AMS, Diabetic Emergencies, & Allergic Reactions

• Altered mental status (AMS)


  Patient displays change in normal mentation
• Diabetes mellitus is a common cause for alterations in mental status
• Diabetes mellitus is found in 7% of the population
• Scene size-up

  1. Use clues at the scene to determine suspected mechanism of injury vs. no injury

  2. More than 1 patient may indicate hazardous environment
• Primary Assessment


  1. ABCS

  2. Consider manual c-spine

  3. Establish patient priority
• Guideline for determining high priority status

  • Acute change in mental status (regardless of cause)
  • Airway discrepancy (regardless of cause)
  • Breathing inadequacy (regardless of cause)
  • Circulatory deficit/major bleed (regardless of cause)
• Emergency Medical Care

  1. Maintain spinal stabilization

  2. Ensure clear airway

  3. Provide high flow oxygen
• History & Physical Exam

  1. SAMPLE History

  2. Baseline vital signs

  3. Physical exam
• Ongoing assessments


  1. Rule out any other concerns

  2. Continuously monitor for patient status changes

  3. Provide any other treatments appropriate, based upon need

  4. Repeat & record vitals
• Conditions that can cause AMS

  • Shock
  • Poisoning/drug overdose
  • Post-seizure
  • Infection
  • Traumatic head injury
  • Hypoxia (Inadequate airway/breathing)
  • Alcohol intoxication
  • Stroke
  • Diabetes (low or high)
• Diabetes mellitus


  Disease characterized by breakdown in relationship of insulin & glucose
• Diabetic emergencies are usually from hyperglycemia, not hypoglycemia
• Types of diabetes

  • Type 1 Diabetes
  • Type 2 Diabetes
• Type 1 Diabetes


  Produces little to no insulin, requires daily insulin injections, typically develops during childhood, more likely to have metabolic problems & organ damage, considered an autoimmune problem
• Type 2 Diabetes

  Produces inadequate amounts of insulin or normal amount doesn't function effectively, usually appears later in life, treatments may be diet, exercise, oral meds, or insulin
• Hyperglycemia


  High blood glucose (sugar) levels, low insulin levels, untreated results in Diabetic Keto-Acidosis (DKA), "diabetic coma"
• Signs of hyperglycemia

  • Fruity-smelling breath
  • Pale, warm, dry skin
  • Shortness of breath
  • Frequent urination, drinking, eating
  • Dry mouth
  • Weakness
  • Confusion, coma
• Hypoglycemia


  Low blood glucose (sugar) level, high insulin levels, untreated results in unresponsiveness & hypoglycemic coma, "insulin shock"
• Signs of hypoglycemia


  • Pale, cool, clammy skin
  • Rapid, weak pulse
  • Combative
  • Shakiness
  • Dizziness
  • Sweating
  • Hunger
  • Inability to concentrate
• Scene size-up & initial assessment

  1. Performed in the same fashion as for any AMS patient

  2. Be extra vigilant for medical alerts
• AMS due to diabetic emergency

  Typically has sudden onset, after missing a meal/taking insulin, after vomiting a meal/taking insulin, after unusual exercise or physical work/stress, no identifiable cause
• AMS from hyperglycemic episode

  Typically has gradual onset
• Don't delay transport for auto via
• Checking Blood Glucose Level (BGL)

  1. Glucometers are commonly found in EMS units

  2. EMT can check BGL

  3. Glucometers determine amount of glucose in the blood

  4. Sample usually coming from fingerstick
• Normal, hypoglycemic, and hyperglycemic BGL ranges

  • Normal: 70-120 mg/dL
  • Hypoglycemia: BGL under 60 mg/dL
  • Hyperglycemia: BGL over 120 mg/dL
• Equipment necessary for glucose meter

  • Glucose meter
  • Lancet/lancet device
  • Glucose meter test strips
  • Alcohol swabs
• Emergency care for patients with a history of diabetes

  1. Establish/maintain an open airway

  2. Administer high flow O2

  3. Obtain & record patient's vital signs & level of consciousness incl. GCS

  4. Perform BGL test if BGL <60

  5. Administer oral glucose (only if patient is AMS, BGL <60, and responsive enough to swallow)
• Seizures

  Sudden & temporary alteration in brain function due to massive electrical discharge
• Causes of seizures

  • Fever
  • Infection
  • Poisoning
  • Hypoglycemia
  • Trauma
  • Hypoxia
  • Idiopathic (unknown cause)
• Initial assessment of seizure

  1. Airway, ventilation

  2. Apply high flow O2

  3. Support breathing if inadequate

  4. Evaluate quality of circulation

  5. Determine priority status
• History & physical exam for seizure

  1. Rule out trauma

  2. Test BGL to see if hypoglycemic
• Phases of a grand mal (generalized tonic-clonic) seizure

  • Aura phase
  • Tonic phase
  • Clonic phase
  • Postictal phase
• Petit mal seizure


  Absent seizure
• Status epilepticus


  Seizure lasts more than 5 minutes or 20 seizures in a row, life-threatening
• Allergic reaction


  Exaggerated immune response to anything
• Pathways for antigen to enter the body

  • Injection
  • Ingestion
  • Inhalation
  • Absorption
• Anaphylaxis


  Systemic, life-threatening allergic reaction from contact with allergen, rapid onset, multisystem
• Signs of anaphylaxis


  • Occluded airway
  • Abnormal airway sounds
  • Oral cavity/airway swelling
  • Difficulty swallowing
  • Bilateral wheezing
• Anaphylactic shock


  Severe form of allergic reaction with systemic alterations in the patient's airway, breathing, & circulatory status
• Emergency care for allergic reaction

  1. Maintain patent airway

  2. Provide high flow O2

  3. Ensure breathing adequacy

  4. Obtain vitals, SAMPLE, OPQRST

  5. Epipen

  6. Call ALS backup

  7. Initiate transport