Early Management

RESUSCITATION
Aggressive resuscitation and the management of life-threatening injuries, as they are
identified, are essential to maximize patient survival.
A. Airway
The airway should be protected in all patients and secured when the potential for
airway compromise exists. The jaw thrust or chin lift maneuver may suffice. A
nasopharyngeal airway may initially establish and maintain airway patency in the
conscious patient. If the patient is unconscious and has no gag reflex, an
oropharyngeal airway may be helpful temporarily. However, a definitive airway
should be established if there is any doubt about the patients ability to maintain
airway integrity. 1
B. Breathing/Ventilation/Oxygenation
Definitive control of the airway in patients who have compromised airways due to
mechanical factors, have ventilatory problems, or are unconscious is achieved by
endotracheal intubation, either nasally or orally. This procedure should be
accomplished with continuous protection of the cervical spine. A surgical airway
should be performed if oral or nasal intubation is contraindicated or cannot be
accomplished. A tension pneumothorax compromises ventilation and circulation
dramatically and acutely, and, if suspected, chest decompression should be
accomplished immediately. Every injured patient should receive supplemental
oxygen. If not intubated, the patient should have oxygen delivered by a
mask/reservoir device to achieve optimal oxygenation. The use of the pulse
oximeter is valuable in ensuring adequate hemoglobin saturation. 1
C. Circulation
Control bleeding by direct pressure or operative intervention. A minimum of 2
large-caliber intravenous (IV) catheters should be established. The maximum rate
of fluid administration is determined by the internal diameter of the catheter and
inversely by its length, not by the size of the vein in which the catheter is placed.
Establishment of upper extremity peripheral IV access is preferred. Other
 peripheral lines, cutdowns, and central venous lines should be utilized as
necessary in accordance with the skill level of the doctor caring for the patient.1
At the time of IV insertion, draw blood for type and crossmatch and for baseline
hematologic studies, including a pregnancy test for all females of childbearing
age. Aggressive and continued volume resuscitation is not a substitute for manual
or operative control of hemorrhage. Intravenous fluid therapy with a balanced salt
solution should be initiated. Ringers lactate solution is preferred as the initial
crystalloid solution and should be administered rapidly. Such bolus IV therapy
may require the administration of 23 liters of solution to achieve an appropriate
patient response in the adult patient. All IV solutions should be warmed either by
storage in a warm environment (37C to 40C or 98.6F to 104F) or by fluid-
warming devices. 1

D. Disability (neurologic evaluation)

This neurology is evaluation established the patients level of consciousness,
pupillary size and reaction, lateralizing signs, and spinal cord injury level. The
GCS is a quick, simple method for determining the level of consciousness that is
predictive of patient outcome, particularly the best motor response. The score of
this patient in Glasgow Coma Scale is: eyes score is 1, verbal score is 2, and
motoric score is 3, with a total score is 6. Patients with GCS scores of 8 or less
require prompt intubation.1

E. Exposure and environmental control

The patient should be completely undressed, usually by cutting off his or her
garmets to facilitate a thorough examination and assessment is completed, the
patient should be covered with warm balnkets or an extrenal warming device to
prevent hypothermia i the trauma receiving area. Intravenous fluids should be
warmed before being infused, and a warm environment should be maintained.1

Adjuncts To Primary Survey And Resuscitation

 Adjuncts that are used during the primary survey include electrocardiographic
monitoring; urinary and gastric catheters; other monitoring, such as ventilatory rate,
arterial blood gas (ABG) levels, pulse oximetry, lood presure, and x-ray
examination.1

Secondary survey
The secondary survey is a head-to-toe evaluation of the trauma patient, that is a
complete history and physical examination, including reassessment of all vital signs.
Each region of the body is completely examined. During the secondary survey, a
complete neurologic examination is performed, including a repeat GCS score
determination. X-rays are also obtained, as indicated by the examination. Special
procedures, such as spesific radiographic evaluations and laboratory studies, also are
performed at this time. Complete patient evaluation requires repeated physical
examination.1

Specific Assessment
After the secondary survey, theres some possibility that can cause the
unconsciousness from this patient such as:
1. Hyperglycemia or hypoglycemia
Two different conditions can lead to a diabetic emergency; hyperglycemia and
hypoglicemia. Hyperglycemia is a state in which the blood glucose level is above
normal. Hypoglicemia is a state in which the blood glucose level is below normal.
Extremes of hyperglycemia and hypoglycemia can lead to a diabetic emergencies.
Ketoacidosis results from prolonged and exceptionally high hyperglycemia.
Diabetic coma then results when ketoacidosis is not treated adequately.
Hypoglycemia, on the other hand, will progress into unresponsiveness and
eventually insulin shock. The signs and symptoms of hypoglycemia and
hyperglycemia can be quite similar. For example, staggering and an intoxicated
appearance or complete unresponsiveness are signs and symptoms of both. Note
that your assessment of these potential emergencies should not prevent you from
providing prompt care and transportat as detailed in this chapter. However, in
such urgent emergencies, the earlier clues are gathered, the better for the patient.
With specific information about the type of emergency, you can help the hospital
to prepare prompt, definitive care for the patient.2

Diabetic Coma
Diabetic coma is a state od unconsciousness resulting from several problems,
including ketoacidosis, dehydration because of excessive urination,
hyperglycemia. Too much blood glucose by itself does not always cause diabetic
coma, but on some occasions, it can lead to it.2
The central problem in diabetes is the lack of infective action of insulin, without
insulin, cells begin to starve because insulin is needed, like a key, to let glucose
into cells. Without glucose to supply energy for cells, the body must turn to other
fuel source. The most abundant is fat. Unfortunately, when fat is used as an
immediate energy source, chemicals called ketones and fatty acids are formed as
waste products and are hard for the body to excreate as they accumulate in blood
and tissue, certain ketones can produce a dangerous condition called acidosis. The
form of acidosis seen in uncontrolled acidosis is called diabetic acidosis (DKA),
in which an accumulation of acids occurs when insulin is not available in the
body and result from prolonged and exceptionally high hyperglycemia.
Diabetic coma may occur in the patient who is not under medical treatment, who
takes insufficient insulin, who markedly overeats, or who is undergoing some of
short stress that may involve an infection, illness, over exertion, fatigue, or
drinking alcohol. Usually, ketoacidosis develops over a period of time lasing from
hours to days. The patient may ultimately be found comatose with the following
physical signs:2
- Kussmaul respirations
- Dehydration, as indicated by dry, warm skin and sunken eyes
- A sweet or fruity (aceton) odor on the breath caused by the unusual waste
products in the blood (ketones)
- A rapid pulse
- A normal or slighthly low blood pressure
Varying degress of unresponsiveness

Management of DKA
Aside from assessing and managing the airway, breathing, and circulation, there is
very little an EMT can do for this high-priority patient in the field. Patient with
DKA and any patient with an altered mental status should be given high-flow
oxygen. Rapid transport to the emergency department is the best treatment.
Treatment of DKA includes rehydration, insulin administration, and correction of
electrolyte deficit. Administer 3.5-5 L of normal saline in the first 5 hours and 6-
12 L in the first 24 hours. The average duration of fluid administration is 48
hours. Intravenous infusion of insulin is preferable to intramuscular or
subcutaneous injection. Pay particular attention to the correction of hypokalemia.
Once the patient can eat, discontinue intravenous insulin and start subcutaneous
intermediate or long acting insulin together with preprandial rapid acting insulin.
Correction of metabolic acidosis may be indicated when arterial pH in less than
7.0.3

Insulin Shock
In insulin shock, the problem is hypoglycemia, insufficient glucose in the blood.
When insulin levels remain high, glucose is rapidly taken out of the blood to fuel
the cells. If glucose levels get too low, there may be an insufficient amount to
supply the brain. If blood glucose remains can be quickly follow. Insulin shock
occurs when the patient has done one of the following:2
- Taken too much insulin
- Taken a regular dose of insulin but has not eaten enough food
- Had an unusual amount of activity or vigorous exercise and used up all
available glucose
 Insulin shock may also occur after the patient vomits a meal after he or she took a
regular dose of insulin. At times, insulin shock may occur with identifiable
predisposing factor.
Children who have diabetes may pose a particular management problem. First,
their high levels of activity mean that they can use up circulating glucose more
quickly than adults do, even after a normal insulin injection. Second, they do not
always eat correctly and on schedule. As a result, insulin shock can develop more
often and more severely in children than in adults.2
Insulin shock develops much more quickly than diabetic coma. In some distances,
it can occur in a matter of minutes. Hypoglycemia can be associated with the
following signs and symptoms:2
- Normal or rapid respirations
- Pale, moist (clammy) skin
- Diaphoresis (sweating)
- Dizziness, headache
- Rapid pulse
- Normal to low blood pressure
- Altered mental status (aggressive, confused, lethargic, or unusual behavior)
- Anxious or combative behavior
- Hunger
- Seizure, fainting, or coma
- Weakness on one side of the body (may mimic stroke)

Management of the hypoglycemic unconscious patient. An initial assesment should

be performed, with time taken to open, assess,suction,and secure the airway. High
concentration oxygen should be given via either a bag-valve-mask or a partial
nonrebreather mask,as appropriate. The EMT should not delay the transportation of
the patient ad shoukd proceed so package the patient immediately. Minutes count,and
the patient should be taken to the closest ALS provider,whether that is the emergency
departement or interception with an ALS unit. Glucose administered through an IV
will rapidly reverse the hypoglycemia and can be lifesaving. 2
-
Treatment hypoglycemic unconscious,two treatment option are available. The most
common treatment especially in hospital and emergency room setting is intravenous
glucose. Administer a bolus of 10-20 ml of 50% dextrose (glucose) followed by 10%
dextrose infused at 100mL/h until blood glucose level are estabilized. Document the
blood glucose levels every 30 minuts during intial intravenous treatment. The second
treatment option is the subcutaneous or intramuscular administration of
glucagon.Glucagon stimulates glycogenolysis and glukoneogenesis in the liver,
dramatically increasing hepatic glucose output. (note that patient with cirrhosis,severe
cechexia, or other condition may not have any glycogen stores. In such
cases,glucagon may be ineffective in stimulatin hepatic glycogenolysis). Glucagon is
not the preferred agent for the treatment of hypoglycemia in most hospital settings,
but in may be the only option in some individuals for logistical reasons or special
circumference. The standard dose is 1,0 mg for adults and 0,5 mg for children
weighing less than 50 punds (22,5 kg). Alternatively the dose for children may be
calculated at 15mg/kBB.4
Assessment of the Diabetic Patient2
Initial Assessment
General Impression
Form a general impression of the patient. Does the patient appear anxious,
restless, or listless? Is the patient apathetic or irritable? Is the patient with his or
her environment appropriately? These initial observations may help you to
suspect high or low blood glucose values. Determine the patients level of
consciousness. If the patient is conscious, what the chief of complain? If a
suspected diabetic patient is unresponsive, call for ALS immediately.

Airway and Breathing

As you are forming your general impression, assess the patients airway and
breathing. Patient showing signs of inadequate breathing or altered mental status
should receive high-flow oxygen at 10 to 50 L/min via non rebreathing mask. A
patient in a diabetic coma who is hyperglycemic may have rapid, deep respiration
(Kussmaul respirations) and sweet, fruity breath. A patient in insulin shock who is
hypoglycemic will have normal to rapid respirations. If the patient is not
 breathing or is having difficulty breathing, open the airways, give oxygen, and
assist ventilation. Continue to monitor the airway as you provide care.

Circulation
Once you have assessed airway and breathing and have performed the necessary
interventions, check the patients circulatory status. A patient with dry and harm
skin indicates diabetic coma, whereas a patient with moist and pale skin indicates
insulin shock. The patient in insulin shock will have a rapid, wake pulse.

Transport Decision
Whether you decide to transport will depend on the patients level of
consciousness and ability to swallow. Patient with an altered mental status and
impaired ability to swallow should be transported promptly. Patient who had the
ability to swallow and are conscious enough to maintain their own airway may be
further evaluated on scene and interventions performed.

Focused History and Physical Exam

Assess unresponsive medical patient first from head to toe with a rapid physical
exam, looking for clues as to their condition. The patient may have suffered
trauma resulting from changes in level of consciousness or dizziness. Next obtain
the patients vital sign and assess history. Remember that environment, by
sanders, and medical identification about your patients condition.
Responsive medical patients are able to provide their own medical history to help
you identify a cause for their altered mental status. Next perform a focused
physical exam and obtain your patients baseline vital signs.
SAMPLE History
Ask following question of known diabetic patient in additiom to obtaining a
SAMPLE history:
- Do you take insulin or any pills that lower your blood sugar?
- Have you taken your usual dose of insulin (or pillsP today?
- Have you eaten normally today?
- Have you had any illness, unusual amount of activity, or stress today?
 If the patient has eaten but has not taken insulin, it is more likely that ketoacidosis
is developing. If the patient has taken insulin but has not eaten, the problem is
more likely to be insulin shock. A patient with diabetes will often know what is
wrong. If the patient is not thinking or speaking clearly (or is unconscious), ask a
family member or bystander the same questions.
When you are assessing a patient who might have diabetes, check to see whether
he or she has an emergency medical identification symbol-a wallet card, necklace,
or bracelet-or ask the patient or a family member. Remember, however, that even
though a person has diabetes, the diabetes may not be causing the current
problem. A heart attack, stroke, or other medical emergency may be the cause. For
this reason, you must always do a thorough, careful assessment, paying attention
to the ABCs. Inform medical control that you are at the scene of a diabetic
emergency.

Focused Physical Exam

When you suspect a diabetes-related problem, the focused physical exam should
focus on the patients mental status and ability to swallow and protect the airway.
Obtain a Glasgow Coma Scale score to track the patients mental ability.
Otherwise, physical signs such as tremors, abdominal cramps, vomiting, a fruity
breath odor, or a dry mouth may guide you in determining whether the patient is
hypoglycemic or hyperglycemic.
Baseline Vital Signs
Obtain a complete set of vital signs, including a measurement of the patients
blood glucose level using a glucometer or chemical test strips if available. In
hypoglycemia respirations are normal to rapid, pulse is weak and rapid, and skin
is typically pale and clammy with a low blood pressure. In hyperglycemia
respiration are deep and rapid, pulse is full and bounding at a normal or fast rate,
and skin is warm and dry with a normal blood pressure. At times the blood
 pressure may be low. Is is easy to identify abnormal vital signs when we know the
blood glucose value. When this is the case, something else may be causing the
patients altered mental status, vomiting, or other complaints.

Interventions
If your patient is conscious and able to swallow without the risk of aspiration, you
should encourage him or her to drink juice or milk or other drink that contain
sugar. If you are permitted by local protocol, you may also administer a highly
concentrated sugar gel, squirted between the patients cheek and gums or placed
between the cheek and gum on a tongue depressor. The patient will usually
become more alert within minutes.
If your patient is unconscious, or if there is any risk of aspiration, the patient will
need IV glucose, which you are not authorized to give. Your responsibility is to
provide prompt transport to the hospital, where the proper care can be given. If
you are working in a tiered system, EMT-Intermediates and paramedics able to
start an IV with glucose.
A patient in insulin shock (rapid onset of altered mental status, hypoglycemia)
needs sugar immediately, and a patient in diabetic coma acidosis, dehydration,
hyperglycemia) needs insulin and IV fluid therapy. These patients need prompt
transport to the hospital for appropriate medical care.
For the conscious patient in insulin shock, protocols usually recommend oral
glucose. Glucose will usually reserve the reaction within several minutes. Do not be
afraid to give too much sugar. The problem often will not be solved with just a sip of
juice. An entire candy bar or a full glass of sweetened juice is often needed. Do not
give sugar-free drinks that are sweetened with saccharin or other synthetic sweetening
compounds, as they will have little or no effect. Remember that even if the patient
responds as the receiving glucose, he or she may still need additional treatment.
Therefore, you must transport the patient to the hospital as soon as possible.
 When there is any doubt about whether a conscious patient with diabetes is going into
insulin shock or diabetic coma, most protocols will err on the side of giving glucose,
even though the patient may have diabetic ketoacidosis. Untreated insulin shock will
result in loss consciousness and can quickly cause significant brain damage or death
the condition of a patient in insulin shock is far more critical and far more likely to
cause permanent problems when compared to a patient with diabetic ketoacidosis.
Furthermore, the amount of sugar that is typically given to a patient in insulin shock
is very unlike to make a patient in diabetic ketoacidosis significantly worse. When in
doubt, consult medical control.

Detailed Physical Exam

As in every call, you should perform a detailed physical exam when time permits.
With unconscious patients or patients with an altered mental status, you must play
detective and look for problems or injuries that are not obvious because the patient is
unable to communicate these to you. Although an altered mental status may be caused
by a blood glucose level that is too high or too low, the patient may have sustained
trauma or suffer from another metabolic problem. The altered mental status may also
be caused by something else, such as intoxication, poisoning, or a head injury. A
careful physical exam may provide you with information essential to proper patient
care.

Ongoing Assessment
It is important to reevaluate the diabetic patient frequently to assess changes. Is
there an improvement in the patients mental status? Are the ABCs still intact? How is
the patient responding to the interventions performed? How must you adjust or
change the interventions? In many patients with diabetes you will note marked
improvement with appropriate treatment. Document each assessment, your findings,
the time of the interventions, and any changes in the patients condition. Base your
glucose administration on serial readings if you have to a glucometer. If a glucometer
is unavailable, a deteriorating level of consciousness indicates that you need to
provide more glucose. Again, the use of glucometers and the administration of
glucose will be based on your services protocols and standing orders.

Emergency Care of Diabetic Emergencies

Giving Oral Glucose
Oral glucose is a commercially available gel that dissolves when placed in the
mouth. One toothpaste-type tube of gel equals one dose. Trade names for the gel
include Glutose and Insta-Glucose. Glucose gel acts to increase a patients blood
glucose level. If authorized by your system, you should administer glucose gel to
any patient with decreased level of consciousness who has a history of diabetes.
The only contraindications to glucose are an inability to swallow or
unconsciousness, because aspiration (inhalation of the substance) can occur. Oral
glucose itself has no side effect if it is administered properly; however, the risk of
aspiration in a patient who does not have a gag reflex can be dangerous. A
conscious patient (even if confused) who does not really need glucose will not be
harmed by it. Therefore, do not hesitate it under these circumstances.
Reassess the patients condition regularly after giving glucose, even if you see
rapid improvement. Watch for airway problems, sudden loss of consciousness, or
seizure. Provide prompt transport to the hospital; do not delay transport just to
give additional oral glucose.

1. American college of surgeons. 2008. Advance Trauma Life Support Program for
Doctors, 8th edition. USA
2. American Academy of Orthopaedic Surgeons. 2005. Emergency care and
transportation of the sick and injured. United Kingdom: Jones and Bartlett
Publishers
3. Katsilambros, N et al. 2011. Diabetic Emergencies: Diagnosis and
Clinical Management. Hoboken USA: Willey Blackwell
 4. Mazze, R et al. 2012. Staged Diabetes Managemen. Hoboken USA: Willey
Blackwell

2. Infections