Hyperglycemia isn't the answer

[bigbaldguy]

Crew is called for a "sick person" at a large place of business. Upon arrival you find a 45 year old African American woman who had been sitting in a class room while taking a work training class. About 4 hours into the class she had LOC and slid out of her chair and onto the floor. She was unresponsive for "a minute or two" then came around. Upon questioning she states she does not remember anything of the events. She informs us she tested her blood sugar and it was high and that she hasn't "felt right" since that morning. She appears slightly weak and confused.

Patient is insulin dependent but has not had insulin in "a couple of days"

Patient has history of Hyper tension

Meds
Insulin
A medication for hypertension (she could not remember the name and did know if she had taken it that day)

Her vitals are
HR 60
BP 140/100
Resp normal 18 minute
Skin normal
Temp normal
Blood glucose 490
ECG normal

En route to hospital patient is unable to remember her phone number and address but can remember her birth date and is oriented to place and time.

So here's the question we handled this call and we missed something that looking back on it we should have probably caught. Any ideas on what it might have been?

 

[46Young]

12 lead, L/S and a stroke assessment?

 

[bigbaldguy]

We did 12 lead and it was normal. Glasgow Coma Score was checked and it was a few points off but we assumed that was due to high blood sugar. We did not do a stroke assessment and that's exactly what it was. Patient was treated with O2 and fluids and transported emergency so missing this probably didn't affect patient outcome but it was still kind of a wake up call for me. I'll be adding a stroke assessment to all my hypoglycemic/hyperglycemia patients from here on out. Hospital found she had had minor TIA and treated her for it.

By the way what is a L/S I'm not familiar with that?

 

[abckidsmom]

We did 12 lead and it was normal. Glasgow Coma Score was checked and it was a few points off but we assumed that was due to high blood sugar. We did not do a stroke assessment and that's exactly what it was. Patient was treated with O2 and fluids and transported emergency so missing this probably didn't affect patient outcome but it was still kind of a wake up call for me. I'll be adding a stroke assessment to all my hypoglycemic/hyperglycemia patients from here on out. Hospital found she had had minor TIA and treated her for it.

By the way what is a L/S I'm not familiar with that?

Pretty sure he meant lung sounds.

CVA is right up there in ANY altered mental status, especially with hypertension and diabetes involved in the PMH.

Are you a BLS provider like your profile indicates? Was there an ALS provider on the call, or are you able to do all this as a basic?

 

[bigbaldguy]

I'm a basic and was riding as third with a intermediate and a paramedic so the IV and 12 lead were done by them. I'm kicking myself for not speaking up because I remember thinking the woman's face just didn't "look right". I'm sure I was picking up on something. I just got out of class in August and they didn't really teach us much about stroke assessments but since then I have read plenty about CVA's and TIA's. Ill be reading up on stroke assessments before my next shift. Do you have any practical advice on what methods of stroke assessment work best in the field? The only ones they even touched on in class was having them hold your hands and squeeze and to check for facial droop.

 

[abckidsmom]

http://en.wikipedia.org/wiki/Cincinnati_Prehospital_Stroke_Scale

I know wikipedia isn't completely well-regarded around here, but for something this simple, I'm a fan.

Anyone can do the Cincinatti Scale, and it is either documented as normal or abnormal, and then what specifically the patient missed on.

I was glad you asked the question, because I learned somethign new in this study about the stroke scale: http://www.ncbi.nlm.nih.gov/pubmed/10092713

Did you get a chance to talk to the medic? Was he surprised by the TIA? Knowing what you know now, how might you have addressed this if you were not the lead person on the call? If the lead person blew you off, or didn't care to hear what you had to say, what do you think you'd do then?

If you were alone with this patient, what would you have done? Would you have called for ALS? What if you were 20 minutes further from the hospital?

These are the questions I ask myself or my preceptees as I attempt to learn from a miss, or a mistake. I hate missing something, but I would guess that it is a common thing for a medic to have "that one patient" with the blood glucose problem masquerading as a CVA or vice versa. Only one, if you're smart though. Nothing feels dumber than give a whole report on your patient with a CVA only to have the staff check their sugar and it's 32.

Good work, learning from this!

 

[johnmedic]

Do you have any practical advice on what methods of stroke assessment work best in the field?

Grip strength is perfect, but don't just put your fingers in the pt's hands.. have them reach out & grab your fingers that way you can tell if one hand reaches out & the other misses. You already know to have them squeeze. Facial droop?
You can ask them to smile real big & show you their teeth, this can make facial droop much less of a guessing game like you mentioned you were kicking yourself for (it happens!).
Or have them to stick their tongue straight out too, if it juts to one side or the other, there's your sign.
If you have them stick their arms straight out palms up or down then close their eyes while keeping their arms extended, the arms should stay in that position.. if during those tests one arm drops & the other does not, that's a famous sign.
Are the pupils both equal & reactive, or just one side?

There are dozens of others, just google & ask coworkers, you'll pick up a great routine that comes natural. I tend to do the Cincinatti Stroke Screen on more patients than I probably have to, but it's something you can check off that is embarassing if you miss it!

 

[JPINFV]

I'll be adding a stroke assessment to all my loss of consciousness patients from here on out. Hospital found she had had minor TIA and treated her for it.

By the way what is a L/S I'm not familiar with that?

Here's the problem. You're treating a patient who had loss of consciousness. That same patient happened to have a high level of blood glucose. However, what other things can cause a loss of consciousness? Have you ruled them out? Also, screw the stroke screen. Why wasn't a basic neurological exam done? Dermatomes, muscle strengths, most cranial nerves, and a bunch of other tests can be done by anyone, including basics. The results of which can then be applied to a stroke scale.

 

[AndyK]

Here's the problem. You're treating a patient who had loss of consciousness. That same patient happened to have a high level of blood glucose. However, what other things can cause a loss of consciousness? Have you ruled them out? Also, screw the stroke screen. Why wasn't a basic neurological exam done? Dermatomes, muscle strengths, most cranial nerves, and a bunch of other tests can be done by anyone, including basics. The results of which can then be applied to a stroke scale.

Surely the old FAST test would have picked up on that.. sure, it's crude but it might have been enough to have set alarm bells ringing?

 

[bigbaldguy]

Surely the old FAST test would have picked up on that.. sure, it's crude but it might have been enough to have set alarm bells ringing?

I've since starting doing the Cincinnati stroke scale on everyone. I hadn't heard of the FAST test till you mentioned it. It probably would have picked it up had I known enough at the time to use it.

 

[JPINFV]

Surely the old FAST test would have picked up on that.. sure, it's crude but it might have been enough to have set alarm bells ringing?

The components of a FAST (I'm assuming you're talking about the "Act FAST" PSA campaign) are included, but not inclusive, of a proper basic neurological exam.

 

[AndyK]

The components of a FAST (I'm assuming you're talking about the "Act FAST" PSA campaign) are included, but not inclusive, of a proper basic neurological exam.

Indeed, that's really what I was alluding to.. the fact that it was missed means that a basic neuro assessment hadn't been done?

To clarify for those unfamiliar with it:

Face - can the Pt. smile & frown, is it equal?
Arms - can the Pt. extend, raise & lower both?
Speech - can the Pt. speak clearly?
Time - onset sudden?

As i said, it's pretty crude, but no more so than any other primary assessment.

 

[HappyParamedicRN]

My dx is SEVERE boredom from a possibly useless mandatory class!

 

[blinnbuc89]

Tia

Well if it truly was a TIA, then the Neuro assessment may not have picked it up. TIA is just a warning that the 'big one' is coming. The Hyperglycemia would have been of no consequence for me, at least in determining what caused her LOC. I have noticed that whenever I see HTN and DM together with on a pt presenting with AMS, or reported AMS, with a 'normal' BGL to be weary of stroke or TIA. If the person has A-fib, HTN, DM; then clearly god hates them and they better be on a lot of coumadin, warfarin, or ASA.

 

[blinnbuc89]

Also, I just read back through the OP,
You could almost suspect a vasovagal syncopal episode, initially. Then due to the trauma of hitting her head on the floor led to her AMS.
Just one possibility. That was just something to think about before you get there and rule it out while narrowing down your field diagnosis.

 

[mycrofft]

Going back to OP....from your description, many possibilites.

....but not hyperglycemia. Any LOC gets some sort of neuro screen or exam if you're a trained bystander or above; even with an atypical EKG, don't fixate because some arrythmias toss or promote clots.

Intracranial neoplasm, TIA, early CVA, undiagnosed seizure disorder, positional asphyxia (poor posture/tight desk and clothes plus obesity...what's her weight?), emotionally triggered vasovagal syncope, Munchhausen, other psychiatric problem, pharmaceutical (prescription or otherwise) or cardiac, to name a bunch. (Had an MD start going out like that, turned out he's lost patency of a heart valve).
And the "TIME" in F.A.S.T., in my training video, is time of onset. CVA can be slow onset and deceptively leisurely exacerbation.