# hyperglycemia



## daff243 (Apr 8, 2009)

i tired to find the old thread on this but couldnt. i just recently moved out into the county were i started to volunteer as a ff. being that i have extra time from my city job. and being pretty much the only emt that responds with my new dept most patient care is mine unitl amr arrives. with that said, we responded to a call the other night for a 'diabetic emergency' upon arrival, patient a&ox4 assessment found the following

sob
headache
chest pain
bgl 244
spo2 91
bp 132/72
hr 92
rr 23
hx: anxiety attacks, dm, htn, recent diagnosis of sepsis which resulted in toe amputation..

i had placed patient on 15 lpm NRB called to ask for eta on amr and they were about 10 min out. so i went ahead and gave 2 baby asprin and asked her to chew it to see if her chest pain would go away and i didnt. 10 min had lapsed and i called again and amr was lost. i then went ahead and gave the patient 1 tablet of nitro and reassed vitals her sob had subsided along with her headache
spo2 was at 99
bp 122/68
hr 78
rr 18

at that time, amr arrived told them what i have done and they took over an transported.
my guess anxiety attack? and the sepsis and toe amp. cause the slightly elevated bgl?

anyway, is there anything else i could have done for this pt.? the whole time frame was about 15-20 min.


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## CAOX3 (Apr 8, 2009)

If in fact it was a anxiety attack you may want to choose a lesser O2 delivery devices first as a mask may sometimes make these patients more anxious.

What did her lungs sound like?

Was she diaphoretic?

Did she have a temp?

Also if its an anxiety attack the oxygen is not the main concern.  Try to concentrate on slowing the breathing.

A BGL of 244 in itself is not a life threatening emergency. I'm not to concerned with that.

ASA is a platelet inhibitor.  

It causes a rapid and near-total inhibition of thromboxane A2 production. 

Basically it prevents platelet clotting.

There is almost a 30% drop in mortality rate for patients receiving ASA in the presence of a MI.


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## boingo (Apr 9, 2009)

Anxiety attack, while maybe the actuall culprit, should be far down your list of differentials.  Knowing nothing about the patient other than what was posted, hx of HTN, DM with chest pain/sob, I'd have cardiac at the top.


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## LAS46 (Apr 22, 2009)

daff243 said:


> i tired to find the old thread on this but couldnt. i just recently moved out into the county were i started to volunteer as a ff. being that i have extra time from my city job. and being pretty much the only emt that responds with my new dept most patient care is mine unitl amr arrives. with that said, we responded to a call the other night for a 'diabetic emergency' upon arrival, patient a&ox4 assessment found the following
> 
> sob
> headache
> ...



The one thing I would have also done different with this is give nitro first if the patient had their own, if the PT did not have one of their own then I would have used one from the unit.

According to the NREMT Skills sheets I have for meds it says:
*Nitro*
Initial Assessment
Focused Physical Exam
Basline Vitals (Systolic BP >100)
_Don't forget your indications for nitro:
Chest Discomfort
PT has Rx
Medical Direction gives OK for this patient
Also do not forget your contraindications:
Systolic BP <100
Use of sexual enhancement drugs within the last 72 hours
Head Injury, NOT PTs Rx
Exceeded Max Dose (3)_
*After your indications and contras:*
Check Medications, Assure med is for PT, check the exp date.
Then Call Medical Direction
*4 R's: Right Pt, right drug, right date, right route.*
PT Alert Enough to take nitro
Assist PT with nitro (place sublingual (SL))
Reassess Vitals after 2 min
Contact MD if PT still has chest discomfort and systolic BP still ^100
Document your time, dose, MD ordering, PT responce
Transport.

*Asprin:*
Indications:
-Chest discomfort, not allergic to ASA, can swallow
-PT not taking a blood thiners
-No Hx of Asthma
-MD gives OK for this patient
Contraindications:
-Allergy to ASA, Active GI bleed, known bleeding disorder
-Recent Surgery, Pregnant, already taking meds to prevent clotting.
Check medication, assure med is not expired
Call Medical Direction
4 R's
Assist PT with Asprin
 - PT alert enough to chew and swallow
 - Give 4 baby asprin (81mg Each) for a total of 324mg by PO (mouth)
Reassess vitals after 2 min
Document
Transport

Be sure to go by your local regulations also.

Dustin
MFR, NREMT-B Student


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## reaper (Apr 22, 2009)

LAS46 said:


> The one thing I would have also done different with this is give nitro first if the patient had their own, if the PT did not have one of their own then I would have used one from the unit.
> 
> According to the NREMT Skills sheets I have for meds it says:
> *Nitro*
> ...



I do think you are reading it wrong? Why would you give NTG prior to an assessment and vitals? If you do not know what is wrong with the pt, how do you treat them? Do you give NTG to every pt you come across?


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## Mountain Res-Q (Apr 22, 2009)

reaper said:


> I do think you are reading it wrong? Why would you give NTG prior to an assessment and vitals? If you do not know what is wrong with the pt, how do you treat them? Do you give NTG to every pt you come across?



It's what the Cookbook says so every First Responder can have a malpractice suit to accompany their new shinny Certification!


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## JPINFV (Apr 22, 2009)

Since we've got some new members on board and we're discussing nitro with contraindications listed, I'm going to give my standard boilerplant statement about pulmonary HTN.

If your patient has a history of pulmonary HTN, check the medication list again. Sildenafil (known as Viagra and Revatio) is also used to treat pulmonary HTN.

Just curious Vent, is there any reason why the contraindications hasn't been increased to include Pul HTN Rxs like this as well?


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## lightsandsirens5 (Apr 23, 2009)

reaper said:


> Do you give NTG to every pt you come across?



You mean you _don't_???? That is why all my pts b/p is in the tank!

----------------

Also, I beleive that ASA is not administered for pain in a cardiac emergency, it acts as an anti-clotting agent, dosen't it?


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## boingo (Apr 23, 2009)

JPINFV said:


> Since we've got some new members on board and we're discussing nitro with contraindications listed, I'm going to give my standard boilerplant statement about pulmonary HTN.
> 
> If your patient has a history of pulmonary HTN, check the medication list again. Sildenafil (known as Viagra and Revatio) is also used to treat pulmonary HTN.
> 
> Just curious Vent, is there any reason why the contraindications hasn't been increased to include Pul HTN Rxs like this as well?




NTG isn't contraindicated in Pul HTN, in fact, it is sometimes used as tx.


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## JPINFV (Apr 23, 2009)

I doubt that it's used when the patient is on PDE5 inhibitors.


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## MSDeltaFlt (Apr 23, 2009)

daff243 said:


> i tired to find the old thread on this but couldnt. i just recently moved out into the county were i started to volunteer as a ff. being that i have extra time from my city job. and being pretty much the only emt that responds with my new dept most patient care is mine unitl amr arrives. with that said, we responded to a call the other night for a 'diabetic emergency' upon arrival, patient a&ox4 assessment found the following
> 
> *sob*
> *headache*
> ...


 
With those VS and c/c's and PMHx, I'd say yeah. It was an anxiety attack. Anxiety attacks will have SOB because they're all keyed up from panicking. They may have some chest discomfort for the exact same reason. They will have a HA because they're blowing all their CO2 off *because they're panicking*. What they need is to *calm down.* The best thing we can do is to enhance a calming environment.

I'm not griping by no means. This is just something to think about.

The ASA did nothing. The recommended dosage for a HA on the side of the bottle is higher than what you gave. I'd be careful giving NTG with a BP that low. It could bottom them out. True CP will usually have a higher BP. One of the best ways clinically distinguish cardiac pain from pleuritic pain is from tactile stimulus. Translation, if it looks like BS and they're c/o CP, poke on it. If they scream in pain, odds are it ain't cardiac.

Did you do anything wrong? Your reassessment proves you didn't. Was there anything else you could have done? Nope. With anxiety attacks, the problem is all in their heads.  Therefore the solution is also all in their heads. 

If you followed your protocols, good job.


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## boingo (Apr 23, 2009)

JPINFV said:


> I doubt that it's used when the patient is on PDE5 inhibitors.



Probably not.  The contraindication should be for patients on PDE5 inhibitors, not people with pulmonary HTN who aren't.  Most of the patients out there taking viagra and similar rx are taking them for erectile disfunction, not pulmonary HTN.  I wouldn't make erectile dysfunction a contraindication to NTG either, unless they have recently (past 24hrs) taken a PDE5 inhibitor.


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## LAS46 (Apr 24, 2009)

reaper said:


> I do think you are reading it wrong? Why would you give NTG prior to an assessment and vitals? If you do not know what is wrong with the pt, how do you treat them? Do you give NTG to every pt you come across?



No you do your ABCs and vitals before you give NTG. And no I do not give everyone one of my patients NTG. If they have the indications after ABCs and Vitals are in place then you can give them NTG. Read my notes again.



> Initial Assessment
> Focused Physical Exam
> Basline Vitals (Systolic BP >100)



I did do the Inital Assessment and Vitals before giving NTG..

Dustin C. 
MFR, NREMT-B Student


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## reaper (Apr 24, 2009)

LAS46 said:


> The one thing I would have also done different with this is give nitro first if the patient had their own, if the PT did not have one of their own then I would have used one from the unit.
> 
> According to the NREMT Skills sheets I have for meds it says:
> *Nitro*
> ...




The way you wrote that sounds like you are saying to give the NTG first, before anything else? That is why I questioned it.


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## DV_EMT (Apr 24, 2009)

lightsandsirens5 said:


> You mean you _don't_???? That is why all my pts b/p is in the tank!
> 
> ----------------
> 
> Also, I beleive that ASA is not administered for pain in a cardiac emergency, it acts as an anti-clotting agent, dosen't it?



thats correct. you should always be cautious administering any drug. But aspirin is one that you have to watch out for because it reduces the clotting effect. this is very bad for both internal or external bleeds that the pt may have.

Aspirin is a Salicylate.
Nitro is a Vasodialator.

Aspirin reduces clotting by lowering platelets, whereas nitro just dialates the blood vessels.


just dont give viagra when you give them nitro... bad kimchi!


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## VentMedic (Apr 24, 2009)

boingo said:


> Probably not. The contraindication should be for patients on PDE5 inhibitors, not people with pulmonary HTN who aren't. *Most of the patients out there taking viagra and similar rx are taking them for erectile disfunction, not pulmonary HTN.* I wouldn't make erectile dysfunction a contraindication to NTG either, unless they have recently (past 24hrs) taken a PDE5 inhibitor.


 
Not necessarily correct. We now have many people, including infants and peds, taking Sildenafil for pulmonary hypertension. While erectile function may lead the sales market, one should be familiar with the other possibilities. We have had several patients transported to us by ambulance and not one mention of Sildenafil even though it was noticed in the med list section on the Paramedic's PCR. Also, in report they dropped the word "Pulmonary" and just stated Hypertension. Thus, in reviewing the Paramedic text books, there seems to be a deficit in learning about Pulmonary Hypertension as well as V/Q mismatch.

Sildenafil, the prototypical PDE5 inhibitor, was originally discovered during the search of more treatments for angina.

Good article about Pulmonary Vasodilators:
http://www.rcjournal.com/contents/07.07/07.07.0885.pdf

Now to the OP. As an EMT-B, one should be very, very careful about writing something off as anxiety. Headache can also be cerebral vessel dilation, CO2 retention and acidosis. As well with this patient's hx, there is still a chance of micro emboli especially if the patient has been bedridden for any length of time. Did I miss a temperature posted here? Unless you can do an ALS assessment, and even that may not be enough, anxiety or the misused word "hyperventilation" should be you very last choice after you have rules out all other etiologies or carry and iSTAT machine to do some lab work. I also wouldn't put much faith into a post op patient's SpO2 when the Hb is not known. And then there is that silly little oxygen-haemoglobin dissociation curve to skew numbers even more.

In continuing with the theme of other posts, this is why I advise an EMT-B to keep on with their education and not just work on a BLS truck for experience. One picks up assessment habits that are later difficult to break. If you continue you gain knowledge, your assessments will make sense and you won't have to resort to just saying "anxiety" when you can think of nothing else.


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## boingo (Apr 24, 2009)

VentMedic said:


> Not necessarily correct. We now have many people, including infants and peds, taking Sildenafil for pulmonary hypertension. While erectile function may lead the sales market, one should be familiar with the other possibilities. We have had several patients transported to us by ambulance and not one mention of Sildenafil even though it was noticed in the med list section on the Paramedic's PCR. Also, in report they dropped the word "Pulmonary" and just stated Hypertension. Thus, in reviewing the Paramedic text books, there seems to be a deficit in learning about Pulmonary Hypertension as well as V/Q mismatch.
> 
> Sildenafil, the prototypical PDE5 inhibitor, was originally discovered during the search of more treatments for angina.
> 
> ...



Yes, but the majority of people are taking it for erectile dysfunction.  It is the class of medication that should be the relative contraindication, not the dx of pulmonary htn or erectile dysfunction for that matter.  This is the problem with giving medication to BLS, or poorly eductated ALS.  In your line of work I'm sure you have seen plenty of pts with pulmonary htn who have been tx with NTG, you wouldn't suggest the dx as being a contraindication, would you?


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## VentMedic (Apr 24, 2009)

boingo said:


> Yes, but the majority of people are taking it for erectile dysfunction. It is the class of medication that should be the relative contraindication, not the dx of pulmonary htn or erectile dysfunction for that matter. This is the problem with giving medication to BLS, or poorly eductated ALS. In your line of work I'm sure you have seen plenty of pts with pulmonary htn who have been tx with NTG, you wouldn't suggest the dx as being a contraindication, would you?


 
I would have an IV established with access to whatever rescue meds I needed if the BP did drop.  If I am told they have pulmonary htn, I would ask specific questions about their med list.  

Nitrates and pulmonary vasodilators usually do not go well together so we will do another line of treatment if needed to control angina. Or we might do a more selective route for the pulmonary vasodilator.

See the link I posted.


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## DV_EMT (Apr 24, 2009)

VentMedic said:


> I would have an IV established with access to whatever rescue meds I needed if the BP did drop.
> 
> Nitrates and pulmonary vasodilators usually do not go well together so we will do another line of treatment if needed to control angina.  Or we might do a more selective route for the pulmonary vasodilator.
> 
> See link I posted.



just need to be sure about what you can and can't give IV push. I was in the hospital the other day and they wanted me to pull up 8cc of fosphenetoin (400mg) to give a seizure pt via IV push.. they then stopped and wanted us to do it in a piggyback. we were looking at each other like... "are you insane?"

technically you can give a certain amount IV push, but it takes 20 minutes for the loading dose to kick in (both ways iv push or piggyback).


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## boingo (Apr 24, 2009)

VentMedic said:


> I would have an IV established with access to whatever rescue meds I needed if the BP did drop.  If I am told they have pulmonary htn, I would ask specific questions about their med list.
> 
> Nitrates and pulmonary vasodilators usually do not go well together so we will do another line of treatment if needed to control angina. Or we might do a more selective route for the pulmonary vasodilator.
> 
> See the link I posted.




I did.  And thank you for posting the links you do.  I may be a Mass Hole but I do appreciate the info you post.


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## JPINFV (Apr 24, 2009)

boingo said:


> It is the class of medication that should be the relative contraindication, not the dx of pulmonary htn or erectile dysfunction for that matter.


Oh, I completely agree. The problem is that most EMS protocols talk about ED medications, and not necessarily the class of drug.


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## LAS46 (Apr 27, 2009)

lightsandsirens5 said:


> You mean you _don't_???? That is why all my pts b/p is in the tank!
> 
> ----------------
> 
> Also, I beleive that ASA is not administered for pain in a cardiac emergency, it acts as an anti-clotting agent, dosen't it?




ASA is also given to PTs with chest discomfort in a cardiac emergency. It is a vaso-dilator and works similar to NTG. ASA and NTG can be used together.

*Directly from Brady Emergency Care 11th Edition:*


> Medication Name:
> 1. Generic: Nitroglycerin
> 2. Trade: Nitrostat, Nitrolingual
> Indications:
> ...



Even though the book does state the above please be sure to check with your local protocol on what you have available to you. Colorado goes by the National Registry information listed above for the administration of NTG and ASA.

Dustin C.
MFR, NREMT-B Student


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