PCTH - Opioid/Hypoglycemia/Adrenal Crisis Directives Flashcards
What is glucagon?
- hormone produced by alpha cells in the pancreas that is naturally released when blood glucose levels drop
- causes liver to convert glycogen stores into glucose
Does glucagon always work? Why or why not?
may not always work because if you have already used up your glycogen stores, then glucagon will not work (no more stores to access)
Glucagon is classified as a _________ agent. Besides acting on liver glycogen, what other effects does it have?
hyperglycemic agent
relaxes smooth muscles of the stomach, duodenum, small bowel, and colon (so somettimes IV glucagon is given at the hospital to relax smooth muscles for relieving esophageal foreign bodies)
The treatment of choice for hypoglycemia in the pre-hospital setting is
dextrose
What form does dextrose come in and how is it administered?
- D50 or D10 (50% or 10% dextrose in water)
- 50G/100mls
- considered a caloric agent
- administsered IV only (cannot be injection because will cause almost instaneously necrosis)
Hypoglycemia Medical Directive
Indications
Conditions
Contraindications
Indications: suspected hypoglycemia
Conditions:
- Dextrose: ≥2 y.o., altered LOA, hypoglycemia
- Glucagon: altered LOA, hypoglycemia
Contraindications:
- Dextrose: allergy or sensitivity to dextrose
- Glucagon: allergy or sensitivity to glucagon; pheochromocytoma (rare adrenal tumor that can cause massive release of epinephrine increasing risk of stroke if given glucagon)
Hypoglycemia Medical Directive
Treatment
Clinical Considerations
Treatment: see screenshot
- Consider glucometry
- Consider dextrose (if available and authorized)
- Consider glucagon (if not using dextrose)
Clinical Considerations:
- If pt responds to dextrose or glucagon, they may receive oral glucose or other simple carbs
- If only mild S/S exhibited, pt may receive oral glucose or other simple carbs instead of dextrose or glucagon
- If a patient initiates an informed refusal of transport, a final set of vital signs including blood glucoemtry must be attempted and documented
- IV admin for PCP Autonomous IV only
- note (this one not in ALS): all pts who take oral hypoglycemic agents (metformin, glyburide, glicazide) should be transported to hospital after hypoglycemic event (due to long half time of the drug so will continuously work in system and cause hypoglycemic event to bounce back)
Hypoglycemia Medical Directive
Considerations for Treat & Discharge (if authorized)
Pt must meet all the following criteria:
* ≥18 AND <65 years old;
* has Dx of diabetes
* hypoglycemia can be explained by insulin administration w/ inadequate oral intake
* hypoglycemia responded to single admin of dextrose and/or 1mg glucagon and/or consumed oral glucose or other complex carbohydrates
* this is single isolated episode of symptomatic hypoglycemia within the past 24 hours
* BGL >4mmL after tx
* pt returned to normal LOC & asymptomatic
* a complete set of vital signs are within expected normal ranges
AND
* not an intentional OD
* hypoglycemia must not be related to alcohol or substance abuse or withdrawal
* no seizure/reported hx of seizure prior to paramedic tx
* not on an oral hypoglycemic medication
* hypoglycemia is not considered to be related to an acute medical illness
* pt not pregnant
If pt meets criteria for treat & discharge following hypoglycemic events, what should the paramedic do?
- pt has access to appropriate carbs
- responsible adult agrees to remain with pt for the 4 hrs
- all of pt or SDM questions answered & care plan developed
- pt/SDM has been advised to follow up with 1’ health care team/provider
- clear instructions to call 911 were provided should sx redevelop
- pt/SDM has ability to access 911 (if ^)
- pt/SDM consents to discharge
PATCH to BHP for consult if you are unclear if pt meets all of the discharge criteria
What S/S would cause you suspect hypoglycemia?
agitation
altered LOA/LOC (or syncope)
seizure
CVA Symptoms
Describe the steps you would take to a BGL.
1) Prep site: use alcohol swab on side of finger and ensure swab comes back clean (or else continue wiping until it’s clean) & allow dry (alcohol can inaccurately skew the BGL reading)
2) Obtain sample: need ARTERIAL drop of blood
3) Treat site
What BGL is considered hypoglycemia?
if ≥2 yo: < 4.0 mmol
if <2 yo: <3.0 mmol
To determine if patient needes a second dose, aftering the appropriate dosing interval what do you have to do?
ensure they are still meeting clinical parameters (i.e. take a BGL, assess LOA, etc.)
If a patient gives themself glucagon/dextrose prior to EMS arrival, are you still allowed to give the amount of drug allocated within your medical directive?
Yes - you can ALWAYS max out your drug directives (the only exception is if the doses given to the patient is by another on-duty paramedic such as a first response truck)
Describe the steps for administering injections.
1) Prepare site: EtOH swab (if it’s <1mL of solution, you can use deltoid, if >1mL the use bigger muscle mass)
2) Check the drug - can also double check with partner
3) Prepare the drug - prepare syringe and materials, and first aid stuff if you need to treat site after; DO NOT SHAKE GLUCAGON (or else lots of bubbles will form and you will have to wait or throw it out)
4) Administer the drug - spread the skin so it’s tight, aspirate to ensure no blood, and then complete a slow steady injection
5) Follow up care
When would it be appropriate to provide the patient with oral glucose?
- Administer once patient’s LOA increases
- can be administered if patient is exhibiting mild S/S
- 15-30g each tube (and you want pt to have 30 g total)
- taken sublingually
- Explain to patient: even though they are feeling better, this will help build up those glycogen stores so it’s good
What are the 6 rights to drug administration?
1) Right patient - they meet all the conditions, indications, contraindications, etc.
2) Right drug
3) Right time
4) Right dose
5) Right route
6) Right to Know - why we are giving it, what benefits it may have
Opiate vs opioid
Opiate: narcotic drug from a natural source
Opioid: narcotic drugs that bind to opioid receptors including synthetic compound (anything that is manufactured)
Common Opioids (13)
- Heroin (smack, H, horse)
- Morphine (statex, MS Contin)
- oxycodone (Oxycontin, Oxyneo)
- Percocet (oxycodone, acetaminophen)
- Percodan (Oxycodone + ASA)
- hydromorphone (Dilaudid)
- pentazocine (Talwin)
- fentanyl (Duragesic)
- codeine (Tylenol 2, 3)
- methadone
- Suboxone (buprenorphine + naloxone)
- Demerol (meperidine)
- opium
Common street names for Bath salts
Meow meow
Drone
Lunar X
Common street names for cocaine
yayo
sneeze
Bernice
Common street names for fentanyl
Apache
Dance Fever
Goodfella
Common street names for crystal meth
Tina
Go
Whizz
Common street names for heroin
Dragon
Skunk
Boy
Common street names for Ketamine
Honey Oil
Special La Coke
Purple
Common street names for Oxycontin
Kickers
Hillbilly Heroin
Routes of entry for opioid overdose
- injection
- PO
- Absorption (transdermal) - like fentanyl patches
- Intranasal (snorting)
- Inhalation (smoking)
Short acting opioids
- morphine
- fentanyl (PO/IV)
- hydromorphone
- Heroin
Long acting opioids
- methadone
- Oxycontin
- Transdermal Fentanyl
What are the 3 types of opioid receptors in the body?
mu
kappa
delta
Key features of an opioid OD
- altered mental status - confusion, agitation, delirium, unconsciousness
- hypoventilation
- bradycardia
- hypotension
- pulmonary edema
- hypothermia
Opioid Overdose Triad
1) Decreased LOA
2) Miosis (pinpoint pupils) - however cannot always rely on this because if they are mixing with other drugs like cocaine, they may not always show this)
3) Respiratory depression
What is naloxone?
- aka Narcan
- Strong opioid antagonist
- competes with opiates to bind with receptors in the CNS
- if no opioids are there, naloxone just won’t do anything and you’d just wait for it to pass our of your system
Naloxone is supplied most commonly in what dosages?
0.4 mg/ml
2 mg/ml
Onset of naloxone via IM/SC, IN, and IV
- IM/SC: 2-5 minutes
- IN: 8-18 minutes
- IV: 1-2 minutes
Duration of naloxone (i.e. half life)?
30-60 minutes
During an opioid overdose when naloxone is given, what can it potentially cause/lead to?
- agitation
- withdrawal symptoms
- unmask a toxidrome
- response to naloxone is unpredictable
Opioid Toxicity Medical Directive
Indications
Conditions
Contraindications
Indications:
- Altered LOC AND
- Resp depression AND
- Inability to adequately ventilate OR persistent need to assist ventilations; AND
- suspected opioid overdose
Conditions: for Naloxone
- Age: ≥24 hours
- LOA: altered
- RR: <10 breaths/min
Contraindications: allergy or sensitivity to naloxone
Opioid Toxicity Medical Directive
Treatment
Clinical Considerations
Treatment:
- IV: Titrate naloxone only to restore patient’s respiratory status.
- Dose: up to 0.4mg (only enough to restore resp status)
- Max single dose: 0.4mg
- Dosing interval: 5 mins (timer starts when you finish completing the dose)
- Max # of doses: 3
- IM: can give via deltoid
- Dose: 0.4mg
- Max single dose: 0.4mg
- Dosing interval: 5 mins
- Max # of doses: 3
- IN:
- Dose: 2-4 mg
- Max single dose: 2-4 mg
- Dosing interval: 5 mins
- Max # of doses: 3
- SC: can give in deltoid
- Dose: 0.8mg
- Max single dose: 0.8mg
- Dosing interval: 5 mins
- Max # of doses: 3
- Note: Take police and fire with you!
Clinical Considerations:
- IV administration applies only to PCPs authorized for PCP Autonomous IV
-
Upfront aggressive management of the airway is paramount and the initial priority.
- i.e. if you can control the airway and get to the hospital in a reasonable time then you don’t have to give it
- If no response to initial treatment; consider patching for further doses.
- If the patient does not respond to airway management and the administration of naloxone, glucometry should be considered.
- Combative behaviour should be anticipated following naloxone administration and paramedics should protect themselves accordingly, thus the importance of gradual titrating (if given IV) to desired clinical effect: respiratory rate ≥10, adequate airway and ventilation, not full alertness.
What is the primary goal of Naloxone?
restoration of adequate spontaneous respirations NOT wakefulness (which is why we don’t give it to VSA pts)
Common stressors that may cause a “stable” patient with primary adrenal failure (Addison’s disease) to present in crisis
hypoglycemia
infection/illness
trauma/surgery
note that hydrocortisone is lifesaving in these situations so if pt is hypoglycemic & experiencing adrenal crisis, give hydrocortisone first
Suspected Adrenal Crisis Medical Directive
Indications
Conditions
Contraindications
Indications: A pt with primary adrenal failure who is experiencing clinical signs of an adrenal crisis
Conditions: Hydrocortisone
-
Other:
- Paramedics presented with vial of hydrocortisone for pt AND
- Age-related hypoglycemia OR
- GI sx (vomiting, diarrhea, abdo pain) OR
- Syncope OR
- Temp ≥ 38C or suspected/hx of fever OR
- Altered LOA OR
- Age-related tachycardia OR
- age-related hypotension
Contraindications: allergy/sensitivty to hydrocortisone
Suspected Adrenal Crisis Medical Directive
Treatment
Clinical Considerations
Treatment:
- Route: IM/IV
- Dose: 2mg/kg* (rounded to the nearest 10mg)
- Max single dose: 100mg
- Dosing interval: n/a
- Max # of doses: 1
Clinical Considerations: IV admin of hydrocortisone for PCP AIV only.
If giving IM hydrocortisone, where is the optimal location for injection?
vastus lateralis (quick uptake of medication since these pts are very sick)
