Medical Emergencies

AEIOU-TIPS mnemonic

A checklist of the causes of AMS. Go through the whole list, top to bottom. Don't stop at the first cause that fits.

Assessment approach

• Quick AVPU: What's their level of consciousness?
• SAMPLE history: Any clues to the cause?
• Blood glucose: Check it if you have a glucometer. Low blood sugar can kill quickly, and you can fix it.
• Vital signs: Fever points to infection, a fast heart rate to shock or overdose, a slow one to head injury.
• Physical exam: Look for needle marks (overdose), head trauma, and focal neurologic deficits.

Treatment for any AMS

• Airway: Position them to protect it.
• Position: Recovery position if they're unconscious and you have no spine concern.
• Keep them warm: Prevent hypothermia.
• Glucose: If they're a known diabetic (or a meter shows low blood sugar) and they can still swallow, give glucose. Otherwise, nothing by mouth for a confused patient.
• Oxygen: If you have it and suspect hypoxia.
• Evacuation: Altered mental status that your fix doesn't fully and quickly reverse means an emergent evacuation.

Types of seizures

• Generalized tonic-clonic (grand mal): They lose consciousness, go stiff (tonic), then jerk (clonic). The one most people picture.
• Absence: Brief staring spells, no jerking.
• Focal/partial: Jerking in one limb or one side of the body.

Causes

• Epilepsy (seizure disorder)
• Head trauma
• Low blood sugar (hypoglycemia)
• Low oxygen (hypoxia)
• Low sodium (hyponatremia)
• High fever
• Toxins or drugs

Field management during a seizure

• Don't restrain them. Holding them down can injure them.
• Don't put anything in their mouth. It can break teeth or block the airway.
• Protect the head with padding if any is nearby.
• Time the seizure. EMS will ask how long it lasted.
• Clear the area of rocks and gear they could hit.
• Roll them onto their side if you can, to protect the airway.
• Watch their breathing, and watch their color for cyanosis (turning blue).

After the seizure (post-ictal phase)

• After a seizure: Expect confusion and drowsiness for minutes to hours. That's normal.
• They may not remember the seizure happened.
• Reassure and reorient them, probably more than once.

When to evacuate

• Always evacuate for:
  • A first-ever seizure
  • A seizure lasting over 5 minutes (status epilepticus, which is life-threatening)
  • Multiple seizures without full recovery in between
  • Focal deficits after the seizure
  • Known epilepsy with an unusual seizure pattern
  • A seizure after head trauma
• Known epilepsy: If the seizure is typical for them, short, and they fully recover, they may not need evacuation. Still watch them closely.

Hypoglycemia (low blood sugar)

Definition: Blood glucose under 70 mg/dL.

• Onset: Fast, over minutes to hours.
• Signs:
  • Confusion, altered mental status
  • Sweating (diaphoresis), tremor
  • Fast heart rate (tachycardia)
  • Pale, cool skin
  • Hunger
  • Anxiety, personality change
• Treatment, awake and able to swallow:
  • Glucose tablets, juice, candy, or sugar
  • Reassess in 15 minutes. Still confused? Give sugar again and start an emergent evacuation.
  • If they've improved, follow with longer-acting carbs like granola or crackers.
• Treatment, unresponsive or can't swallow safely:
  • Nothing by mouth. No food, drink, or glucose gel. They can inhale it (aspiration), and almost none absorbs through the cheek.
  • Put them in the recovery position to protect the airway.
  • Emergent evacuation. You can't treat an unconscious diabetic in the field.

Hyperglycemia (high blood sugar)

Definition: Blood glucose over 300 mg/dL (can be over 400-500 in DKA).

• Onset: Slow, over hours to days.
• Signs:
  • Excessive thirst and urination
  • Fruity-smelling breath (ketones, in DKA)
  • Kussmaul respirations (deep, fast breathing in DKA)
  • Dehydration
  • AMS in severe DKA (diabetic ketoacidosis)
• Treatment:
  • Fluids are the main treatment.
  • Have them drink water, but only if they're fully alert and swallowing normally.
  • Nothing in the field brings high blood sugar down quickly.
  • Evacuate for DKA.

When in doubt: give sugar

Cardiac or non-cardiac?

Cardiac causes: ACS (acute coronary syndrome, meaning angina or a heart attack) and pericarditis.

Non-cardiac: Musculoskeletal, esophageal, pleurisy, pulmonary embolism, pneumothorax, HAPE.

• Signs that point to the heart:
  • Crushing or pressure-type pain
  • Pain that spreads to the arm, jaw, or back
  • Sweating (diaphoresis), nausea
  • History of heart disease, or risk factors for it
  • Age over 45
• Any concern it's the heart: Treat it as ACS until a hospital says otherwise.

Field management of suspected cardiac chest pain

• Stop all exertion now. Sit them down. No walking, no pack, no hiking to a better spot.
• Position: Whatever's most comfortable, usually sitting up.
• Aspirin: 325 mg regular, or 4 × 81 mg chewable. Have them chew it so it works faster. Only if they're not allergic and have no active bleeding or ulcer.
• Prescription meds like nitroglycerin: That's the patient's call or EMS's, not a WFA skill.
• By mouth: No food. Small sips of water are fine if they're alert and stable and help is hours away.
• Oxygen: If you have it and their SpO2 is low.
• Call for help early: Start the evacuation call as soon as you suspect the heart. Don't wait to see if it passes.
• Emergent evacuation for all suspected cardiac chest pain.
• Expect denial. "It's just indigestion" is part of the presentation. Don't let it slow the call.

FAST stroke assessment

Other stroke signs

• Sudden severe headache (the worst of their life)
• Vision changes
• Sudden confusion or trouble understanding
• Sudden weakness or numbness on one side

Why time is brain

• Clot-busting drugs (thrombolytics): They work within 3-4.5 hours of symptom onset. Given early, they can prevent permanent brain damage.
• Outside that window: There are fewer options, but some clot-removal treatments still work many hours later. It's an emergent evacuation either way.
• In the field: Recognize the signs and start an emergent evacuation.

Field management

• Watch the airway: Stroke can wreck swallowing, so aspiration is a real risk.
• Head position: Slightly raised (15-30°) if blood pressure isn't low.
• Nothing by mouth: Same aspiration risk. That includes aspirin, because from the outside a bleeding stroke looks the same as a clot.
• Nothing to reverse out here: You can't undo a stroke in the field.
• Emergent evacuation: Time to the hospital is the treatment.

Stroke mimics

• Hypoglycemia: Low blood sugar can look like a stroke. Check blood glucose first if you have a meter. If it's low and they can swallow safely, give sugar. If they can't, nothing by mouth, and evacuate.
• Todd's paralysis: Weakness after a seizure. It's temporary and goes away.
• Complex migraine: Can cause focal neurologic symptoms.