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
