EMT Lecture - Diabetes, AMS, Stroke, Seizure, Allergies, Toxicology/Poisoning

Name: EMT Lecture - Diabetes, AMS, Stroke, Seizure, Allergies, Toxicology/Poisoning
Uploaded: 2018-01-10T03:49:35.000Z
Duration: 4 h 14 min 31 s
Description: It's Official!!! We've published The Book of Eli: EMT Lectures. Get it here: https://amzn.to/2s3ikAr

Medical Emergencies Overview

Introduction to Medical Emergencies

The session covers critical topics relevant to EMTs, including altered mental status, seizures, allergies, poisonings, and overdoses.

Understanding Altered Mental Status

Altered mental status (AMS) refers to a change in a person's normal behavior or cognitive function. It can range from mild confusion to coma.

Identifying AMS often relies on reports from family or friends who notice the individual is "not acting right." This initial observation is crucial for diagnosis.

Causes of Altered Mental Status

There are numerous potential causes for AMS; it can manifest through incorrect answers to questions or disorientation regarding time and place. Hypoglycemia is highlighted as the most common cause seen in EMS settings.

A case study illustrates that even when hypoglycemia seems likely, other factors must be considered before concluding the diagnosis. For instance, ruling out seizure disorders and head trauma is essential.

Case Study: Diagnosing AMS

An example involving an elderly woman with AMS demonstrates the diagnostic process:

Initial assessment ruled out hypoglycemia based on medical records.

Further evaluations included checking for seizure history and signs of stroke or head trauma.

Ultimately, low oxygen saturation was identified as the underlying issue; administering oxygen resolved her symptoms quickly.

Key Takeaways on Altered Mental Status

While hypoglycemia is a frequent cause of AMS, EMTs should maintain an open mind about other possible diagnoses.

Understanding Diabetes: Key Insights

What is Diabetes?

Diabetes is fundamentally an endocrine problem, specifically related to the pancreas and its production of insulin, rather than merely a sugar issue.

The common classifications of diabetes are Type 1 and Type 2. Type 1 was previously known as insulin-dependent diabetes mellitus (IDDM).

A mnemonic for distinguishing between the two types: "Type 1" has an 'I' for insulin-dependent, while "Type 2" can be remembered as non-insulin dependent.

Types of Diabetes

Historically, doctors would taste urine to diagnose diabetes based on sweetness; this practice highlights the historical understanding of the disease.

There are primarily two types of diabetics: Type 1 (insulin-dependent) and Type 2 (non-insulin dependent). Gestational diabetes occurs during pregnancy but is not covered in detail here.

Other forms like diabetes insipidus exist but are unrelated to sugar metabolism.

Insulin Functionality

Insulin is produced by the pancreas in the islets of Langerhans and plays a crucial role in glucose uptake by cells.

Glucose cannot enter cells without insulin opening specific channels; it acts like a key that allows glucose to enter for energy production.

Understanding Insulin Production

In healthy individuals, insulin facilitates glucose entry into cells from food intake. This process is vital for cellular energy needs.

Diabetics may require insulin shots if their bodies do not produce sufficient amounts; this applies mainly to Type 1 diabetics who have little or no natural insulin production.

Differences Between Type 1 and Type 2 Diabetes

Type 1 diabetics rely on external insulin injections due to insufficient internal production, while Type 2 diabetics often manage their condition with oral medications that enhance their body's ability to use existing insulin.

Symptoms such as polydipsia (excessive thirst) and polyuria (increased urination) are critical indicators of diabetes. These symptoms arise from separate physiological processes linked to high blood sugar levels.

Understanding Diabetic Emergencies

Initial Assessment of a Child with Symptoms

The speaker describes an encounter with a mother concerned about her child who has been unwell for two weeks, exhibiting signs that suggest a serious condition rather than just a viral infection.

Observations reveal the child has very red skin and is excessively thirsty, indicating potential dehydration or other underlying issues.

A significant behavioral change is noted when the child wet the bed for the first time, prompting suspicion of diabetes; a blood test is deemed necessary.

The glucometer reading confirms high blood sugar levels (in the 500s), which had been overlooked by previous doctors focusing on infections instead.

Understanding Diabetes and Its Emergencies

The speaker emphasizes two critical diabetic emergencies: hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), regardless of whether it’s type 1 or type 2 diabetes.

It’s crucial to recognize these emergencies without getting bogged down in classifications; understanding symptoms is key to effective response.

Hypoglycemia: Signs and Symptoms

Hypoglycemia refers specifically to low sugar levels in circulating blood, not within cells. This distinction is vital for diagnosis and treatment.

Common symptoms include rapid onset changes in behavior, cold clammy skin, rapid pulse, and low blood glucose readings (below 60).

Patients may present as confused or disoriented; family members often report sudden changes in their condition ("he was fine just moments ago").

Mechanisms Behind Hypoglycemia

High insulin levels can lead to hypoglycemia because there isn’t enough glucose available for cellular uptake despite elevated insulin presence.

The relationship between insulin and glucose must be understood—insulin opens channels for glucose entry into cells but requires sufficient glucose availability.

Key Takeaways on Diabetic Emergencies

Recognizing rapid onset symptoms such as confusion or altered mental status can help identify hypoglycemic episodes quickly.

In contrast to hypoglycemia, hyperglycemia presents differently but also leads to severe complications if not addressed promptly.

Understanding Diabetic Ketoacidosis and Hypoglycemia

The Impact of High Blood Sugar Levels

Blood sugar levels above 120 are considered dangerously high, potentially reaching into the hundreds. This condition leads to low insulin levels in the blood, causing sugar to circulate without entering cells.

Symptoms develop gradually over days or weeks, including warm dry skin and increased thirst (polydipsia) and urination (polyuria).

Cellular Response to Low Insulin

Cells starve for sugar due to lack of insulin; they cannot access glucose from the bloodstream.

As a backup, cells burn fats for energy, converting them into sugars. This process produces ketones as a byproduct.

Ketone Production and Acidosis

The production of ketones can lead to diabetic ketoacidosis (DKA), characterized by an acetone odor on breath similar to nail polish remover.

DKA develops slowly; it is not common but can occur under severe hyperglycemic conditions.

Breathing Patterns in DKA

Patients may exhibit Kussmaul respirations—an irregular breathing pattern due to acidosis caused by ketone accumulation.

The body must maintain a specific pH level; excessive acidity from ketones disrupts this balance.

Causes of Hypoglycemia

Hypoglycemia often occurs when patients take insulin without eating afterward. Insulin lowers blood sugar levels by facilitating its entry into cells.

Patients need to eat after taking insulin because rising insulin levels require corresponding food intake for balance.

Insulin Administration Changes Over Time

Insulin administration has evolved significantly over the past two decades, with options ranging from daily injections to weekly doses for better management.

Understanding Diabetes Management

Impact of Illness on Diabetic Patients

When diabetics become ill (e.g., flu or colds), their normal blood sugar levels can fluctuate significantly, leading to emergencies.

Individuals with hypoglycemia often cannot fast due to the necessity of insulin intake and food consumption.

Insulin Administration Challenges

Hyperglycemia occurs when patients do not take enough insulin, which can lead to diabetic ketoacidosis (DKA).

For instance, if a patient consumes high-sugar foods at a party without adequate insulin, their blood sugar levels will rise uncontrollably.

The body struggles to transport glucose into cells effectively when there is insufficient insulin available.

Treatment Protocol for Diabetes

Understanding how to treat diabetes is crucial; medical alert bracelets are recommended for identification purposes.

Administering oral glucose is appropriate if the patient is conscious and has a gag reflex intact.

Seizures: Causes and Types

Overview of Seizures

Seizures are involuntary changes in behavior caused by electrical impulses in the brain that result in various physical manifestations.

Common Causes of Seizures

Febrile seizures are noted as the most common type among children, often triggered by fever.

Head trauma can also lead to seizures due to damage inflicted on the brain during an injury.

Types of Seizures

Understanding Seizures: Types and Phases

Absence Seizures

Absence seizures, also known as petit mal seizures, typically resolve before adolescence. Children experiencing these should be evaluated by neurologists.

Tonic-Clonic Seizures

The most common seizure type encountered in EMS is the tonic-clonic seizure (formerly called grand mal). This seizure has two main phases: tonic and clonic.

Tonic phase involves muscle tension where all skeletal muscles contract, often leading to a fall if the person is standing. This phase is rarely witnessed by EMTs unless they are present during an incident.

Phases of Tonic-Clonic Seizures

A typical tonic-clonic seizure consists of four phases:

Tonic Phase: Muscle stiffening occurs.

Clonic Phase: Characterized by rhythmic shaking or convulsions; it’s not random but follows a pattern.

Postictal Phase: After the seizure, individuals may enter a deep sleep or coma-like state, which can last for varying durations. This phase is crucial for EMTs to recognize as part of the seizure process.

Aura Before Seizure

Many patients experience an aura—a premonitory sensation—before a seizure that can manifest as feelings or hallucinations indicating an impending episode. Pets may also sense this aura in their owners. Most patients find themselves in safe positions when the seizure begins due to this warning sign.

Summary of Key Points

Generalized seizures include absence seizures and tonic-clonic seizures.

Tonic-clonic seizures are characterized by distinct phases that EMT personnel should be familiar with.

Recognizing the aura can help prevent injuries during a seizure event.

Understanding Seizures and Postictal Phases

Duration of Clonic Phase and Postictal State

The clonic phase duration is uncertain, but the postictal state typically lasts about as long as the clonic phase, potentially longer.

During the postictal state, individuals may appear to be in a sleep-like coma; they might not respond immediately after a seizure.

Recognizing Seizure Types

Panic symptoms are often absent in clinical settings; however, postictal confusion can be overlooked if medical knowledge is lacking among bystanders.

In situations where someone appears unresponsive after a seizure, it’s crucial to assess whether they had a seizure or another issue entirely.

Management of Status Epilepticus

Status epilepticus is defined as continuous seizures without regaining consciousness between them. This condition requires immediate medical intervention.

A case example illustrates that even after stopping one seizure, patients can enter another episode quickly if not monitored properly.

Patient Care Considerations

Patients may become incontinent during seizures; caregivers should be prepared for this when assisting them post-seizure.

Individuals with tonic-clonic seizures usually have epilepsy and require regular monitoring of their anti-seizure medication levels.

Do's and Don'ts During Seizures

It is critical not to place anything in the mouth of a seizing patient; doing so can lead to injury due to their potential superhuman strength.

Instead of restraining the patient, focus on protecting them from nearby hazards that could cause harm during a seizure event.

Understanding Seizures and Strokes

Managing Seizures

During a seizure, individuals may bite their tongues or the inside of their mouths, which can lead to bleeding. The primary concern is ensuring safety by keeping others away and avoiding placing anything in their mouths.

Restraining a person during a seizure is discouraged; instead, gently turning their head to one side is recommended. Suctioning should not be performed while they are seizing.

Benzodiazepines can be used to stop seizures, but maintaining airway safety is crucial. If the patient enters a postictal state (after the seizure), suctioning may be necessary if there are airway concerns.

Understanding Cerebrovascular Accidents (CVA)

A cerebrovascular accident (CVA), commonly known as a stroke, has two main types: thrombolytic and hemorrhagic strokes. Thrombolytic strokes occur due to blockages in cerebral arteries.

Hemorrhagic strokes result from an aneurysm that bursts, leading to bleeding in the brain. This type often has poor outcomes and can lead to rapid deterioration of the patient’s condition.

Recognizing Stroke Symptoms

In cases of hemorrhagic stroke, blood accumulation within the skull creates pressure on the brain due to limited space. Surgical intervention may be complicated based on various factors such as age and size of the hemorrhage.

It’s essential for responders to recognize signs of CVA accurately and transport patients to appropriate medical facilities known as stroke centers for timely treatment.

Terminology Related to Strokes

The term "brain attack" was proposed by the American Heart Association as an alternative name for stroke; however, it did not gain widespread acceptance among Americans who still primarily refer to it as a stroke.

Non-traumatic brain injury (NTBI), which includes strokes, contrasts with traumatic brain injuries (TBI). These terms are increasingly used in medical contexts.

Identifying Stroke Indicators

Common symptoms indicating potential strokes include altered mental status (AMS), severe headaches described as "the worst headache of their life," unequal pupils, hemiplegia (weakness on one side of the body), drooling, and facial droop.

Hemiplegia affects one side of the body; if there are issues with facial movement on one side, it typically indicates problems on the opposite side due to nerve crossover in the neck region.

Understanding Stroke Diagnosis and Treatment

Key Terminology and Concepts

Hemiplegia: Refers to paralysis on one side of the body, often associated with strokes.

Aphasia: Impairment or inability to speak, which can occur during a stroke.

Signs and Symptoms

Patient Positioning:

Conscious patients should be in a semi-Fowler's position.

Unconscious patients should be placed in the left lateral position to prevent aspiration.

Stroke Diagnosis

Cincinnati Pre-Hospital Stroke Scale: A tool used for diagnosing strokes based on three tests:

Arm extension test.

Facial symmetry test (smiling).

Speech repetition test.

Diagnostic Tests Explained

Arm Extension Test: Patients are asked to extend their arms while closing their eyes. If one arm droops or does not move, it indicates potential stroke symptoms.

Facial Symmetry Test: Patients are asked to smile. An inability to smile bilaterally suggests a stroke.

Speech Repetition Test: Patients must repeat a sentence. Inability or difficulty indicates possible speech impairment due to a stroke.

Interpreting Results

If patients fail all three tests, they are likely having a stroke. Failing two out of three significantly increases the likelihood of a stroke diagnosis.

Treatment Protocol

TPA (Tissue Plasminogen Activator): The definitive treatment for strokes; its administration is time-sensitive based on when the patient was last seen normal.

Important Considerations for TPA Administration

The critical window for administering TPA has evolved from three hours to potentially six hours post-stroke onset, emphasizing the importance of timely medical intervention.

Conclusion on Patient Care

Stroke Management and Response

Understanding Stroke Symptoms and Emergency Response

The speaker discusses the limitations of emergency services in certain states, emphasizing that they cannot provide advanced treatments like TPA or CAT scans on-site.

It is highlighted that if a patient shows signs of losing their airway or has breathing issues during a stroke, it is crucial to call for medical assistance immediately.

The concept of "time is muscle" is introduced, indicating that delays in treatment can lead to more brain damage as oxygen deprivation increases during a stroke.

Case Study: A Prominent Patient's Stroke Experience

A personal account is shared about a prominent individual who experienced a stroke but was initially able to walk and talk; however, he could only respond with numbers during transport to the hospital.

The importance of understanding the patient's condition before arrival at the hospital is emphasized, including gathering information about their prior state.

Importance of Quick Medical Intervention

The speaker recounts calling ahead to inform neurology staff about an incoming patient requiring immediate attention upon arrival at the hospital.

There are mentions of other cases where patients did not receive timely care leading to severe outcomes, stressing the need for quick action when strokes are suspected.

Differentiating Between Strokes and Mini-Strokes

The discussion shifts towards mini-strokes (transient ischemic attacks), which present similar symptoms as full strokes but may mislead responders due to their transient nature.

Clarification on how mini-strokes can mimic full strokes leads into discussions about proper documentation and communication with medical teams upon arrival.

Headaches and Their Relation to Strokes

The speaker explains that sudden severe headaches can indicate serious conditions such as strokes; thus, any new headache should prompt further investigation for potential underlying issues.

Different types of headaches are discussed, including migraines and cluster headaches. Oxygen therapy is noted as an effective treatment for cluster headaches.

Understanding Allergic Reactions

Basics of Allergic Responses

An explanation begins regarding allergic reactions, noting that an immune response cannot occur without prior exposure to an allergen.

It’s clarified that first-time exposure does not trigger allergies; rather, sensitization occurs after initial contact with allergens.

Symptoms and Management

Allergic Reactions and Anaphylaxis Overview

Understanding Allergic Reactions

Allergic reactions manifest as raised red rash blotches on the skin, often accompanied by warm, tingling sensations. Common allergens include medications and various foods.

Symptoms of an allergic reaction can include hives, redness, and itching on the skin. The severity of the reaction does not change its classification as an allergic response.

Progression to Anaphylaxis

As allergic reactions worsen, they may lead to more severe symptoms such as respiratory distress or cardiovascular issues like hypotension.

Anaphylactic shock is a life-threatening progression of an allergic reaction characterized by significant respiratory distress or cardiovascular problems.

Identifying Respiratory Distress

Key indicators of respiratory distress in anaphylaxis include wheezing, cyanosis (bluish discoloration), gasping for air, and use of accessory muscles for breathing.

Early signs of respiratory distress may involve swelling in areas such as the tongue or larynx due to edema caused by anaphylaxis.

Treatment Protocol

Immediate treatment for suspected anaphylaxis involves administering epinephrine via EpiPen. EMT protocols allow drawing up medication in certain regions.

Proper usage of EpiPen includes injecting into the lateral thigh and holding it in place for 10 seconds to ensure effective delivery.

Dosage Guidelines

Dosage recommendations are 0.3 mg for adults (over 9 years old) and 0.15 mg for children under this age threshold. Recent updates have adjusted weight-based dosing guidelines.

Poisoning: Definitions and Types

Understanding Poisoning

A poison is defined as any substance harmful to the body; toxins can be man-made or naturally occurring substances that cause harm when introduced into the body.

Routes of Exposure

Poisons can enter the body through various routes:

Inhalation (e.g., carbon monoxide)

Absorption (e.g., through skin contact)

Injection (e.g., animal bites or insect stings)

Understanding Medical Control and Poisoning

Overview of Medical Control Protocols

The speaker emphasizes the importance of contacting online medical control when dealing with certain substances like ipecac and activated charcoal, indicating that specific protocols must be followed.

Signs and symptoms of carbon monoxide poisoning are discussed, including vomiting, dizziness, and loss of consciousness.

Key Information for Medical Control

Essential questions for medical control include: what substance was ingested, when it was taken, and how much was consumed.

A method to calculate pill ingestion is explained using an example where a patient may have consumed more pills than prescribed due to accessibility in a grandparent's home.

Understanding Drug Interactions

The concept of "synergism" is introduced as the interaction between two drugs that can enhance their effects.

Withdrawal symptoms are defined as signs experienced after stopping drug use; examples include caffeine withdrawal leading to severe headaches.

Substance Abuse Insights

Alcohol as a CNS Depressant

Alcohol is identified as a central nervous system (CNS) depressant, which affects reaction times and coordination.

The distinction between nausea (the feeling of wanting to vomit without doing so) and vomiting itself is clarified.

Withdrawal Symptoms from Alcohol

Delirium tremens (DT), characterized by shaking but conscious awareness during withdrawal from alcohol, is discussed.

Understanding Narcotics and Their Effects

Overview of Narcotics

The discussion begins with a focus on narcotics, emphasizing that they are not merely about drugs but specifically about derivatives like opioids.

Examples of narcotics include morphine, oxycodone, and fentanyl; however, marijuana is explicitly excluded from this category in the context of the discussion.

Pain Relief and Addiction

The primary purpose of these narcotics is pain relief; they are highly effective but also carry a significant risk of addiction.

Key signs to monitor for overdose include decreased respiratory drive, which can lead to respiratory failure—a critical condition requiring intervention with Narcan.

Stimulants vs. Depressants

A distinction is made between stimulants (like cocaine and crack), which increase heart rate and energy levels, and depressants (like Valium), which slow down the central nervous system.

Stimulant users may appear unresponsive or hyperactive; it’s advised to involve law enforcement if necessary due to potential aggression.

Hallucinogens and Their Effects

Hallucinogens such as LSD and Molly can cause altered perceptions; users may exhibit unusual behaviors like sucking lollipops or excessive hugging.

Marijuana is mentioned as commonly used but rarely leads to emergency calls compared to more potent substances like heroin.

Treatment Protocol for Substance Abuse

In cases of substance abuse, particularly opiate overdose, treatment focuses on maintaining airway safety rather than waking patients unnecessarily.

It’s crucial not to confuse intoxication with other medical conditions such as hypoglycemia; thorough assessments are essential for accurate diagnosis.

Conclusion: Recognizing Symptoms