Case Study: Leg Pain

[medic001918]

Poorly controlled blood glucose levels tend to increase the onset and effects of neuropathy. The neuropathy and poor circulation to the extremities can cause ischemic events and tissue damage or death. Ischemia in itself is enough to cause pain.

As far as treatment prehospitally, you could consider pain management but I think the most common modality is just a saline bolus. Use starling's law to try to increase peripheral circulation by increasing cardiac output.

In hospital treatment would consist of pain management and constant management and monitoring of blood glucose level. To begin to correct the effects of the problem, you have to correct the underlying cause. Start with the diabetes and move on from there.

Shane

NREMT-P

[fiznat]

Hyperglycemia = osmotic diuresis = pee pee = dehydration + hypokalemia?

You got it VS!

This is diabetic ketoacidosis. The patient had persistent hyperglycemia despite normal insulin dosing over the course of a week, had been drinking water like crazy and urinating every couple hours. The patient had weakness, malaise, decrease in appetite. The SOB was not SOB but a mild version of kussmaul breathing. Due to the frequent urination, the patient's electrolyte balance was swayed (particularly K+ and Na-) resulting in the leg cramps. All of these are signs of DKA.

At the ED the patient was found to have a mild acidosis, and profound hypokalemia + hyponatremia. Rapid precautions were taken for potential cardiac issues arising from the imbalance, and the patient was immediately given an extra IV line for electrolyte replacement. After that came the insulin.

I thought this was interesting because though I remember this lesson from paramedic school, I have never seen this presentation for DKA and I admit I was a bit mystified about the relation between hyperglycemia and 10-10 painful leg cramps in this patient.

Thinking about it more, I wonder about what things we can do in the ambulance for this. We are supposed to give lots of fluid for hyperglycemia for obvious reasons, but I wonder if given the electrolyte balance it might even help to use ringers instead of NS, which has both sodium and potassium. Not enough to replenish, but maybe it could help....?

[vs-eh?]

I hope that any paramedic would have to patch (call a doctor) for that type of patient presentation. If you wouldn't have to patch, please tell me your education and your standing orders...

Good case.

[ERDoc]

This pt is even more hypokalemic than it appears. Acidosis brings the K out of the intracellular space. As you correct the acidosis you will drive the K back into the cells making the pt more hypokalemic. LR would not be a good choice because of the lactate. It has the potential to worsen the acidosis. Rehydrate with NS and we will take care of the electrolyte problems in the ER.

[fiznat]

I thought lactate metabolizes into bicarb?

[ERDoc]

I thought lactate metabolizes into bicarb?

Not quite, but I was off also. LR will lead to worsening alkalosis. Sorry about the incorrect information, I was a little distracted when I posted.

[CBEMT]

I hope that any paramedic would have to patch (call a doctor) for that type of patient presentation. If you wouldn't have to patch, please tell me your education and your standing orders...

Good case.

Conditions requiring physician Medical Control [other than med/procedure orders}:

*impaired consciousness;

*any age-related abnormal heart rate, respiratory rate, or blood pressure, as defined in the Table of Abnormal Vital signs;

*poisoning or overdose;

*deterioration from a previously stable condition.

As such, this patient would fall under "routine hospital staff notification." As in, calling triage to let them know you're coming.

That said, I am encouraged to contact Medical Control any time I feel it would benefit the patient. However, since we don't hve a protocol for DKA, nor insulin or the kinds of electrolytes ERDoc is referring to, I'm not really sure what more he can tell me to do that I wouldn't have done already (IV, monitor, and transport). I 'spose I could toss him some Thiamine in addition to the saline, but I doubt it would make that much difference.

[fiznat]

^^ you have to call your medical control doc for all of those cases? As in, actually talk to a doc and ask his advice? How do you find time for that?

We have to patch to some hospitals before we get there... some hospitals want a patch for every patient, some want notification only for critical ones. Is that what you are referring to? I cant imagine having to call a doc for all of those circumstances, just to see if he/she has anything they'd like to say/add.

[CBEMT]

^^ you have to call your medical control doc for all of those cases? As in, actually talk to a doc and ask his advice? How do you find time for that?

We have to patch to some hospitals before we get there... some hospitals want a patch for every patient, some want notification only for critical ones. Is that what you are referring to? I cant imagine having to call a doc for all of those circumstances, just to see if he/she has anything they'd like to say/add.

If I called a doc for every one of those cases I'd never get anything done. At my full time job I'd be at the hospital before I dialed the phone.

It's just like the line in our protocols that require Med Control for Albuterol (some people read it as "All EMTs" some read it as "BLS providers). Either way, nobody here knows anybody else at any level who's ever done it.

The only time we talk to an MD is for things we need orders for. Everything else goes through the triage nurse, except at the trauma center. Their nurses don't want to hear a word out of you unless you need a Critical room.

[AnthonyM83]

In LA County, I can't think of a single ALS transport that doesn't require base contact for orders (though you can start doing certain procedures prior to base contact). It's a nurse that answers.