohol
• More often taken by someone
attempting suicide
• Immediate transport is essential.
3
Food Poisoning
• Salmonella bacterium causes severe GI
symptoms within 72 hours.
• Staphylococcus is a common bacteria
that grows in foods kept too long.
• Botulism often results from improperly
canned foods.
3
Care for Food Poisoning
• Try to obtain as much history as
possible.
• Transport patient to hospital promptly.
• If two or more persons have the same
illness, bring some of the suspected
food to the hospital, if possible.
3
Plant Poisoning
Several thousand cases of plant poisonings
occur each year.
If you suspect plant poisoning:
• Assess the patient’s airway and vital
signs.
• Notify poison control center.
• Take the plant to the emergency
department.
• Provide prompt transport.
Questions
• What questions do you have?
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