# Syncope



## MidTech (Apr 23, 2014)

BLS job
11:30PM you are dispatched to location for a middle aged man who fell. 
40 y/o m pt found lying on sidewalk in front of a bodega states he remembers blacking out. Upon initial assessment he appears weak and tells you, even as he's lying there, that he's "OK", and then tells you he has a hx of DM. Pt is diaphoretic (weather unrelated). No injuries sustained in fall and no complaints of pain.
Vitals B/P 88/54, Resp 20, Pulse 92, Pupils PERL, CTC cool/moist/unremarkable

Are we thinking possible hypoglycemia yet as to reason of syncopal episode?

PT further states he has had these episodes before and was related to his DM.
Pt answers 3 questions correctly, though appears weak and slow. Are you warranted in giving oral glucose on the BLS level for this job? What are your protocols?

< Answers coming >


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## OnceAnEMT (Apr 23, 2014)

Need a BGL first, and if that's low, provide sugar. Let's get to a more comfortable area after that, say, the back of a handy dandy ambulance. If he is AnOx4 and feels he can stomach oral glucose, send it. If he's not AnO, load and go with a D50 drip (which I wouldn't do, as a Basic, just throwing it out there). After the oral glucose, if given, provide 10-15 minutes. If improvement is obvious, explain to Pt what all this means and propose a hospital visit. If Pt refuses, walk in to the restaurant and watch him eat some carbs. (Is Bodega a restaurant? Either way, watch him eat carbs obtained from somewhere). 

So to answer the question, I haven't been around a system or MD where BLS couldn't provide glucose (I have been in a system where the MD said Basics can't do D-sticks. That was fun.). That said, I would say a D-stick is always needed before administering glucose. A hypoglycemic Pt can look just like a dehydrated person with a bad attitude.


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## Angel (Apr 23, 2014)

In my county BLS can give oral glucose only...not allowed to check BGL though. So yes I would've given him the glucose. And recheck vitals after 5 mins. A BGL is nice, but even in the event of meter failure, we are allowed to use our clinical judgement on wether to give dextrose (medics) or oral glucose.


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## captaindepth (Apr 23, 2014)

I would not immediately attribute the fall/episode to the pts hx of DM. He needs a thorough assessment to rule out other causes of the syncope before just giving him oral glucose. I agree that a more comfortable environment is appropriate for the assessment. Before standing the pt up I would prepare to assess for orthostatic BP changes, if any changes are noted he needs to be laid on the cot and transferred into the back of the ambulance. Once in the back obtain a BGL, double check for injuries (RTA), reassess mentation, complete a simple neuro exam, and obtain a complete SAMPLE hx. If the BGL comes back low you can administer oral glucose but I would start a line and give 50ml of D50 (all within my EMT-B protocols). I would strongly suggest this pt be evaluated at the ER due to reoccurring episodes of syncope. If the pt is able to refuse (AAOx4, no ETOH/drugs on board, and able to walk) I'd try to get a hold of a family member to come pick him up.


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## Angel (Apr 23, 2014)

If he's had this happen before and it was due to diabetes....why now would you think it's something else?


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## OnceAnEMT (Apr 23, 2014)

Angel said:


> If he's had this happen before and it was due to diabetes....why now would you think it's something else?



Assumptions just can't be made in the real world. As captaindepth rightfully said, you can't assume its syncope just because of the Hx. That's like assuming a Pt from a rollover MVC doesn't have a c-spine injury because he is walking around.

Another example is with Pts with a seizure Hx. Perhaps they are used to it, so they refuse transport. But what about the off chance that this time, that seizure was not related to the Hx at all? Especially if the Pt claimed to be on seizure meds.

Point is, never assume. Especially when you didn't see it happen. We didn't see him fall, and as far as we know, there were no witnesses of the fall. My favorite pointer from school is, "Did the old lady fall from the stairs and become unconscious on impact, or did she fall because she was already unconscious?"


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## teedubbyaw (Apr 23, 2014)

Angel said:


> If he's had this happen before and it was due to diabetes....why now would you think it's something else?




Because diabetes opens you up to a lot of bad things. CVA and MI would be my first immediate "think worst case scenario" differentials that I'd rule out.


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## Angel (Apr 23, 2014)

Devils advocate here, no we didn't see it but the patient was there and said (from what I read) this has happened before, and it was because of his diabetes. So i would investigate that first. BLS is limited in the tools they have so it makes things difficult. Sure it could be something else ie you mentioned CVA and do a CPSS if you like but I've not seen a CVA cause diaphoresis or hypotension especially since the patient isn't altered. 

His skin signs and history point me toward hypoglycemia, he probably was syncopal due to his BP 

Absolutely do as best an assessment you can but I don't see a reason to go chasing zebras.


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## OnceAnEMT (Apr 23, 2014)

Angel said:


> Absolutely do as best an assessment you can but I don't see a reason to go chasing zebras.



Getting a BGL isn't chasing a zebra, as it is essentially a vital sign. Once that is done, you can rule in or out hypoglycemia. If the Pt isn't hypoglycemic, then you'd already start an assessment and are on a whole different path.  If its low, get glucose on board, method aside. While that happens you can then run through the rest just to make sure. Doesn't hurt to do what you're paid to do.


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## Angel (Apr 23, 2014)

BLS cannot get blood sugars. Not in CA as far as I know and not in my county. 
If we suspect hypoglycemia we are allowed to give it ie patient has a history of diabetes and (tells you) their sugar is low they are showing signs of hypoglycemia. 
Obviously as a medic I'd run the call a bit different but he specifically stated BLS.


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## OnceAnEMT (Apr 23, 2014)

Angel said:


> BLS cannot get blood sugars. Not in CA as far as I know and not in my county.
> If we suspect hypoglycemia we are allowed to give it ie patient has a history of diabetes and (tells you) their sugar is low they are showing signs of hypoglycemia.
> Obviously as a medic I'd run the call a bit different but he specifically stated BLS.



Copy that, sorry, didn't know you were running with those protocols. Like I mentioned, where I'm from getting a BGL is in a Basic's scope.


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## mycrofft (Apr 23, 2014)

Since presumptive oral sugar for a diabetic who can swallow is a basic first aid measure, fingerstick glucometry is not a treatment-dictating vital sign when one is not titrating dose to blood sugar...and in the field titration is even trickier than it is in hospital, where it is a real balancing act. Oral sugar syrup will not cause bad things as a "sugar overdose", but it's sort of bad if the pt aspirates it. Dry granulated sugar can be potentially aspirated more deeply. No, the amount absorbed through the mucosa short of the stomach and gut is not significant, mostly it dissolves and is swallowed. So no IV order=>no need for glucometry for treatment.  If I was the ED I'd like to see an *accurate*  fingerstick in the incoming vitals though.

D50 drip...drip in 50% dextrose? Or add it as a constituent to an extant IV line carrying normal saline or something (diluting it far below 50%)? Or start the IV then give D50 as a bolus? Or (shudder) just mainline the D50 right into the vein?


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## Angel (Apr 23, 2014)

Grimes said:


> Copy that, sorry, didn't know you were running with those protocols. Like I mentioned, where I'm from getting a BGL is in a Basic's scope.



It should be like that everywhere IMO, it's hard to mess up, but CA is restrictive in general. Any who, I wasn't getting upset just trying to reiterate the limitations of BLS in this scenario. 
A good debate nonetheless


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## captaindepth (Apr 23, 2014)

Protocols aside, both BLS and ALS providers are responsible to do a thorough assessment. An EMT-B can and should complete the same assessment of this pt as a paramedic, the only difference is what interventions both can do. An EMTs bread and butter should be getting accurate BPs and completing a SAMPLE history. Never assume anything, most pts cannot tell you why something happened to them, even if it has happened to them before. I trust my assessment more than some some guy wandering around in the middle of the night who fell for an unknown reason.


Also we carry 50ml premixed D50 syringes. Usually give one whole syringe to the pt if they are altered. Works a lot faster than waiting 20 minutes for the oral glucose to take effect.


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## teedubbyaw (Apr 23, 2014)

captaindepth said:


> An EMT-B can and should complete the same assessment of this pt as a paramedic




Since when?


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## STXmedic (Apr 23, 2014)

This whole scenario would be a lot more clear if OP would just post a BGL. It's a simple, quick test that (guestimating) 95% of even BLS providers could do. This would have been completed within 30 seconds of arriving at the patient's side. Hypoglycemic? Eat this. Not hypoglycemic? Investigate further. As was mentioned, when you hear hooves, think horses. When you rule-out that it could be a horse, start thinking more exotic.

So OP, it seems like you're trying to hint towards a zebra here. A BGL would aid in the progression of your scenario.


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## Angel (Apr 23, 2014)

Angel said:


> Absolutely do as best an assessment you can but I don't see a reason to go chasing zebras.



Im glad we agree. 

So what was it? This thread got way off topic.


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## captaindepth (Apr 23, 2014)

teedubbyaw said:


> Since when?



When assessing a pt there should be no difference between and EMT-B and a paramedic until in an ALS situation.


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## teedubbyaw (Apr 23, 2014)

captaindepth said:


> When assessing a pt there should be no difference between and EMT-B and a paramedic until in an ALS situation.




Oh, so 2 years of school with the main end goal of in-depth assessments is the same as what a basic does?


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## STXmedic (Apr 23, 2014)

captaindepth said:


> When assessing a pt there should be no difference between and EMT-B and a paramedic until in an ALS situation.



They may follow a similar algorithm, but I would expect- and regularly see- a difference in knowledge base, differentials, and clinical correlation. If you feel you're on par, great. You aren't most basics.


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## captaindepth (Apr 23, 2014)

teedubbyaw said:


> Oh, so 2 years of school with the main end goal of in-depth assessments is the same as what a basic does?



I don't see any difference between an EMT-Bs ability to assess this pt and a paramedics ability to assess this pt. obviously when dealing with cardiac related events, respiratory distress/failure, medication administration, and severe trauma a paramedic has the increased knowledge and scope to address life threatening illnesses. I'd say 75% of 911 calls are truly BLS calls and proficient EMT-Bs are more than capable of handling these calls.


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## FLdoc2011 (Apr 23, 2014)

In evaluating syncope the most important element is arguably the history.   

Taking a good history will most of the time give you an idea of the etiology, but can be tricky to do. 

If he says he had the exact same episode before due to hypoglycemia then just playing the odds that's probably what happened, but I'm sill going to go through my usual questions dealing with syncope to evaluate other more serious causes.


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## teedubbyaw (Apr 23, 2014)

captaindepth said:


> I don't see any difference between an EMT-Bs ability to assess this pt and a paramedics ability to assess this pt. obviously when dealing with cardiac related events, respiratory distress/failure, medication administration, and severe trauma a paramedic has the increased knowledge and scope to address life threatening illnesses. I'd say 75% of 911 calls are truly BLS calls and proficient EMT-Bs are more than capable of handling these calls.




I wouldn't disagree that most calls are BLS, but as stx said, basics follow an algorithm. They more than likely won't know the correlation of the questions they're asking to the processes of what's going on. 

OPQRST and SAMPLE do not equal an assessment. Paramedics are clinicians, basics are technicians. There is a separation, and it's not just putting on a monitor and giving meds. That is not to say that there are some exceptional basics with years of experience that could teach me a lot of real world knowledge.


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## STXmedic (Apr 23, 2014)

Does neuro fall into your realm of equal footing, too? And who's to say this isn't a cardiac event? It's fairly apparent that OP is hinting at a zebra. This is not likely going to be "check his sugar and give him an amp", so there will likely be a more thorough assessment. If it turns out that this is a simple hypoglycemic, then I agree that both an EMT and a paramedic can both use a glucometer equally well.


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## OnceAnEMT (Apr 23, 2014)

captaindepth said:


> I'd say 75% of 911 calls are truly BLS calls and proficient EMT-Bs are more than capable of handling these calls.



I think its more like 95%, in all seriousness.

That said, in Basic school we were always told to know the major diagnoses and the common ones, but only to report the S/S, including to the ED. As in, I can't roll in with a Pt who presents apneic and discolored from the nipple line up and say he/she has a PE. Not sure if it is an unsung rule or what, but they really stressed the fact that we need to be knowledgeable but not go as far as diagnosing. What is this like on the Paramedic level?


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## MidTech (Apr 23, 2014)

The NYC BLS protocols for AMS state:
In order of relevance...
* Administer oxygen
* Request Advanced Life Support assistance, if appropriate.
* If the patient is conscious, is able to swallow, and is able to drink without assistance, provide a glucose solution
* Transport
* Assess and monitor the Glasgow Coma score.

Unfortunately glucometers are not used in BLS setting here in NYC. I enjoyed reading all of your thoughts on the limited information I gave.

In ER BGL showed 312


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## STXmedic (Apr 23, 2014)

I'm going to stop reading scenarios from new people.


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## usalsfyre (Apr 23, 2014)

captaindepth said:


> Protocols aside, both BLS and ALS providers are responsible to do a thorough assessment. An EMT-B can and should complete the same assessment of this pt as a paramedic, the only difference is what interventions both can do. An EMTs bread and butter should be getting accurate BPs and completing a SAMPLE history. Never assume anything, most pts cannot tell you why something happened to them, even if it has happened to them before. I trust my assessment more than some some guy wandering around in the middle of the night who fell for an unknown reason.


Not gonna happen for the same reason I can't give as in-depth exam as an EM attending. I don't have the knowledge base to pull it off. I get what you're trying to say and are likely parroting what you've been told but lets be realistic.




captaindepth said:


> Also we carry 50ml premixed D50 syringes. Usually give one whole syringe to the pt if they are altered. Works a lot faster than waiting 20 minutes for the oral glucose to take effect.


This statement alone is enough to show you really have no idea on the ins and outs of care beyond the very basic algorithms you've learned. D50 for this patient is far more invasive than is needed and 25gms is probably a good bit more than needs to be administered.


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## mycrofft (Apr 23, 2014)

Grimes said:


> I think its more like 95%, in all seriousness.
> 
> That said, in Basic school we were always told to know the major diagnoses and the common ones, but only to report the S/S, including to the ED. As in, I can't roll in with a Pt who presents apneic and discolored from the nipple line up and say he/she has a PE. Not sure if it is an unsung rule or what, but they really stressed the fact that we need to be knowledgeable but not go as far as diagnosing. What is this like on the Paramedic level?



:beerchug:


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## mycrofft (Apr 23, 2014)

FLdoc2011 said:


> In evaluating syncope the most important element is arguably the history.
> 
> Taking a good history will most of the time give you an idea of the etiology, but can be tricky to do.
> 
> If he says he had the exact same episode before due to hypoglycemia then just playing the odds that's probably what happened, but I'm sill going to go through my usual questions dealing with syncope to evaluate other more serious causes.



Personally, regarding syncope cases' histories, I've had a high percentage of difficulty because the subject is unconscious or obtunded.

Couldn't resist.


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## mycrofft (Apr 23, 2014)

*D50 mui macho*



usalsfyre said:


> …..
> 
> This statement alone is enough to show you really have no idea on the ins and outs of care beyond the very basic algorithms you've learned. D50 for this patient is far more invasive than is needed and 25gms is probably a good bit more than needs to be administered.



Yeah. Having worked with unstable diabetics for six years, I saw it wasn't the _*25 grams*_ of 50% glucose that effects improvement, it is the initial influx of sugar beyond a basic amount. Sort of like using a two inch nail when a one inch nail will do. If the D50 isn't exfiltrating there is no harm done, just keep the pt awake long enough to eat mixed carbs if it is otherwise safe, or go to the hospital as is medically necessary.


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## Ewok Jerky (Apr 24, 2014)

captaindepth said:


> When assessing a pt there should be no difference between and EMT-B and a paramedic until in an ALS situation.



In an ideal world, I agree that a basic SHOULD have the same H&P skills as a medic.  The only tools used for an H&P is your brain, eyes, ears, mouth and hands.

In the real world, Bees are not anywhere close unless they have taken it upon themselves to learn more in depth pathophys and have the experience/pt contact to back it up (rare).


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## Handsome Robb (Apr 25, 2014)

Grimes said:


> I think its more like 95%, in all seriousness.
> 
> That said, in Basic school we were always told to know the major diagnoses and the common ones, but only to report the S/S, including to the ED. As in, I can't roll in with a Pt who presents apneic and discolored from the nipple line up and say he/she has a PE. Not sure if it is an unsung rule or what, but they really stressed the fact that we need to be knowledgeable but not go as far as diagnosing. What is this like on the Paramedic level?



I generally will tell the Charge Nurse my differential Dx in my radio report and will tell the RN in my report as well. If we don't diagnose how do we decide what treatments to provide?


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## OnceAnEMT (Apr 25, 2014)

Robb said:


> I generally will tell the Charge Nurse my differential Dx in my radio report and will tell the RN in my report as well. If we don't diagnose how do we decide what treatments to provide?



Exact question that I asked, and was answered with we treat symptoms, not diseases.


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## mycrofft (Apr 25, 2014)

If I'm an EMT, if matching observations to protocols' signs and symptoms is diagnosis, then I'm diagnosing.


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## Chupathangy (Apr 27, 2014)

In my county if you suspect hypoglycemia, give them glucose. The fact he has a hx of DM just leads you to suspect it all the more. Im not really sure about CVA causing syncope, but Id do a stroke scale anyways to rule it out before giving him glucose. An O2 sat could be helpful as well.


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## mycrofft (Apr 27, 2014)

*Tongue in cheek*

Now, wait. You're gathering important info. We can't have that. Chief, make sure none of these ambulances has a thermometer or a glucometer on board whatever you do!

PS on the OP, it isn't common for people to _remember_ losing consciousness unless it was gradual. There's a factoid. But while they look puzzled when you ask them if they blacked out, they may look even more so when you ask if they remember waking up, and they say "Hey, yeah….!".


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