During a pickup hockey game at a local ice arena, Peter, a 27-year-old male, takes a hard fall onto the ice. He lands face first, causing an episode of epistaxis. His fellow players pick him up and make him sit until the bleeding from his nose stops a few minutes later.
Peter assures his teammates he’s fine, but that he’s done playing for the day. He tells them he’ll be back next week to make up for his injury and leaves the ice alone, headed to the facility’s locker room to change.
Approximately 30 minutes later, Peter’s teammates finish their game and return to the locker room to find him laying unresponsive on the floor. He’s breathing, but they can’t wake him up. They call 9-1-1.
“Medic 72, Delta-level response to the City Ice Arena at 2645 Blackhawks Street for the unresponsive male after a fall. E-Edward is your channel assignment. Time out 13:46.”
Paramedics from Station 72 respond from approximately six minutes away. Their response is uneventful and they’re greeted by the facility staff as they arrive. They load their usual complement of BLS and ALS equipment on their cot and are led into the locker room where the patient is laying supine on the floor. They observe his head and neck being stabilized by a bystander who identifies himself as an off-duty EMT.
Peter’s teammates tell the paramedics what happened. They deny that he lost consciousness immediately after the fall, explaining, “He had a bloody nose but seemed fine to us after we picked him up.”
They don’t know his medical history but state that the information sheet he filled out prior to joining the pickup league lists his girlfriend as an emergency contact. They’ve called her and she’s on her way.
The paramedics find the patient is breathing and maintaining his own airway. He responds to a deep sternal rub with a groan. It appears the patient was in the middle of changing out of his hockey uniform when he went unresponsive and he’s wearing the clothing he had under his pads and jersey.
The medics note dried blood under his nose and on his chin. His skin is pale, cool and moist. His pupils are equal and reactive. His trachea is midline and mobile, and his chest moves equally when he breathes. His lung sounds are clear, and his abdomen is soft and doesn’t show any abnormalities to either a physical exam or palpation. Palpation of his pelvis and extremities reveals no abnormalities.
His vital signs show a pulse of 88 and bounding, respirations of 18 and blood pressure at 118/76. The paramedics use the EMT bystander as an assistant and place the patient in spinal motion restriction for transport using a C-collar, backboard and cervical immobilization device. They secure the patient on the cot and quickly take him to the ambulance for further assessment and treatment.
Once in the ambulance, they cut off the patient’s remaining clothing to expose him for a full trauma assessment. They find no further injuries on their secondary head-to-toe assessment. They place the patient on a cardiac monitor, which reveals a sinus rhythm without ectopy, then place an 18-gauge IV catheter in the patient’s right antecubital attached to 1,000 mL warm normal saline running TKO.
They wrap the patient in warm blankets and ensure the ambulance is warm enough to keep the patient normothermic. Just before they leave, the patient’s girlfriend arrives. She is distraught but asks the paramedics if they’ve checked the patient’s blood sugar, as he’s a Type 1 insulin-dependent diabetic.
The paramedics obtain a finger stick blood glucose measurement for the first time and find Peter’s blood sugar level is 34 mg/dL.
After finding the patient is hypoglycemic, the paramedics determine cautious administration of IV dextrose is warranted despite the patient’s possible head trauma and their concerns about causing further neurological damage should a head injury exist.
They administer half of a prefilled ampule of 50% dextrose through the IV. A few minutes later, the patient regains consciousness and begins answering questions appropriately. His blood sugar is rechecked and found to be 165 mg/dL.
Transport is initiated to the local hospital’s trauma center, which is approximately 20 minutes away from the scene. During transport, the patient becomes fully alert and oriented. He has no medical complaints and the paramedics find no other injuries in the course of their ongoing assessments.
The patient is evaluated by the hospital’s trauma team in the ED. His cervical spine is manually cleared by the emergency physician and the spinal precautions are removed. Because of his possible head injury, the patient is sent for a CT scan of his head, which reveals no abnormalities.
The patient is monitored for a few hours, fed lunch and subsequently discharged with a diagnosis of hypoglycemia secondary to physical activity. Based on the patient’s radical history of diabetes, the hypoglycemia is thought to have been the cause of his initial fall.
The assessment of patients with actual or suspected head trauma can be confused by the presence of many conditions that cause altered mentation. In this case, the patient’s altered mental status was caused by profound hypoglycemia that was confounded by his witnessed fall and resulting head trauma.
The paramedics in this case didn’t consider hypoglycemia as the cause of the patient’s condition until they received the late clinical clue from the patient’s girlfriend. Had they not completed their full assessment of the patient and obtained his blood glucose level, they probably would have assumed the patient to be obtunded from his head injury and he would’ve suffered from being in a hypoglycemic state for longer than necessary.
Although it’s hopeful to assume the ED would catch the hypoglycemia in a timely manner, this may not always be the case and it’s incumbent upon prehospital providers to thoroughly assess each patient and rule out as many potential etiologies as possible.
Patients with confirmed hypoglycemia should have their blood glucose level brought up to normoglycemic levels (between 70–130 mg/dL) using no more dextrose than necessary, as hyperglycemia is associated with poor outcomes in patients with traumatic brain injury (TBI).1 Previous practice of empirically administering 50% dextrose to all patients presenting with altered mental status has been proven to be harmful in those with head injury, but that shouldn’t stop providers from administering any at all—hypoglycemia must be corrected.2
Current recommendations for parenteral IV fluid administration call for isotonic crystalloids such as 0.9% saline or lactated Ringers solution over fluids such as 5% dextrose in water. These will affect plasma osmolarity, which is believed to push water into cerebral tissue and decrease cerebral perfusion by worsening intracranial hypertension.3,4
In TBI patients, the prevention of secondary insults to the brain tissue is of paramount importance. Unfortunately, secondary brain insults are common in initial care and are associated with poor patient outcomes in the short and long term.1 Prevention and correction of conditions such as hypoglycemia, hypotension, hypoxia and hypercarbia is necessary in the prehospital phase of treatment and provide for better patient outcomes.
Providers should be alert to assess for and treat these conditions in all patients with altered mental status but especially in patients presenting with potential head trauma—even short occurrences can worsen a patient’s outcome.
TBIs are associated with severe morbidity and mortality and can result in life-changing disability, as well as in high medical costs.4 Aggressive prehospital treatment that prevents and minimizes secondary insult by ensuring adequate cerebral perfusion is of paramount importance.2 (Read “The Lethal Triad: Hypothermia, acidosis & coagulopathy create a deadly cycle for trauma patients” on p. 56 for more.) Providers should prevent hypoxia without inducing hyperoxia and keep the end-tidal carbon dioxide within normal, eucapnic ranges.2 However, because of the prevalence of conditions mimicking TBIs that have poor outcomes if not identified and treated—such as hypoglycemia—EMS providers should give a full assessment of these patients. Be alert for the many causes of altered mentation and be thorough in assessing and treating all correctable causes.
1. Escobedo LVS, Habboushe J, Kaafarani H, et al. Traumatic brain injury: A case-based review. World J Emerg Med. 2013;4(4): 252–259.
2. Browning RG, Olson DW, Stueven HA, et al. 50% dextrose: Antidote or toxin? Ann Emerg Med. 1990;19(6):683–687.
3. Control of intracranial hypertension. (n.d.) Trauma.org. Retrieved Jan. 28, 2013, from www.trauma.org/archive/neuro/icpcontrol.html.
4. Levine JM, Kumar MA. Traumatic brain injury [white paper]. Neurocritical Care Society Practice Update: Pennsylvania, 2013.