Seizure + Hypoglycemia + Opioid Toxicity Flashcards by JESSIE ANSELL

Treat and Dischrage Medical Directives

What is the IDEAL mnemonic?

What should you do if you are unclear if the patient meets all of the discharge criteria?

INCLUDE the patient and family as full partners

DISCUSS with the patient and family key areas to prevent problems

EDUCATE the patient and family in plain language

ASSESS the patient’s understanding

LISTEN to the patient’s goals, preferences, observations, and concerns

Patch to BHP for a consultation.

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Seizure Medical Directive - AUXILIARY

What are the first 7 considerations criteria for treat and discharge?

What are the 5 AND criteria the patient needs to meet for treat and discharge?

The patient is ≥ 18 and <65 years old

Pt must have a history of epilepsy

The pt is taking their anticonvulsant medications as prescribed

The pt must have only had a single seizure episode in the past 24h

The seizure pattern and duration must be similar to past seizures

The pt has returrned to their normal level of consciousness

A complete set of vital signs including temp are within expected normal ranges

The seizure must not be related to hypoglycemia, alcohol, or substance abuse or withdrawal

The pt must not have received midazolam by paramedics

The pt did not injure themselves during seizure activity

The pt must not have a fever, preceding illness or recently started new medications

The pt is not pregnant

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Seizure Medical Directive - AUXILIARY

What are the 6 requirements that must be met for the paramedics to discharge?

A responsible adult agrees to remain with the patient for the next 4 hours

All of the patient or substitute decision makers questions were answered, and a care plan was developed

The patient or SDM has been advised to follow up with their primary health care team or provider

Clear instructions to call 911 were provided should symptoms redevelop

Patient or SDM has the ability to access 911 should symptoms redevelop

Patient or SDM consents to the discharge

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Seizure Medical Directive - AUXILIARY

What does a confirmed hx of epilepsy mean?

What does new medication refer to with regards to seizures?

Means diagnosed by a physician

The addition of new or changes to anti-seizure medications (dosage or type) in the past 30 days should be considered as they can potentially lower a patient’s seizure threshold

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Seizure Medical Directive - AUXILIARY

What is a seizure cluster?

multiple seizures that occur within a 24 hour period

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Opioid Toxicity and Withdrawal Medical Directive

What are the INDICATIONS?

What is Buprenorphine/naloxone (Suboxone)?

What is naloxone/narcan?

Suspected opioid toxicity

mixed opioid agonist-antagonist used for opioid withdrawal symptoms

non-specific + competitive opioid receptor antagonist metabolized in the liver

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Opioid Toxicity and Withdrawal Medical Directive

What are the CONDITIONS for Naloxone?

What are the CONTRAINDICATIONS?

GREATER/EQUAL to 24h old

Altered LOA

LESS than 10 breaths/min

Inability to adequetely ventilate
OR
persistant need to assist ventilations

Allergy or sensitivity to naloxone

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Opioid Toxicity and Withdrawal Medical Directive

Why is IV use preferred 1st for naloxone?

Can you make a judgment call on the route of naloxone?

What are aloquotes? - are they considered a dose?

Because you can titrate i.e. administer slowly

Yes - sometimes IN is better

They are smaller doses compared to the standard/desired dose - it is considered a full dose once they accumulate to meet it

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Opioid Toxicity and Withdrawal Medical Directive

What should you do if the pt was administered naloxone before your arrival?

The timing interval is 20min so you should wait and vetilate the pt based on their timing of the naloxone administration. If the patient isn’t improving then administer.

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Opioid Toxicity and Withdrawal Medical Directive

What are the CONDITIONS for Buprenorphine/naloxone?

What are the CONTRAINDICATIONS?

GREATER/EQUAL to 16y/old

Unaltered LOA

Pt has received naloxone for current opioid toxicity episode
AND
Patient is exhibiting acute withdrawal with a COWS score ≥ 8

Allergy or sensitivity to buprenorphine

Taken methadone in the past 72 hours

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Opioid Toxicity and Withdrawal Medical Directive

What is the preferred ROUTES and TREATMENT PLAN for Naloxone?

Who does the administration of IV naloxone apply to?

What is the IV route ONLY used for?

ROUTE - IV
Dose - up to 0.4mg

Max. Single Dose - 0.4mg

Dosing Interval - 5min

Max # of Doses - 3

ROUTE - IM
Dose - 0.4mg

Max. Single Dose - 0.4mg

Dosing Interval - 5min

Max # of Doses - 3

ROUTE - IN
Dose - 2-4mg

Max. Single Dose - 2-4mg

Dosing Interval - 5min

Max # of Doses - 3

ROUTE - SC
Dose - 0.8mg

Max. Single Dose - 0.8mg

Dosing Interval - 5min

Max # of Doses - 3

PCPs authorized for PCP autonomous IV

to restore the patient’s respiratory status

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Opioid Toxicity and Withdrawal Medical Directive

What is the ROUTE and TREATMENT PLAN for Buprenorphine/Naloxone?

What is paramount and the initial priority in this medical directive?

What do you do if the patient shows no response to the initial treatment?

ROUTE - PO
Initial Dose - 16mg

Subsequent Dose(s) - 8mg

Dosing Interval - 10minutes

Max culmative Doses - 24mg (2 total)

Upfront aggressive managemet of the airway

Consider patching for futher doses

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Opioid Toxicity and Withdrawal Medical Directive

When should you consider glucometry (BGL)?

What should you anticipate about the administration of naloxone?

What are the desired clinical effects for titrating IV naloxone?

If the patient does not respond to airway management and the administration of naloxone!

The pt may show combative behaviour and you should protect yourselves

RR GREATER/EQUAL to 10 breaths/min

Adequate airway and ventilation

not full alertness

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Opioid Toxicity and Withdrawal Medical Directive

What’s preferred over naloxone if available?

Does naloxone completely correct an opioid overdose?

BVM and basic airway management

Naloxone is shorter acting than most narcotics and these patients are at high risk of having a recurrence of their narcotic effect.

Every effort should be made to transport the patient to the closest appropriate receiving facility for ongoing monitoring

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Opioid Toxicity and Withdrawal Medical Directive

Why is the age limit now GREATER/EQUAL to 24h old.

What alternative toxidromes could be unmasked from naloxone?

Because it’s to minimize the risk of life threatening opioid withdrawal syndrome in the newborn

seizures

Hypertensive crisis

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Opioid Toxicity and Withdrawal Medical Directive

Is the administration of naloxone considered for patients that are not end-of-life or palliative?

Yes

Opioid Toxicity and Withdrawal Medical Directive

Show me the COWS Scale

what are the categories?

When do the Signs and Symptoms show up/when should you assess them?

Resting pulse rate
Restlessness
Runny nose or tearing
Sweating
Tremor
GI Upset
Yawning
Bone or joint aches
Gooseflesh Skin
Pupil Size
Anxiety or irritability

30min after administration of naloxone

Hypoglycemia Medical Directive

What are the INDICATIONS?

What is dextrose?

What is Glucagon?

Suspected Hypoglycemia

Liquid formula; simple sugar monosaccharide (carbohydrate!)

Hormone in powder form. Stimulates liver to move stored glycogen into glucose (glycogenolysis) to be released into bloodstream. (remember…this hormone is produced by the pancreas).

Hypoglycemia Medical Directive

What are Signs of hypoglycemia?

What are symptoms of hypoglycemia?

Diaphoretic

Shaking/Gittery

Bezzare

Irritable

Pail

Feeling low

Feeling very hot

Feeling Out of sort

Palpitations

Being out of breath

Lethargy

Hypoglycemia Medical Directive

What is a normal BGL value for an adult?

What is a low/hypoglycemia value for an adult?

What is a high/hyperglycemia value for an adult?

4 - 7mmol/L

< 4 mmol/L

> 8 – 9 mmol/L

Hypoglycemia Medical Directive

What are the pediatric hypoglycemia values for a patient LESS than 2 years old?

What does insuline vs glucagon do?

What are the pediatric hypoglycemia values for a patient GREATER/EQUAL than 2 years old?

< 3 mmol/L

Insulin stores glucose away, glucagon brings it out to play

< 4 mmol/L

Hypoglycemia Medical Directive

What are the CONDITIONS for dextrose?

What are the CONTRAINDICATIONS?

≥ 2 years

Altered LOA

Hypoglycemia

Allergy or sensitivity

Hypoglycemia Medical Directive

What are the CONDITIONS for glucagon?

What are the CONTRAINDICATIONS?

Altered LOA

Hypoglycemia

Allergy or sensitivity to glucagon

Pheochromocytoma

Hypoglycemia Medical Directive

What is pheochromocytoma/why does it matter?

Is oral intake the best route of choice for glucagon (if avaliable and possbile)? WHY?

A rare tumor on adrenal gland (on the kidney) - glucagon causes a release of norepi and epi from (cancer) cells - could cause a sudden/increase in BP and HR i.e. possible multi-organ injury

Phe0 -dark, Chromo - colour, Cy - cell, toma - tumor

Yes it’s always best. The GCS isn’t always indicative of the BGL because it varries in every person.

# Hypoglycemia Medical Directive What is the AGE, ROUTE, and TREATMENT PLAN for dextrose D10W? ## Footnote What is the AGE, ROUTE, and TREATMENT PLAN for dextrose D50W?

AGE - ≥ 2 years ROUTE - IV Dose - 0.2g/kg (2mL/kg) Max. Single Dose - 25g (250mL) Dosing Interval - 10min Max # of Doses - 2 ## Footnote AGE - ≥ 2 years ROUTE - IV Dose - 0.5g/kg (1mL/kg) Max. Single Dose - 25g (50mL) Dosing Interval - 10min Max # of Doses - 2

# Hypoglycemia Medical Directive What is the ROUTE, and TREATMENT PLAN for glucagon for a patient LESS than 25kg? | What could happen after administering glucagon? ## Footnote What is the ROUTE, and TREATMENT PLAN for glucagon for a patient GREATER/EQUAL to 25kg?

ROUTE - IM Dose - 0.5mg Max. Single Dose - 0.5mg Dosing Interval - 20min Max # of Doses - 2 | Common side effect - vomitting ## Footnote ROUTE - IM Dose - 1mg Max. Single Dose - 1mg Dosing Interval - 20min Max # of Doses - 2

# Hypoglycemia Medical Directive When do you give oral glucose or other simple carbohydrates? ## Footnote When should you give oral dextrose or simple carbohydrates over giving dextrose/glucagon?

If the patient responds to dextrose or glucagon. ## Footnote If the patient presents with mild signs and symptoms

# Hypoglycemia Medical Directive What do you do if a patient initiates an informed refusal of transport?

Obtain a full set of vital signs including blood glucometry

# Hypoglycemia Medical Directive What are the 8 considerations for Treatment and Discharge? ## Footnote What are the 6 AND considerations for Treatment and Discharge?

The pt is ≥ 18 and <65 years old The pt has a diagnosis of diabetes The hypoglycemia can be explained by insulin administration with inadequate oral intake The hypoglycemia promptly responded to a single administration of dextrose as per the Medical Directive and/or 1mg Glucagon and/or consumed oral glucose or other complex carbs This was a single isolated episode of symptomatic hypoglycemia within the past 24 hours The blood glucose is ≥ 4.0 mmol/L after treatment The pt has a return to their normal LOC and is asymptomatic A complete set of vital signs are within expected normal ranges ## Footnote Not an intentional OD The patient is not pregnant No seizure or reported history of seizure prior to paramedic treatment Not on an oral hypoglycemic medication Hypoglycemia is not considered to be related to an acute medical illness The hypoglycemia must not be related to alcohol or substance abuse or withdrawal

# Hypoglycemia Medical Directive What are the 7 additional requirements needed in order for a paramedic to discharge the patient?

The patient has access to appropriate carbohydrates A responsible adult agrees to remain with the patient for the next 4 hours All of the patient or substitute decision makers questions were answered and a care plan was developed The patient or SDM has been advised to follow up with their primary health care team or provider Clear instructions to call 911 were provided should symptoms redevelop Patient or SDM has the ability to acess 911 shuld symptoms re-develop Patient or SDM consents to the discharge

# Hypoglycemia Medical Directive True or Flase - Blood glucometry is performed using the Paramedic’s supplied device | What are the Capillary Blood Sample Sites? ## Footnote True or False - Samples can be obtained from the flash chamber of an IV catheter

TRUE | fingertips and the heel of the foot (pediatrics not begun to walk yet) ## Footnote False

# Hypoglycemia Medical Directive What is the administration option for dextrose? | Over how many minutes should you gradually administer D10W or D50W? ## Footnote What should you do with a premixed D10W? (how to administer into IV)

Dextrose 10% to a maximum of 25 g or 50% to a maximum of 25 g | 3min ## Footnote Run it as a piggyback onto an existing IV line to ensure accurate dose administration

# Hypoglycemia Medical Directive What should you do if the patient remains hypoglycemic after the administration of glucagon and there is an IV established?

Administer dextrose regardless of the elapsed time since the glucagon administration

# Hypoglycemia Medical Directive What is the 15-15 rule and why should you use it? ## Footnote What are some examples?

Ingest 15g of simple carbohydrates then check BGL in 15min - this is to reuduce the likelyhood of rebound hyperglycemia that occurs after eating large quantities of food. ## Footnote 15g of glucose tabs, paste, or other formulation 15ml of water with 3 sugar packets dissolved 150ml of juice or regular soft drink o 15ml of honey

# Hypoglycemia Medical Directive Can patients still be considered for discahrge from care if they initially weren't able to safely consume carbohydrates and required dextrose and/or glucagon prior to consuming carbohydrates. | What if you can't determine the patients class of diabetic medication? ## Footnote True or False - Patients who receive multiple doses of the same medication for example, two doses of glucagon, D50 or D10, should be transported to hospital

YES | Patch to the BHP to discuss the suitability of the treat and discharge. ## Footnote TRUE

What is a responsible adult defined as?

a person that is the age of majority (>18 years old) and is someone who, in the reasonable belief of the paramedic, is capable of remaining with the patient and will assume responsibility for the patient