ch15 eec3diabetic emergencies and altered mental status

ChapterChapter

Diabetic Diabetic Emergencies andEmergencies and

Altered Altered Mental StatusMental Status

FifteenFifteen

ChapterChapter

Recognition and management of

diabetic emergencies, including

oral glucose Recognition and management of

seizures and stroke

CORE CONCEPTSCORE CONCEPTSFifteenFifteen

Altered Mental StatusAltered Mental Status

KKEY TERMEY TERM

Any mental status that is not normal or Any mental status that is not normal or expected for that patientexpected for that patient

Causes of AlteredCauses of AlteredMental Status:Mental Status:

4H Mnemonic4H Mnemonic• Hypoglycemia or hyperglycemiaHypoglycemia or hyperglycemia

• HypoxiaHypoxia• Hypovolemia Hypovolemia (shock)(shock)• Head injuryHead injury

Patient Patient CARECARE

Altered Mental StatusAltered Mental Status

Emergency Care StepsEmergency Care Steps

Secure airway.Secure airway. Ventilate and suction as needed.Ventilate and suction as needed. Transport.Transport.

Treat patient as trauma patient ifTreat patient as trauma patient if injury cannot be ruled out.injury cannot be ruled out.

DDIABETIC IABETIC EMERGENCIESEMERGENCIES

DiabetesDiabetes

KKEY TERMEY TERM

Condition brought about by decreased Condition brought about by decreased insulin production, which prevents the insulin production, which prevents the body’s cells from taking the simple body’s cells from taking the simple sugar called glucose from the sugar called glucose from the bloodstreambloodstream

Insulin allows sugar to pass from theInsulin allows sugar to pass from thebloodstream into the cells.bloodstream into the cells.

Diabetes is treated with injections ofDiabetes is treated with injections ofinsulin or oral medications.insulin or oral medications.

Diabetic patients test their blood glucose at home.

Blood Glucose MetersBlood Glucose Meters

Prepare blood glucose meter and test strip.Prepare blood glucose meter and test strip.

Cleanse skin with alcohol prep.Cleanse skin with alcohol prep.

Use lancet to perform finger stick.Use lancet to perform finger stick.

Apply the blood to test strip.Apply the blood to test strip.

Read blood glucose test results.Read blood glucose test results.

Blood Glucose ReadingsBlood Glucose Readings

80-120 mg/dl Normal60-80 mg/dl Moderate hypoglycemiaBelow 50 mg/dl Severe hypoglycemiaAbove 140 mg/dl Hyperglycemia

Question results that are inconsistent with patient’s condition.

Causes of Inaccurate ReadingCauses of Inaccurate Reading

Meter not calibrated

Low batteries in meter

Improperly stored or expired test strip

Insufficient blood on test strip

HypoglycemiaHypoglycemia

Hypoglycemia (low blood sugar) is a Hypoglycemia (low blood sugar) is a life-threatening emergency for people life-threatening emergency for people with diabetes. But it is one that the with diabetes. But it is one that the EMT-B can treat.EMT-B can treat.

KKEY TERMEY TERM

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Rapid onset (Rapid onset ( just minutes) of just minutes) of alteredalteredmental status:mental status:

• After taking insulin and missing a mealAfter taking insulin and missing a meal• After taking insulin and vomitingAfter taking insulin and vomiting• After unusual amount of exerciseAfter unusual amount of exercise• For unknown reasonFor unknown reason

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Intoxicated appearance, staggering, Intoxicated appearance, staggering, slurred speech, unconsciousness slurred speech, unconsciousness

Cold, clammy skinCold, clammy skin

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Rapid heart rateRapid heart rate HungerHunger Seizures (in severe cases)Seizures (in severe cases) Insulin or oral antidiabetic medicationInsulin or oral antidiabetic medication

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Unusual behaviorUnusual behavior AnxietyAnxiety Refusal to cooperate orRefusal to cooperate or combativenesscombativeness

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Perform initial assessment.Perform initial assessment. Perform focused history andPerform focused history and

physical exam.physical exam. Get SAMPLE history.Get SAMPLE history. Take baseline vital signs.Take baseline vital signs.

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Perform initial assessment.Perform initial assessment.

(Some hypoglycemic patients are (Some hypoglycemic patients are unconscious. You must make sure the unconscious. You must make sure the airway remains airway remains patent in these patent in these individuals.)individuals.)

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Perform focused history andPerform focused history andphysical exam.physical exam.• How did episode occur?How did episode occur?• When did it start?When did it start?• How long did it last?How long did it last?• Complaints of other symptoms?Complaints of other symptoms?

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Perform focused history Perform focused history and physical exam.and physical exam.

• Trauma involved?Trauma involved?• Has the patient seized?Has the patient seized?• Fever?Fever?• Interruptions in episode?Interruptions in episode?

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Get a SAMPLE history.Get a SAMPLE history.If history of diabetes:If history of diabetes:• When did patient last eat?When did patient last eat?• What medications? When last taken?What medications? When last taken?• Any other illnesses?Any other illnesses?• Can the patient swallow?Can the patient swallow?

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

DiabeticDiabetic

Signs and SymptomsSigns and Symptoms

Take baseline vital signs.Take baseline vital signs.

(In some areas, protocols direct the (In some areas, protocols direct the EMT-B to treat the patient before EMT-B to treat the patient before getting vital signs.)getting vital signs.)

FOLLOW YOUR LOCAL PROTOCOL!FOLLOW YOUR LOCAL PROTOCOL!

Patient Patient CARECARE

Diabetic EmergenciesDiabetic Emergencies

Emergency Care StepsEmergency Care Steps

Give oral glucose if all of these Give oral glucose if all of these

• History of diabetesHistory of diabetes• Altered mental statusAltered mental status• Patient can swallowPatient can swallow

conditions are met:conditions are met:

Patient Patient CARECARE

Diabetic EmergenciesDiabetic Emergencies

Emergency Care StepsEmergency Care Steps

Reassess patient.Reassess patient.• If patient becomes unconscious,If patient becomes unconscious,

stop glucose administration stop glucose administration immediately and secure the immediately and secure the airway!airway!

• If no improvement, consult If no improvement, consult medical direction.medical direction.

Patient Patient CARECARE

Diabetic EmergenciesDiabetic Emergencies

Emergency Care StepsEmergency Care Steps

If patient is not awake enoughIf patient is not awake enough

• Secure airway.Secure airway.• Ventilate, if necessary.Ventilate, if necessary.• Position appropriately.Position appropriately.• Transport promptly.Transport promptly.

to swallow:to swallow:

AADMINISTRATION OF DMINISTRATION OF ORAL GLUCOSEORAL GLUCOSE

Squeeze glucose onto Squeeze glucose onto tongue depressortongue depressorand place between and place between cheek and gums.cheek and gums.

If patient is awake enough, If patient is awake enough, let her squeeze orallet her squeeze oralglucose into mouth.glucose into mouth.

When glucose is gone, remove tongueWhen glucose is gone, remove tonguedepressor and reassess patient.depressor and reassess patient.

If patient loses consciousness, removeIf patient loses consciousness, removetongue depressor, secure airway,tongue depressor, secure airway,

and transport promptly.and transport promptly.

Oral GlucoseOral Glucose Altered mental statusIndicationsIndications

with history of diabetes

Unconsciousness Diabetic who has not

taken insulin for days Inability to swallow

ContraindicationsContraindications

DosageDosage One tube

Oral GlucoseOral Glucose

AdministrationAdministration

Assure altered mental status with history of diabetes.

Assure patient is conscious.

Oral GlucoseOral Glucose

AdministrationAdministration

Administer glucose on tongue depressor betweencheek and gum or letpatient self-administer.

Perform ongoing assessment.

Oral GlucoseOral Glucose

Increases blood sugarActionsActions

None when given properly May be aspirated if given

to patient without gag reflex

Side EffectsSide Effects

Oral GlucoseOral Glucose

Reassessment Reassessment StrategiesStrategies

If patient seizes or losesconsciousness, removetongue depressor;secure airway.

Oral GlucoseOral Glucose

SeizureSeizure

Sudden change in sensation, behavior, or Sudden change in sensation, behavior, or movement caused by irregular electrical movement caused by irregular electrical activity of the brainactivity of the brain

KKEY TERMEY TERM

Causes of SeizuresCauses of Seizures PoisoningPoisoning Brain tumorBrain tumor Congenital brain defectsCongenital brain defects InfectionInfection TraumaTrauma

(Continued)(Continued)

EpilepsyEpilepsy StrokeStroke HypoglycemiaHypoglycemia EclampsiaEclampsia HypoxiaHypoxia UnknownUnknown

(Complications of pregnancy)

Causes of SeizuresCauses of Seizures

Patient Patient ASSESSMENTASSESSMENT

SeizuresSeizures

Signs and SymptomsSigns and Symptoms

What was patient doing before seizure?What was patient doing before seizure? What movements exhibited?What movements exhibited? Loss of bladder or bowel control?Loss of bladder or bowel control? What did patient do after seizure?What did patient do after seizure? Length of episode?Length of episode?

Patient Patient CARECARE

SeizuresSeizures

Emergency Care StepsEmergency Care Steps

Place patient on floor.Place patient on floor. Position patient on side.Position patient on side. Loosen restrictive clothing.Loosen restrictive clothing. Remove harmful objects.Remove harmful objects. Protect patient from injury; Protect patient from injury; do notdo not

hold patient still.hold patient still.(Continued)(Continued)

Patient Patient CARECARE

SeizuresSeizures

Emergency Care StepsEmergency Care Steps

After seizure subsides:After seizure subsides:• Protect airway with positioning Protect airway with positioning

and suction.and suction.• If cyanotic, ventilate with oxygen.If cyanotic, ventilate with oxygen.• Treat injuries.Treat injuries.• Transport.Transport.

Status EpilepticusStatus Epilepticus

A life-threatening condition in which A life-threatening condition in which the patient has two or more convulsive the patient has two or more convulsive seizures without regaining seizures without regaining consciousnessconsciousness

KKEY TERMEY TERM

Patient Patient CARECARE

Status EpilepticusStatus Epilepticus

Emergency Care StepsEmergency Care Steps

Transport immediately.Transport immediately. Secure the airway.Secure the airway. Attempt to ventilate with 100% Attempt to ventilate with 100% oxygen.oxygen.

SSTROKETROKE

Death or injury of brain tissueDeath or injury of brain tissue that is deprived of oxygen. that is deprived of oxygen.

Caused by:Caused by:• Blockage orBlockage or

• Hemorrhage of a blood vessel Hemorrhage of a blood vessel in the brainin the brain

StrokeStroke

Prompt transport is critical.Prompt transport is critical. Identify potential strokeIdentify potential stroke

patients and notify the patients and notify the hospital. hospital.

StrokeStroke

Cincinnati Prehospital Stroke Scale Assess for 1) facial droop, 2) arm drift,

and 3) slurred speech

If the patient’s family members say he/she is just “acting a little strange” or “not him/herself ” the EMT-Basic should always consider the possibility of a diabetic emergency or stroke. Sometimes early symptoms of these medical problems are subtle and overlap. Becoming experienced at obtaining a history and understanding the medications that patients take can help you uncover clues to the problem the patient may be experiencing today.

PPRECEPTOR RECEPTOR PPEARLEARL

Signs & Symptoms of StrokeSigns & Symptoms of Stroke

Intoxicated appearance, slurred speech, unconsciousness

Severe headache, vision changes

One-sided weakness on body

Confusion

Signs & Symptoms of StrokeSigns & Symptoms of Stroke

Loss of bladder/bowel control

Unequal pupils

High blood pressure

Transient Ischemic Attack (TIA)Transient Ischemic Attack (TIA)

“Mini-stroke”

Signs and symptoms of a stroke

Often resolved before EMS arrival

Symptoms resolve without treatment in less than 24 hours

Significant risk of having a “full” stroke

Treatment of StrokeTreatment of Stroke

Prompt transport is critical.

Identify potential stroke patients and notify the hospital.

Maintain airway; administer oxygen.

Cincinnati PrehospitalCincinnati PrehospitalStroke ScaleStroke Scale

Have patient

attempt to smile.

Have patient

attempt to hold

arms straight in

front of them for 10

seconds.

Cincinnati PrehospitalCincinnati PrehospitalStroke ScaleStroke Scale

Evaluate

patient’s

speech.

Cincinnati PrehospitalCincinnati PrehospitalStroke ScaleStroke Scale

Syncope is a brief loss of consciousness.

It can occur at any age; more common in elderly.

It may be an indicator of serious medical problem.

Dizziness & SyncopeDizziness & Syncope

Hypovolemia• Trauma

• Dehydration

Metabolic• Hypoglycemia

• Stroke• Seizure

Causes of Dizziness and SyncopeCauses of Dizziness and Syncope

(Continued)(Continued)

Environmental/ToxicologicalAlcohol/Drugs

Carbon Monoxide

Panic/Anxiety

Causes of Dizziness and SyncopeCauses of Dizziness and Syncope

(Continued)(Continued)

CardiovascularFast or slow heart rates

Electrical system disturbanceVagus nerve stimulation

Causes of Dizziness and SyncopeCauses of Dizziness and Syncope

Obtain a SAMPLE history.

Ask about onset time, activities.

Length of episode?

Any previous episodes?

Assessment of Dizziness Assessment of Dizziness and Syncopeand Syncope

(Continued)(Continued)

Any medications for this condition?

Any nausea/vomiting/bowel changes?

Assessment of Dizziness Assessment of Dizziness and Syncopeand Syncope

Administer high-concentration oxygen.

Loosen restrictive clothing.

Lay patient flat and elevate legs (if no suspected spinal injury).

Treatment of DizzinessTreatment of Dizzinessand Syncopeand Syncope

(Continued)(Continued)

Treat any associated injuries.

Request ALS and transport.

Treatment of DizzinessTreatment of Dizzinessand Syncopeand Syncope

1. List the signs and symptoms1. List the signs and symptoms of hypoglycemia.of hypoglycemia.

2. What are five causes of seizures?2. What are five causes of seizures?3. Explain how to do the Cincinnati stroke 3. Explain how to do the Cincinnati stroke scale.scale.

RREVIEW QUESTIONSEVIEW QUESTIONS