Syncope

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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 >
 
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.
 
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.
 
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.
 
If he's had this happen before and it was due to diabetes....why now would you think it's something else?
 
Angel said:
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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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?"
 
Angel said:
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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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.
 
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.
 
Angel said:
Absolutely do as best an assessment you can but I don't see a reason to go chasing zebras.
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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.
 
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.
 
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.
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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.
 
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?
 
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.
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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
 
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.
 
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.
 
captaindepth said:
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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Oh, so 2 years of school with the main end goal of in-depth assessments is the same as what a basic does?
 
captaindepth said:
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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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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