Adult - Medical

• Diabetic Disorders
• Pain Management

Diabetic Disorders

Applies to: Blood glucose less than 70 mg/dL or greater than 300 mg/dL **and**

• Patient-reported low or high blood glucose
• Diabetic patients with other medical symptoms (e.g., vomiting)
• Altered mental status
• Alcohol intoxication, suspected
• Seizure
• Stroke symptoms
• Unresponsive patients
• Cardiac arrest

Exclusion Criteria: None

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History

• Past medical history
• Medications
• Drug allergies
• Last Meal
• Last BGA check

Signs and Symptoms

• Altered mental status
• Combative / irritable
• Diaphoresis
• Seizures
• Abdominal pain
• Nausea / vomiting
• Weakness
• Dehydration
• Deep / rapid breathing

Differentials

• Alcohol / drug use
• Toxic ingestion
• Trauma; head injury
• Seizure
• CVA
• Altered baseline mental status

Pearls

• Patient’s refusing transport to medical facility after treatment of hypoglycemia:
  • Blood sugar must be ≥ 80, patient has ability to eat and availability of food with responders on scene.
  • Patient must have known history of diabetes and not taking any oral diabetic agents.
  • Patient returns to normal mental status and has a normal neurological exam with no new neurological deficits.
  • Must demonstrate capacity to make informed health care decisions. See Universal Patient Care Protocol UP-1.
    Otherwise contact medical control.
• Hypoglycemia with Oral Agents:
  • Patient’s taking oral diabetic medications should be encouraged to allow transportation to a medical facility.
    They are at risk of recurrent hypoglycemia that can be delayed for hours and require close monitoring even after
    normal blood glucose is established.
  • Not all oral agents have prolonged action so Contact Medical Control or NC Poison Control Center for advice.
    Patient’s who meet criteria to refuse care should be instructed to contact their physician immediately and
    consume a meal.
• Hypoglycemia with Insulin Agents
  • Many forms of insulin now exist. Longer acting insulin places the patient at risk of recurrent hypoglycemia even
    after a normal blood glucose is established.
  • Not all insulins have prolonged action so Contact Medical Control for advice.
  • Patient’s who meet criteria to refuse care should be instructed to contact their physician immediately and
    consume a meal.
• Congestive Heart Failure patients who have Blood Glucose > 250:
  • Limit fluid boluses unless patient has signs of volume depletion such as, dehydration, poor perfusion,
    hypotension, and/ or shock.
• In extreme circumstances with no IV / IO access and no response to glucagon, D50 can be administered rectally,
  Contact Medical Control for advice.

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References

Protocols

Pharmacology

• Dextrose 10%
• Dextrose 50%
• Glucagon
• Glucose

Procedures

• Vascular Access

Pain Management

Applies to: Patient presents with a painful condition that would benefit from treatment with an analgesic. This
includes DNR/MOLST patients and patients being pre-medicated for a painful procedure.

Exclusion Criteria: Medication specific hypersensitivity/allergy. Active Labor.

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History to consider

• Age
• Location
• Duration
• Severity (1 - 10)
• If child use Wong-Baker faces scale
• Past medical history
• Medications
• Drug allergies

Signs and Symptoms to note

• Severity (Pain scale)
• Quality
• Radiation
• Relation to movement
• Respirations
• Reproducible
• Increased upon palpation

Differentials to consider

• Per the specific protocol
• Musculoskeletal
• Visceral (abdominal)
• Cardiac
• Pleural/ Respiratory
• Neurogenic
• Renal (colic)

Pearls

• Do not administer Acetaminophen to patients with history of liver disease or known to have consumed large amounts of ETOH. 
• Fentanyl, Morphine and Ketamine should be reserved for acute pain.
• For patients in Moderate pain for instance, you may use the combination of an oral medication and parenteral if no contraindications are present.
• Ketamine
  • May use Ketamine in combination with opioids to limit total amount of opioid administration
  • Avoid in patients who have cardiac disease or uncontrolled hypertension.
  • Avoid in patients with increased intraocular pressure such as glaucoma.
  • Avoid use in combination with benzodiazepines due to depressed respiratory drive

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References

Protocols

• Nausea / Vomiting

Pharmacology

• Fentanyl Citrate
• Morphine
• Ketamine
• Acetaminophen
• Ofirmev
• Ibuprofen

Procedures

• Vascular Access
• Pain Assessment