# Scenario time.



## EMR06 (Feb 6, 2006)

The scene: you notice the house is fairly dirty but safe to proceed.
bsi procedures taken:gloves,the usual
mother says her daughter is 16 y/o and diabetic
She had a fight with her boyfriend about a half an hour ago.meds missing meds: 6 tablets of propranol 80mg.amitripyline 50 mg. 2 500mg of acephetamine. and to top it off she washed it down with 2 bottles of beer. she slurs and tells you she is nausea'd and has not vomited. Last meal was 4 hours ago.  She refuses to tell you when she last took or insulin.

p:96 and full, bp:100/70 rr:14   skin is warm,dry.


what will you do?


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## fm_emt (Feb 6, 2006)

"C'mon, we're taking you to the hospital."

o2, some glucose paste, check vitals again and transport. 

that's the first thing that comes to mind here. She's gobbled down meds for hypertension, depression, and some painkillers. I'd imagine that 480mg of propranol (for hypertension) could cause an unsafe drop in blood pressure. Transport times around here are > 15 minutes. Might take that long to dig out & administer the activated charcoal.


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## EMR06 (Feb 6, 2006)

Contact online medical control
Inform them of the patients status, vitals etc
do a blood test for sugar.let control know what the results were. go from there. administer glucose or not. activated charcoal I would administer 15-25 mg. Aware of the possibility of vomitting and v-fib. update control with vitals. admit to emerg.


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## EMR06 (Feb 6, 2006)

this is a discussion. please do reply.


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## fm_emt (Feb 6, 2006)

Who, me? or someone else?  It's more of a 'forum' than a 'discussion' - and besides, I was off getting lunch.

We can't do glucose sticks here, that's why I left off "check glucose level." :|


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## emtbuff (Feb 6, 2006)

I would check a blood sugar if she will let me.  Monitor vitals to watch for a drop in B/P.  Call for medical direction to administer Activated Charcoal, or if they want to have glucose administered.  And of course I'm going to treat with diseal.  Most of the time our transport time is about at 15 min, of course that depends on Location.


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## TTLWHKR (Feb 7, 2006)

Hold off on that Glucose...

Since it's BLS.. I'll try to contain myself.

Collect the med bottles, or at least write them down, note when they were filled and the dosage. O2 12 by NRB. Transport. Med Command>Poison Control for Charcoal. Get a sick bag ready, just in case, point head toward rookie. Get your aspirator set up, again, just in case. Maintain airway, use a nasal if she becomes unconscious, bag if the resps are shallow, labored or noisy. 
Keep an eye on the BP, especially with a propranolol and amitriptyline OD. That's an HBP med and depression med, both can cause hypotension. Raise the feet if it goes to 90 systolic, plan ahead. The combination of the two, in high dose, can cause cardiac arrest really quickly.

Call ALS. In this case, it would be better to treat the diabetic problem via IV. You don't want her to aspirate the glucose. That will be the least of her problems.


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## VinBin (Feb 7, 2006)

TTLWHKR said:
			
		

> just in case, point head toward rookie.


 
haha...

Would that be noted in the trip sheet?


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## Ecnalubma (Feb 7, 2006)

"Vomit contained in appropriate location" :lol:


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## Gents82 (Feb 7, 2006)

Do her symptoms really call for oral glucose? She is diabetic, but she also popped a good amount of pills and mixed it with alcohol. I dont see how that can be grounds to administer oral glucose, seemingly her vitals are well within normal range.


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## fm_emt (Feb 7, 2006)

Gents82 said:
			
		

> Do her symptoms really call for oral glucose? She is diabetic, but she also popped a good amount of pills and mixed it with alcohol. I dont see how that can be grounds to administer oral glucose, seemingly her vitals are well within normal range.



I'd say go for the glucose because a)it won't kill her and b)the ER folks might say "you turkey, why didn't you give the diabetic some glucose!!" anyway. 

But for anyone who's gobbled down random pills like that, I'd take them in.


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## fm_emt (Feb 7, 2006)

Doctor I know says this: 

"Amitriptylline..tricyclic antidepressant in high doses it disrupts potassium uptake and stops your heart."


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## Jon (Feb 7, 2006)

Umm.... MEDIC!!!!!.... get an ALS intercept rolling, get on the phone with command / poison control - at the very least, get the ED ready to treat this C-F. Patient should probably get activted charcoal (yay). Make sure to have some large red bags ready for emisis, and try to be quick on getting to the ED.

As for glucose... check with the doc. Probably not a bad idea if pt. is maintaining her airway, but who knows for how long.

You can always ask Mom to check pt's blood sugar (you aren't breaking protocols, that way) if sugar is high, don't give glucose, if borderline or low, give glucose.


Also, if the glucose DOES work, the patient is going to be MORE unhappy to go to the hospital, so getting a second BLS rig / FD / or extra PD rolling for a manpower assist with restraint if needed might not be a bad idea.


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## dhpd9807 (Feb 7, 2006)

w/ the beta blocker on board she is not going to present as your run of the mill hypoglycemic. She will likely not be diaphoretic or tachycardic and if her MS drops due to low BS it will probably happen rather fast. I am not big on BGL's on non-tachy/altered, dry pt's but I think this is a case where you might need to rethink that one. If ya can, check her BGL, if not, throw her an amp of D-50 down the IV. As for the rest, I would way call ALS. The TCA/beta-blockade is a bad thing. Oh yea, what was her mental status?


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## i_drive_code3 (Feb 7, 2006)

i work on an als-rig so i would get a blood sugar reading prior to administering any glucose and  my medic would want a line so he can give her meds via i.v.
i agree with o2, slap her on the ekg, and forget the little emesis bag, i'd cut a hole in a pillowcase and get that around her neck.  not sure about the charcoal i admit, considering the mess it makes on the way back up...
we have a 30 minute transport time (the price you pay for living in such a beautiful area!)

since this would be an als call i'd be relegated to driving which is nice if you have a medic who wants to point the vomit spewing towards the "rookie"...lol of course if there is an irritating young fireperson that wants to ride along who am i to say BEWARE? heh heh

oh and definetely make mom drive in with anyone else but us!

kate


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## Ecnalubma (Feb 7, 2006)

Be careful with oral glucose. This patient could go from conscious to comatose real quick and that brings about a large chance of aspiration. It doesn't sound like this is a blood glucose related incident, though it would be good to keep an eye on it if you can because the rumor is ETOH lowers blood glucose.


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## TTLWHKR (Feb 7, 2006)

VinBin said:
			
		

> haha...
> 
> Would that be noted in the trip sheet?


 
If you want...


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## TTLWHKR (Feb 7, 2006)

i_drive_code3 said:
			
		

> i work on an als-rig so i would get a blood sugar reading prior to administering any glucose and my medic would want a line so he can give her meds via i.v.
> i agree with o2, slap her on the ekg, and forget the little emesis bag, i'd cut a hole in a pillowcase and get that around her neck. not sure about the charcoal i admit, considering the mess it makes on the way back up...
> we have a 30 minute transport time (the price you pay for living in such a beautiful area!)
> 
> ...


 

A pillow case??? :glare:  That would be like using a paper bag as a canteen.


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## i_drive_code3 (Feb 8, 2006)

TTLWHKR said:
			
		

> A pillow case??? :glare:  That would be like using a paper bag as a canteen.



hey don't glare at me :wacko:  silly medic our pillowcases are tyvek(x?) lined and they work _wonderfully_ for those voracious vomiters!

kate


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## ffemt8978 (Feb 8, 2006)

We do the same thing with the large red biohazard bags.  We also use those wooden needle point hoops to hold the bags open.


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## TTLWHKR (Feb 8, 2006)

ffemt8978 said:
			
		

> We do the same thing with the large red biohazard bags. We also use those wooden needle point hoops to hold the bags open.


 
Now that I can relate to...

But a pillow case sounds weird.


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## dhpd9807 (Feb 9, 2006)

Speaking from personal experience I think the rumor that ETOH lowers blood sugar may be just that,a rumor. Unless all the bruises, lacerations and shame can be blamed on hypoglycemia.


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## mightymom7 (Feb 9, 2006)

Here's a nifty link from the American Diabetic Association about the effects of alcohol and diabetes.

http://www.diabetes.org/type-1-diabetes/alcohol.jsp

We're an all ALS system here -- so I'd check her BS, strap her to stretcher, throw her on the monitor, initiate ALS enroute -- and give hospital heads-up.  Here we take all OD's to the closest hospital -- usually no more than 10-15 min away (unless they're on divert or closed) Monitor closely and diesel all the way to the ER.


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## TTLWHKR (Feb 9, 2006)

I'd focus on the two meds she has taken, both of which can bottom out the BP, and one of the LISTED side effects is cardiac arrest in OD.


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## EMR06 (Feb 24, 2006)

I love reading all of your responses. Thank you.


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## Kendall (Aug 10, 2006)

o/a - assess a+o, ABC's, vitals, drugs taken + approx vol. Start O2 @ 8LPM on an NRB, check sugars. If avail, ask BLS to start a line for fluids/diabetic substances & start 3-lead ECG. Monitor vitals and activate ALS. Prep for ALS transport and document.

The standard FR's route!


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## DisasterMedTech (Oct 22, 2007)

I havent heard anything that sounds like HGL yes, so lets hang back on getting that BGL still since its one more thing our equation does need right now especially since we could be watching  a patient who is preparing to code. EKG monitoring with other vitals q5m. Make report to receiving facility. If they advise interecept, you will probably have been thinking that way anyway and can just call it up. Treat pt as if for shock, 4 LPM/NC, start line in left a/c for acess and proceed as normal. What is time to facility now and what are our patients s and sx?

Advise.


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## Rangat (Oct 23, 2007)

I am not entirely sure what all those meds do to a pt, but have picked up some things from the replies.

The BP is still normal for that patient, but you need more than one reading to see where it's going.

She is an Insulin Dependant Diabetic. So her cells will have trouble with glucose uptake. Won't this make her hyperglycaemic? She avoids the insulin question though, this could be because shes feeling guilty for not taking it. 

I wouldn't administer glucose until a glucometer tells me to do otherwise, if she was cold/wet I would consider it more strongly.

fm_emt suggested that TCAs inhibit K+ uptake by myocytes? 

But insulin supports K+ movement into cells, so would rapid acting insulin be a good idea if she starts showing some hypokalaemic EKG patterns? Just throwing it out there?

Lastly I would do something to protect the airway, perhaps lateral.

Lifting the legs and getting up a large bore should save you if her BP falls until u get to the hosp.

What u guys think?


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## medic755 (Oct 24, 2007)

I agree with TTLWHKR



TTLWHKR said:


> Hold off on that Glucose...
> 
> Since it's BLS.. I'll try to contain myself.
> 
> ...



This is an ALS emergency, in my eyes, if you have the resources.

If its ALS, the glucose will be checked, and treated appropriately. EKG will be put on and IV started.  Plus the TCA overdose can be countered with sodium bicarb. The time of ingestion is also important to know, remember, activated charcoal cant be administered orally to someone who cannot maintain their own airway. Depending on transport time, and the aggressiveness of the medic, the patient can be administered the charcoal via NG tube.

For all levels: protect the airway, give her a NPA early, Rx for shock. And put the pt on a non rebreather, not a NC. This is a patient who is most likely going to crash, be wary and constantly assess and reassess

Also, this would be a good type of patient to restrain, just for safety sake. Here's one I learned from experience: patients who make a suicide attempt aren't always happy that they have survived and you are taking them to the hospital. Especially if they regain consciousness in the back of your rig. And ESPECIALLY if the patient is the size of a bull moose. like i said, you learn from experience (and bruises). lol


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## 1799687 (Oct 25, 2007)

I'm with you on this one. ALS can also reverse that beta blocker with Glucagon, depending on DM status, and administer cardiac meds if necessary. 




TTLWHKR said:


> Hold off on that Glucose...
> 
> Since it's BLS.. I'll try to contain myself.
> 
> ...


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## reaper (Oct 25, 2007)

This is a ALS call.

 But, the Betablocker issue was covered before. I have never seen a unit that carries enough glugagon on the truck to help with a BB OD.


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## 1799687 (Oct 26, 2007)

understood, reaper, i'm just a basic, in medic school, going by protocol


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## reaper (Oct 26, 2007)

If you have a protocal for glugagon for BB OD, then maybe your service carries enough on board? I know most around here only carry 2 mg on board. It is a very expensive drug. ($100 a pop) They don't like it used, except as a last resort.


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## Mercy4Angels (Oct 27, 2007)

shes altered if shes slurring to you. so thats your contra indication for glucose usage. call medics i dont care if her vitals are what they are. her vitals can be fine one minute and not the next. get ALS in route. activated charcol is no longer used and we dont carry it so that rules that out also. Oxygen, bring her to the rig wether she likes it or not. shes altered so you can force her if you have to. wait for ALS or meet them line of sight.


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## joo (Nov 11, 2007)

Mercy4Angels said:


> shes altered if shes slurring to you. so thats your contra indication for glucose usage. call medics i dont care if her vitals are what they are. her vitals can be fine one minute and not the next. get ALS in route. activated charcol is no longer used and we dont carry it so that rules that out also. Oxygen, bring her to the rig wether she likes it or not. shes altered so you can force her if you have to. wait for ALS or meet them line of sight.



thats what I would do. Only thing under my protocol I can't give glucose unless I can check her sugar, and I don't carry a glucometer so I better hope she has one around. More than likely for us PD is going to be enroute on scene because its a possible overdose. If its not dispatched as a poss overdose, you might want to get them enroute.


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## DisasterMedTech (Nov 12, 2007)

Mercy4Angels said:


> shes altered if shes slurring to you. so thats your contra indication for glucose usage. call medics i dont care if her vitals are what they are. her vitals can be fine one minute and not the next. get ALS in route. activated charcol is no longer used and we dont carry it so that rules that out also. Oxygen, bring her to the rig wether she likes it or not. shes altered so you can force her if you have to. wait for ALS or meet them line of sight.



I think its time to go back to school.  Simple altered mental status is not a contra-indication for glucose. Check your Brady's. Contras for oral glucose are: loss of consciousness/responsiveness and inability to swallow. The only time that being altered might be a contra for oral glucose is if you suspect that the patient is altered due to a TIA/CVA. Remember, water goes where glucose goes and since glucose goes directly to the brain since that's all it can "eat" you dont want to send a shot of it to the brain and then have possible increased ICP due to the homeostatic process. And if you are going to "force" a patient to do anything you better be %$#& sure they are altered or you may as well go home and flush your license down the toilet along with your paycheck. We dont  "force" patients. Its called implied consent and you better document the hell out of it or your going to be staring down the business end of a malpractice suit. Remind me never to get sick in New Jersey.


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## Rangat (Nov 12, 2007)

*?*

Why don't the USA have glucometers? 

There's money to use Dual Lumen Airways on the road but not a glucometer?

It must be one of the safest invasive things to do pre-hospitally.

And I think the benefits of having a sugar reading is far more useful than the odd cellulitis, or the expense?h34r:


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## DisasterMedTech (Nov 12, 2007)

Rangat said:


> Why don't the USA have glucometers?
> 
> There's money to use Dual Lumen Airways on the road but not a glucometer?
> 
> ...




We do have glucometers, its just that a lot of areas dont let EMT-Bs use them. We have them on my service, in fact I carry one on my belt and use it all the time.  Im not sure what you mean by "the odd cellulitis" though....


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## Rangat (Nov 12, 2007)

Ok. Yes I also saw the glucometer thread downstream.

Erm... Cellulitis was the only complication I could think of?

That and a paediatric patient will NEVER let you near him again. Once you drop the needle, you are out of the circle of trust buddy.


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## bravofoxtrot (Nov 23, 2007)

Haven't finished reading this, but keep in mind that amitriptyline also inhibits noradrenaline reuptake.


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## AntonioEMT (Dec 15, 2007)

*scenario*

I allow a glucometer, <60 mg/dl, 2ml of rapid glucose 33%,...monitorate conscious, blood pression...and transport.


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## certguy (Dec 19, 2007)

*Scenerio*

I've always believed in preparing for the worst and hoping for the best , so , I'd have her on 15 lpm by non - rebreather . I would also slam an NPA , get the suction ready , give her a pillow case ( I've done that too ) for the activated charcoal aftermath , and check on ALS ETA . If it's longer than our transport time , we go , if it's shorter or we can intercept in a shorter time , we ' ll do that . I would grab a FF and have him moniter vitals and be ready for a B/P crash while watching the LOC . I would also bring the bottles and ask mom if she remembers how full they were prior to this incident before we go , mom can ride with family , friends , or PD .


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## certguy (Dec 19, 2007)

Oops , forgot to include assisting ventilations if needed , Ambu would be out and ready behind her just in case .


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## KEVD18 (Dec 19, 2007)

DisasterMedTech said:


> in fact I carry one on my belt



your joking right?


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## NanNan&Dusty (Dec 19, 2007)

Thank you for all these "Scenario times", I will have my practical exam on 01/09 and 01/14. Now I am scared to dead...... because it's hard to have all these different scenario when we are practice by ourselves. Our instrutors never gave us any scenario, only asked us to practice practice and practice but w/o the scenario , I don't know how...


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## Aileana (Dec 19, 2007)

I'd do a glucometry stick first to see her levels, respond to the result accordingly (BLS here can do glucometry). Write down med names and suspected dosages taken, monitor vitals (and prepare to act according to changes). As far as I know, charcoal isn't in our BLS or ALS standards, so I would keep emesis bags/basins within close reach, and transport to the nearest hospital.


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## daedalus (Dec 19, 2007)

Rangat said:


> I am not entirely sure what all those meds do to a pt, but have picked up some things from the replies.
> 
> The BP is still normal for that patient, but you need more than one reading to see where it's going.
> 
> ...


If she avoided the question on insulin, and also took many other  medications, its reasonable to think she also injected lots of insulin to top it all off. Never assume she did not take it, instead, keep a high index of suspicion. Do a full assesment and check RBS.

As for this pt in the thread, call ALS, get the medication bottles, get a history, put her on some O2, throw her in the ambulance and do the assesment in route. Follow protocol on glucose/charcol. Once ALS meets you they can put her on the EKG and stick a line in her.


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