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Questions and Answers
What is the normal range of end-tidal CO2 in an adult patient?
What is the primary goal for oxygen administration to an adult patient?
What is the temperature threshold for initiating rapid cooling treatments in an adult patient?
What is the dose of midazolam (Versed) administered to an adult patient to reduce muscle shivering during rapid cooling?
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What is the maximum amount of morphine sulfate that can be administered to an adult patient during rapid cooling treatments?
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What is the purpose of obtaining a 12-Lead ECG in an adult patient?
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What is the purpose of evaluating pupil size and reactivity in an adult patient?
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What is the purpose of obtaining a CO reading in an adult patient?
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What is the volume of cold normal saline administered to an adult patient during rapid cooling treatments?
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What is the primary goal of the Universal Initial Adult Patient Assessment?
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What should be done first at the scene of multiple impaired patients?
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What is the minimum SpO2 level that should be maintained in an adult patient?
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What is the primary indication for administering cold normal saline during rapid cooling treatments?
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What is the purpose of obtaining and documenting a CO reading?
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What is the maximum dose of morphine sulfate that can be administered to an adult patient during rapid cooling treatments?
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What is the primary purpose of establishing vascular access in an adult patient?
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What is the correct order of steps in rapid cooling treatments?
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What is the primary purpose of obtaining a 12-Lead ECG in an adult patient?
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What is the correct dose of midazolam (Versed) administered to reduce muscle shivering during rapid cooling treatments?
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What should be done to a patient who exhibits hot and dry skin with changes in their mental status and/or develops seizures?
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What should be done if a patient remains unresponsive or symptomatic five minutes after administering glucose?
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What is the primary route of administration for glucagon in a patient with hypoglycemia who cannot take glucose orally?
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What is the dose of oral glucose recommended for a conscious patient with hypoglycemia?
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What should be done if a patient with hypoglycemia is able to take glucose orally?
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What is the blood glucose level that triggers the administration of glucose in a patient with hypoglycemia?
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What is the initial treatment step for a patient with hyperglycemia or DKA?
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What is the exception to repeating the 500 mL normal saline IV administration?
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What is the primary purpose of the Universal Initial Adult Patient Assessment?
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What is the recommended volume of normal saline to administer to a patient with hyperglycemia or DKA?
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What is the blood glucose level that defines hyperglycemia or DKA?
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What is the primary indication for administering naloxone to a patient?
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What is the recommended dose of naloxone for administration through an Advanced Airway?
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After administering naloxone, what should be done to enhance the drug delivery into the lungs?
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What is the recommended route of administration for naloxone if IV access cannot be established?
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How soon can naloxone be repeated if necessary?
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What is the primary reason for avoiding administration of dextrose solutions in a head injury patient?
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What is the correct action to take if a head injury patient's blood pressure is less than 90 mmHg?
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In what position should a head injury patient be placed to reduce ICP?
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What is the primary indication for hyperventilating a head injury patient?
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Why is a saline lock established in a head injury patient?
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What is the recommended ETCO2 range when hyperventilating a head injury patient?
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Study Notes
Single Impaired Patient at Scene
- Initial patient assessment involves determining and documenting Glasgow Coma Scale (GCS) and time last known well
- Blood glucose level should be obtained and documented using a glucometer, and hypoglycemia protocol should be followed if necessary
- Pulse oximeter reading should be obtained and documented, with oxygen administration if SpO2 is less than 94%
Respiratory Care
- Non-intubated end-tidal CO2 should be assessed (if available) and treated appropriately, with a normal range of 35-45 mmHg
Vascular Access and Cooling
- Vascular access should be established for all patients
- Patients with a temperature of 104°F (40°C) or higher (or those with hot and dry skin, changed mental status, and/or seizures) require rapid cooling treatments:
- Move to a cooler environment or use a fan
- Remove excess clothing
- Apply ice packs to neck, axillae, and groin (if available)
- Administer cold normal saline (34°F) at 30 ml/kg IV/IO (max 2 Liters) after documenting baseline temperature
- Administer midazolam (Versed) to reduce muscle shivering (if indicated)
Pain and Agitation Management
- Midazolam (Versed) should be administered to reduce muscle shivering, if indicated
- Morphine sulfate may be administered to agitated and/or painful patients with systolic BP 90 mmHg or greater, in doses of 5 mg IV/IO/IM, up to a total of 20 mg
Additional Assessment and Treatment
- Pupil size and reactivity should be evaluated and documented
- 12-Lead ECG should be obtained and monitored, with stabilization of abnormal rhythms per protocol
- CO reading should be obtained and treated if abnormal
- Overdose should be treated per protocol and/or by contacting Poison Control at 1-800-222-1222
- Accurate medical history should be obtained from caretakers or persons who made the call to determine if altered mental status is chronic (e.g. Alzheimer's, CVA)
- Agitated patients should be referred to Agitated Patient / Excited Delirium protocol
Multiple Impaired Patients at Scene: Treatment
- Ensure scene safety before proceeding with treatment.
Initial Assessment and Care
- Perform Universal Initial Adult Patient Assessment / Care.
- Determine and document the Glasgow Coma Scale (GCS) on initial assessment, including the time the patient was last known well.
Vital Sign Assessment
- Obtain and document a blood glucose level using a glucometer, and follow Hypoglycemia protocol if hypoglycemic.
- Obtain and document a pulse oximeter reading, maintaining SpO2 of at least 94%, and administer oxygen if indicated.
- Obtain and document a CO reading, and treat for CO Poisoning for abnormally high CO readings.
- Assess non-intubated ETCO2 (if available) and treat appropriately (normal range is 35-45 mmHg).
Vascular Access and Cooling
- Establish vascular access.
- For patients with a temperature reading of 104°F (40°C) or higher (or if unable to obtain a temperature and the patient feels hot to the touch), perform rapid cooling treatments:
- Move patient to a cooler environment and/or use a fan.
- Remove as much clothing as possible.
- Apply ice packs to the neck, axillae, and groin if available.
- Take and document a baseline temperature before administering cold normal saline.
- Take and document a temperature at the time of patient transfer in the ED.
- Bolus cold (34°F) normal saline, 30 ml/kg IV/IO (maximum 2 Liters).
- Administer midazolam (Versed), 5 mg slow IV or 10 mg IM / IntraNasal to reduce muscle shivering, if indicated.
- Administer morphine sulfate, 5 mg IV/IO/IM, if the patient is agitated and/or in pain after midazolam (Versed) and the systolic BP remains at 90 mmHg or greater.
Neurological Assessment and Overdose
- Evaluate and document pupil size and reactivity.
- Obtain 12-Lead ECG and monitor the rhythm, stabilizing abnormal rhythms per protocol.
- If an overdose is suspected or identified, treat per protocol and/or contact Poison Control at 1-800-222-1222.
Additional Considerations
- Consider the possibility of poison or toxic gas.
- If the patient is combative, refer to Agitated Patient/Excited Delirium protocol.
- If altered mental status is chronic (e.g., Alzheimer's, CVA), obtain an accurate medical history from the caretaker or person who made the call.
Hypoglycemia Treatment
- Initial assessment and care for adult patients involves universal steps.
- If blood glucose levels are ≤ 60 mg/dL:
- Conscious patients who can swallow: administer one single-dose tube of oral glucose (Glutose) or 25 grams (50 mL) of dextrose 50% (D50W) PO.
- Unconscious patients or those unable to take glucose orally: administer 25 grams (50 mL) of dextrose 50% (D50W) IV.
- If IV establishment is impossible: administer 1 mg of glucagon IM.
- Five minutes after glucose administration, re-check blood glucose levels if the patient remains unresponsive or symptomatic.
- If repeat blood glucose levels are ≤ 60 mg/dL, administer a second bolus of: + 25 grams (50 mL) of dextrose 50% (D50W) IV/IO. + An additional dose of oral glucose (Glutose) or 25 grams (50 mL) of dextrose 50% (D50W) PO. + 1 mg of glucagon IM.
Hyperglycemia and Diabetic Ketoacidosis (DKA)
- Hyperglycemia is characterized by glucose levels > 300 mg/dL without evidence of Congestive Heart Failure (CHF)
Treatment
- Initial treatment for adult patients involves a universal assessment and care approach
- Administer 500 mL of normal saline IV as the first step, which can be repeated once if necessary
- Exceptions to the repeat saline administration include patients on dialysis and those 70 years of age or older
Suspected Opiate-Type Overdose or Unconsciousness of Unknown Origin
- Universal initial assessment and care for adult patients are essential
- Signs of narcotic overdose include pinpoint pupils and track marks
- Respiratory depression, including morphine/fentanyl overdose, requires naloxone administration
- Naloxone (Narcan) dosage: 2 mg slow IV/IM or IntraNasal for suspected opiate overdose
- Alternative naloxone administration method: 4 mg diluted with normal saline to a total of 10 mL through an Advanced Airway if IV access cannot be established
- After naloxone administration, provide 5 rapid ventilations to enhance drug delivery into the lungs
- Naloxone administration can be repeated once in 2-3 minutes if necessary
Head Injury or Signs of Increased ICP
- Cushing's Triad: hypertension, bradycardia, and irregular respirations without hypotension
Treatment
- Universal Initial Adult Patient Assessment / Care is the first step
Positioning
- Elevate the head approximately 30 degrees (12-18 inches) to reduce ICP
- Achieve this by placing the patient in a semi-Fowler's position or elevating the head of the backboard if immobilized
Fluid Management
- Avoid administering dextrose solutions (D50W, D25W, D10W, D5W) unless hypoglycemia (glucose < 60) is identified
- Dextrose administration may increase cerebral edema
Respiratory Management
- Hyperventilate (ventilate to maintain ETCO2 of 30-34 mmHg) only if:
- GCS ≤ 8
- Advanced airway is established
- Signs of brainstem herniation are present (e.g., dilated pupil, blown pupil, decorticate/decerebrate posturing)
IV Management
- Start a saline lock, but restrict fluid administration or run IVs at TKO (to keep open)
- Administer normal saline, 500 mL IV/IO, if BP < 90 mmHg, to maintain ≥ 90 mmHg
- This may be repeated once if necessary
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Description
This quiz assesses your knowledge of the initial treatment and assessment of a single impaired patient at the scene. It covers the Glasgow Coma Scale, blood glucose level, pulse oximeter reading, and more.
