Seizure + Hypoglycemia + Opioid Toxicity Flashcards
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.
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
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
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
Seizure Medical Directive - AUXILIARY
What is a seizure cluster?
multiple seizures that occur within a 24 hour period
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
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
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
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.
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
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
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
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
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
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
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?
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
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?
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
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?
When should you give oral dextrose or simple carbohydrates over giving dextrose/glucagon?
If the patient responds to dextrose or glucagon.
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?
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
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?
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)
False
Hypoglycemia Medical Directive
What is the administration option for dextrose?
Over how many minutes should you gradually administer D10W or D50W?
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
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?
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.
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?
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.
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
