Patient Care Guidelines (Demo)

• Adult - Medical
• Diabetic Disorders
• Pain Management
• Pharmacology
• Dextrose 10%
• Glucagon
• Glucose
• Fentanyl Citrate

Adult - Medical

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

Pharmacology

Dextrose 10%

GENERIC NAME

Dextrose

TRADE NAME

Dextrose 10

DESCRIPTION

Dextrose is a simple sugar that is rapidly metabolized by the body, providing quick restoration of blood glucose levels.

HOW SUPPLIED

Prefilled bag: 25 grams/250 ml (10% solution)

INDICATIONS

• Hypoglycemia

CONTRAINDICATIONS

• No major contraindications for IV administration of Dextrose.
• Known or suspected CVA (stroke) in the absence of hypoglycemia.

MECHANISM OF ACTION

Rapidly restores blood glucose levels in cases of hypoglycemia.

SIDE EFFECTS

• Local venous irritation and potential tissue necrosis if IV infiltration occurs.

AUTHORIZATION

EMT: Not authorized

AEMT: Standing order

Paramedic: Standing order

DOSAGE

• Adult: 250 ml IV/IO wide open, may repeat once if blood glucose remains < 60 mg/dL.
• Pediatric: 5 ml/kg (0.5 g/kg) IV/IO, may repeat once if blood glucose remains < 60 mg/dL.

ADMINISTRATION NOTES

• If desired dose is ≤ 100 ml, draw the required amount of D10 into a syringe and administer via slow IV/IO push using the port closest to the patient.
• If the desired dose is > 100 ml, administer by running wide open as a piggy-back to Normal Saline.

Glucagon

GENERIC NAME

Glucagon Hydrochloride

TRADE NAME

None

DESCRIPTION

Glucagon is used to increase blood glucose levels, particularly in cases where an IV line cannot be immediately established. Intramuscular (IM) administration results in a quicker onset than subcutaneous (SQ) and is therefore the preferred route.

HOW SUPPLIED

Vial: 1 mg powder (activated by injection of 1 cc sterile water)

INDICATIONS

• Hypoglycemia

CONTRAINDICATIONS

• Allergy or hypersensitivity to Glucagon

MECHANISM OF ACTION

Glucagon increases circulating blood glucose levels by promoting the breakdown of stored glycogen to glucose. Return to consciousness typically occurs within 5–20 minutes after administration. However, Glucagon may lose its effectiveness if given within the previous 48 hours.

SIDE EFFECTS

• Hypotension
• Dizziness
• Headache
• Nausea and vomiting

ADDITIONAL INFORMATION

After administration of Glucagon, the patient should eat a carbohydrate-rich meal as soon as possible to prevent recurrent hypoglycemia.

AUTHORIZATION

EMT: Not authorized

AEMT: Not authorized

Paramedic: Standing order

DOSAGE

• Adult: 1 mg IM/SQ
• Pediatric < 20 kg: Refer to specific dosages listed in the 402 – Drug Dosage Chart – Pediatric
• Pediatric > 20 kg: 1 mg IM/SQ

Glucose

GENERIC NAME

Glucose

TRADE NAME

Glutose, Insta-Glucose

DESCRIPTION

Oral glucose is used to provide supplemental glucose in cases of hypoglycemia. It is administered when the patient is conscious and able to swallow.

HOW SUPPLIED

Tube: 15 gm

INDICATIONS

• Hypoglycemia

CONTRAINDICATIONS

• Allergy or hypersensitivity to glucose
• Patient is not awake or unable to swallow

MECHANISM OF ACTION

Oral glucose restores blood sugar levels in patients experiencing hypoglycemia.

SIDE EFFECTS

• None

AUTHORIZATION

EMT: Standing order

AEMT: Standing order

Paramedic: Standing order

DOSAGE

• Adult: 15 gm (1 tube) orally
• Pediatric: 15 gm (1 tube) orally

Fentanyl Citrate

GENERIC NAME

Fentanyl Citrate

TRADE NAME

Fentanyl

DESCRIPTION

Fentanyl is a potent narcotic analgesic used for pain management. It acts quickly and has a short duration of action, making it suitable for trauma patients experiencing pain.

HOW SUPPLIED

Prefilled Syringe: 100 mcg/2 ml

INDICATIONS

• All trauma patients with pain

CONTRAINDICATIONS

• Allergy or hypersensitivity to Fentanyl
• Acute respiratory compromise or bradycardia

MECHANISM OF ACTION

Fentanyl Citrate binds with opiate receptors in the central nervous system, altering the perception of and emotional response to pain.

SIDE EFFECTS

• Nausea
• Vomiting
• Abdominal cramps
• Headache
• Anxiety
• Respiratory depression

AUTHORIZATION

EMT: Not authorized

AEMT: Not authorized

Paramedic: Standing order

DOSAGE

• Adult:
  • IV/IO/IM: 100 mcg, may repeat once after 10 minutes (max 200 mcg total)
  • IN: 200 mcg (administer half in each nostril), may repeat once after 10 minutes (max 400 mcg total)
  • For patients ≥ 65 years: 25 mcg per dose, titrate to effect
• Pediatric:
  • IV/IO/IM: 1 mcg/kg, may repeat once after 10 minutes (max 72 mcg total)
  • IN: 2 mcg/kg (administer half in each nostril), may repeat once after 10 minutes (max 144 mcg total)