19 Diabetic Emergencies and Altered Mental Status

Multimedia Directory Slide 49 Diabetes—Etiology and Pathophysiology Video Slide 94 Transient Ischemic Attacks Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Topics Pathophysiology Assessing the Patient with Altered Mental Status Diabetes Other Causes of Altered Mental Status Planning Your Time: Plan 140 minutes for this chapter. Pathophysiology (15 minutes) Assessing the Patient With Altered Mental Status (20 minutes) Diabetes (45 minutes) Other Causes of Altered Mental Status (60 minutes) Note: The total teaching time recommended is only a guideline. Core Concepts: General approaches to assessing the patient with an altered mental status Understanding the causes, assessment, and care of diabetes and various diabetic emergencies Understanding the causes, assessment, and care of sepsis Understanding the causes, assessment, and care of seizure disorders Understanding the causes, assessment, and care of stroke Understanding the causes, assessment, and care of dizziness and syncope

Pathophysiology Teaching Time: 15 minutes Teaching Tips: Put the general requirements of brain tissue in the context of metabolism. Use real-life examples to enhance an otherwise technical discussion. Relate the requirements of the brain to disorders that occur when the requirements are not met.

Pathophysiology Normal consciousness is regulated by series of neurologic circuits in brain that comprise reticular activating system (RAS) RAS responsible for functions of staying awake, paying attention, and sleeping RAS keeps person alert and oriented Covers Objective: 19.3 Point to Emphasize: The reticular activating system (RAS) is responsible for the functions of staying awake, paying attention, and sleeping. Discussion Topic: Discuss the role of the reticular activating system in the brain. What functions does it serve? continued on next slide

Pathophysiology Requirements for the brain tissue of the RAS to function Oxygen to perfuse brain tissue Glucose to nourish brain tissue Water to keep brain tissue hydrated Covers Objective: 19.3 Point to Emphasize: Brain tissue requires a constant supply of oxygen, glucose, and water to perform its required functions. Discussion Topic: Describe the basic requirements of brain cells. Specifically, what is required of brain cells to accomplish basic functions? Knowledge Application: Ask students to research how the brain uses its specific requirements. Ask them to report on the use of water, glucose, and oxygen. continued on next slide

Pathophysiology Causes of altered mental status Deficiencies in oxygen, glucose, water to brain tissue Trauma, infection, chemical toxins harming brain tissue Primary brain problem (stroke) Problem within another system (hypoxia due to asthma) Covers Objective: 19.3 Point to Emphasize: A lack of any of the brain's requirements can lead to altered mental status. Class Activity: Have a class discussion about how the reticular activating system can be disturbed. Brainstorm various disorders that affect mental status. Knowledge Application: Have students work in small groups. Assign each group a specific brain requirement (water, glucose, oxygen). Have each group research and discuss the results of a deficit of its particular requirement. Critical Thinking: Alcohol abuse can cause altered mental status. How might a patient's alcohol intoxication affect your ability to conduct a thorough assessment?

Assessing the Patient with Altered Mental Status Teaching Time: 20 minutes Teaching Tips: Relate this lesson to previous discussions about primary and secondary assessments. Mental status is a finding that can indicate a priority patient. Altered mental status can be a challenge to patient assessment. Practice makes perfect. Be sure to allow sufficient time to practice this skill. Altered mental status can be subtle. Use both obvious examples and subtle examples during simulation.

Assessing the Patient with Altered Mental Status Patient with altered mental status can be dangerous to responders. Always consider safety of yourself and your team before approaching a patient. Use law enforcement when necessary. Covers Objective: 19.4 Point to Emphasize: Safety is always the most important concern when assessing a patient with altered mental status. Discussion Topic: Discuss the safety threats that can be present when assessing a patient with altered mental status. Class Activity: Have the class brainstorm potential safety hazards associated with altered mental status patients. Discuss. Critical Thinking: How might your scene assessment enhance your ability to assess a patient with an altered mental status?

Assessing the Patient with Altered Mental Status Covers Objective: 19.4 Loss of consciousness with syncope is usually brief. The patient usually regains consciousness very soon after being allowed to lie flat.

Primary Assessment Hypoxia is one of the most common causes of altered mental status. Always consider the possibility of an airway and/or breathing problem. Covers Objective: 19.4 Point to Emphasize: A thorough primary assessment will rapidly identify altered mental status caused by hypoxia. Talking Points: EMTs should complete a thorough primary assessment on every patient, but be especially attentive in the event of altered mental status. Discussion Topic: Discuss how the primary survey can rapidly identify hypoxia as a cause of altered mental status. continued on next slide

Primary Assessment Identify and treat life-threatening problems. Consider oxygen administration. Be alert to the need for positioning and suctioning if patient requires it or if mental status worsens. Determine baseline mental status for patient. Covers Objective: 19.4

Secondary Assessment Thoroughly examine patient exhibiting new, unusual behavior. Even slightly altered mental status indicates serious underlying issues. Covers Objective: 19.4 continued

Secondary Assessment Covers Objective: 19.4 1. Perform a primary assessment. Determine if the patient's mental status is altered.

Secondary Assessment Body systems exam and complete history may reveal information about the suspected cause of altered mental status. Interview family members and bystanders to obtain patient's baseline mental status. Family may provide information patient is unable to give. Covers Objective: 19.4 Point to Emphasize: A secondary assessment will continue the search for a cause of altered mental status. It often can identify life threats not found in the initial assessment. Discussion Topic: Describe findings in the secondary assessment that can help identify the cause of altered mental status. How might the assessment of mental status in a child differ from that in an adult? Knowledge Application: Use programmed patients and practice assessing the mental status of pediatric patients. Simulate involving the parents in the assessment. continued on next slide

Secondary Assessment Patient's medicines may point to relevant medical history Look for medic alert bracelets or other health-related items at scene Covers Objective: 19.4 Class Activity: Divide the class into two groups: primary and secondary. Ask each group to list causes of altered mental status that could be found in their assessment. Which list will be longer? Knowledge Application: Have students work in small groups. Use a programmed patient and have students practice assessment scenarios for patients with altered mental status. Be sure to include the following: safety concerns, hypoxia, subtle altered mental status. Critical Thinking: Consider how you might assess the mental status of a dementia patient. How is this assessment similar to the assessment of a pediatric patient?

Pediatric Note Children may not be able to answer questions in the same manner as adults and therefore mental status is often difficult to establish. Ask parents or caregivers, "Are they acting differently than normal?"

Think About It What kind of information about a patient's altered mental status might you obtain from the scene? How might bystanders help you identify the cause of altered mental status? Covers Objective: 19.4 Talking Points: The scene might reveal drug paraphernalia or other medications. Evidence of trauma or of other medical conditions such as diabetes might also help identify the cause. Bystanders might be able to describe the onset or have information regarding the patient's past medical history.

Diabetes Teaching Time: 45 minutes Teaching Tips: Remind students that they need to know the body's systems. Blood glucose testing, if allowed, will be an important component in assessing a diabetic patient. Spend time on hyperglycemia/hypoglycemia pathophysiology. Although it is complex, it will help the assessment findings make sense. Tell students that, without the ability to monitor glucose, they should err on the side of hypoglycemia. Treating this deficit might be lifesaving.

Glucose and the Digestive System Form of sugar Body's basic source of energy Body cells require glucose to remain alive and create energy Covers Objective: 19.5 Point to Emphasize: Glucose is a form of sugar and is the body's basic source of energy. continued on next slide

Glucose and the Digestive System Glucose molecule is large. Will not pass into cell without insulin Covers Objective: 19.5 Knowledge Application: Trace the path of a sugar molecule (similar to the way in which you traced a drop of blood or an oxygen molecule in previous chapters). Discuss how the sugar molecule moves through the bloodstream and into the cells.

Glucose and the Digestive System Covers Objective: 19.5 Knowledge Application: Trace the path of a sugar molecule (similar to the way in which you traced a drop of blood or an oxygen molecule in previous chapters). Discuss how the sugar molecule moves through the bloodstream and into the cells. Insulin is needed to help the cells take in glucose.

Insulin and the Pancreas Produced by pancreas Binds to receptor sites on cells Allows large glucose molecule to pass into cells Sugar intake–insulin production balance allows body to use glucose effectively as energy source. Covers Objective: 19.5 Point to Emphasize: Insulin transports glucose molecules into the cells. Discussion Topic: What is the role of insulin with regard to glucose distribution in the body?

Diabetes Mellitus Two types Type 1 Pancreatic cells do not function properly. Insulin not secreted normally Not enough insulin to transfer circulating glucose into cells Synthetic insulin typically prescribed to supplement inadequate natural insulin Covers Objective: 19.5 Discussion Topic: Define diabetes. How does the production of insulin in a diabetic patient differ from that in a nondiabetic patient? continued on next slide

Diabetes Mellitus Two types Type 2 Body's cells fail to utilize insulin properly. Pancreas is secreting enough insulin, but body is unable to use it to move glucose into cells. Condition often controlled through diet and/or oral antidiabetic medications. Covers Objective: 19.5 Discussion Topic: Define diabetes. How does the production of insulin in a diabetic patient differ from that in a nondiabetic patient?

Diabetic Emergencies Hypoglycemia Low blood sugar Causes Diabetic takes too much insulin Diabetic does not eat Diabetic overexercises or overexerts Diabetic vomits Diabetic increases metabolic rate (fever or shivering) Covers Objective: 19.5 Point to Emphasize: Hypoglycemia occurs when the bloodstream does not have enough sugar; hyperglycemia occurs when the bloodstream has too much sugar. Knowledge Application: Have students work in small groups. Assign each group a type of diabetic dysfunction. Have the groups research the pathophysiology and present their findings. continued on next slide

Diabetic Emergencies Hypoglycemia Signs Very rapid onset May present with abnormal behavior mimicking drunken stupor Pale, sweaty skin Tachycardia Rapid breathing Seizures Covers Objective: 19.5 Point to Emphasize: Hypoglycemia occurs when the bloodstream does not have enough sugar; hyperglycemia occurs when the bloodstream has too much sugar. Knowledge Application: Have students work in small groups. Assign each group a type of diabetic dysfunction. Have the groups research the pathophysiology and present their findings. continued on next slide

Diabetic Emergencies Hypoglycemia Results Starvation of brain cells Altered mental status Unconsciousness Permanent brain damage Covers Objective: 19.5 Point to Emphasize: Hypoglycemia occurs when the bloodstream does not have enough sugar; hyperglycemia occurs when the bloodstream has too much sugar. Knowledge Application: Have students work in small groups. Assign each group a type of diabetic dysfunction. Have the groups research the pathophysiology and present their findings. continued on next slide

Diabetic Emergencies Hyperglycemia High blood sugar Causes Decrease in insulin May be due to body's inability to produce insulin May exist because insulin injections not given in sufficient quantity Covers Objective: 19.5 continued on next slide

Diabetic Emergencies Hyperglycemia Causes Signs Stress Increasing dietary intake Signs Develops over days or weeks Chronic thirst and hunger Increased urination Nausea Covers Objective: 19.5 continued on next slide

Diabetic Emergencies Hyperglycemia Results Profound dehydration Excessive waste products released into system Diabetic ketoacidosis (DKA) Covers Objective: 19.5 continued on next slide

Diabetic Emergencies Diabetic ketoacidosis Profoundly altered mental status Shock (caused by dehydration) Rapid breathing Acetone odor on breath Covers Objective: 19.5

Patient Assessment Ensure safe scene. Perform primary assessment. Identify altered mental status. Covers Objective: 19.7 Point to Emphasize: The basic elements in the assessment of a diabetic patient are safety, primary assessment, patient history and physical exam, assessment of the patient's ability to swallow, and vital signs. continued on next slide

Patient Assessment Perform secondary assessment. History of present episode How episode occurred, time of onset, duration, associated symptoms, any mechanism of injury or other evidence of trauma, any interruptions to episode, seizures, or fever Covers Objective: 19.7 continued on next slide

Patient Assessment Perform secondary assessment. SAMPLE Determine history of diabetes Question patient or bystanders. Look for medical identification bracelet. Look in refrigerator or elsewhere at scene for medications such as insulin. Perform blood glucose monitoring if local protocols permit you to do so. Covers Objective: 19.7

Blood Glucose Meters Measures amount of glucose in bloodstream Often used by patients at home Sometimes used by EMTs Follow local protocol. Covers Objective: 19.7 continued

Assessment Covers Objective: 19.7 2. Perform a secondary assessment and take the patient's vital signs. Be sure to find out if she has a history of diabetes. Observe for a medical identification device. If your protocols allow, check the patient's blood glucose level. continued

Blood Glucose Meters Blood glucose measurement Less than 60 mg/dL in symptomatic diabetic Hypoglycemia Less than 50 mg/dL Significant alterations in mental status Covers Objective: 19.7 continued on next slide

Blood Glucose Meters Blood glucose measurement Greater than 140 mg/dL Hyperglycemia Greater than 300 mg/dL for prolonged time Dehydration, other more serious symptoms Covers Objective: 19.7 continued on next slide

Blood Glucose Meters Special glucometer readings May display word instead of number "High" or "HI" Indicates extremely high level, usually greater than 500 mg/dL "LOW" Indicates extremely low level, often less than 15 mg/dl Covers Objective: 19.6 Knowledge Application: Have students work in small groups to practice the assessment of diabetic patients. Have them assess both hypoglycemia and hyperglycemia. Critical Thinking: Without blood glucose monitoring capabilities, it can be difficult to differentiate hyperglycemia from hypoglycemia. If the diagnosis is unclear, should you administer oral glucose? Why or why not?

Assessment Covers Objective: 19.6 Knowledge Application: Have students work in small groups to practice the assessment of diabetic patients. Have them assess both hypoglycemia and hyperglycemia. Critical Thinking: Without blood glucose monitoring capabilities, it can be difficult to differentiate hyperglycemia from hypoglycemia. If the diagnosis is unclear, should you administer oral glucose? Why or why not? Many diabetics use home glucose meters to test their blood glucose levels.

Patient Care Occasionally, one can treat person with mild hypoglycemia and minor altered mental status by simply giving something to eat. Never administer food or liquids to patients at risk for aspiration. Covers Objective: 19.7 continued on next slide

Patient Care Oral glucose Criteria for administration History of diabetes Altered mental status Awake enough to swallow Covers Objective: 19.7 Point to Emphasize: Hypoglycemic patients can be treated with oral glucose if they are able to swallow safely. continued on next slide

Patient Care Oral glucose Patient squeezes glucose from tube directly into mouth. EMT can administer glucose using tongue depressor. Covers Objective: 19.7 Class Activity: Have the class taste oral glucose. Give them an idea of what their patients will have to endure. Knowledge Application: Demonstrate the administration of oral glucose. continued

4. Assist the patient in accepting oral glucose. Patient Care Covers Objective: 19.7 Class Activity: Have the class taste oral glucose. Give them an idea of what their patients will have to endure. Knowledge Application: Demonstrate the administration of oral glucose. 4. Assist the patient in accepting oral glucose. continued

Patient Care Oral glucose Reassess after administration. If condition does not improve, consult medical direction about whether to administer more. Covers Objective: 19.7

Hypoglycemia and Hyperglycemia Compared Onset Hyperglycemia has a slower onset, while hypoglycemia tends to come on suddenly. Skin Hyperglycemic patients often have warm, red, dry skin while hypoglycemic patients have cold, "clammy" skin. continued on next slide

Hypoglycemia and Hyperglycemia Compared Breath The hyperglycemic patient typically has acetone breath, but not all patients exhibit this sign.

Diabetes—Etiology and Pathophysiology Video Covers Objective: 19.5 Video Clip Diabetes—Etiology and Pathophysiology What is diabetes mellitus? What are the different types of diabetes? Discuss how insulin works in the body. What is pre-diabetes? About how many people have Type 1 diabetes? Click on the screenshot to view a video on the etiology and pathophysiology of diabetes. Back to Directory

Other Causes of Altered Mental Status Teaching Time: 60 minutes Teaching Tips: A seizure is a dramatic event to witness. If possible, use video graphics to demonstrate tonic-clonic seizures. Discuss the need to identify the causes of seizure. Oftentimes the underlying problem is more dangerous than the seizure itself. Stroke care is a hot-button issue in health care. Many resources exist. Reach out to your local stroke center or the American Stroke Association for lesson enhancements.

Sepsis Collection of problems associated with response to infection Occurs when steps normally taken to fight infection move from the local site and become a systemic problem If severe enough, the microbes of the offending infection can release toxins that harm cardiac output. Covers Objective: 19.8

Patient Assessment The following findings indicate severe sepsis: Altered mental status Increased heart rate Increased respiratory rate Low blood pressure High blood glucose Decreased capillary refill time Covers Objective: 19.8

Seizure Disorders If normal brain function is upset by injury, infection, or disease, the brain's electrical activity can become irregular. Irregularity can bring about seizure. Sudden change in sensation, behavior, or movement Seizure is a sign of underlying defect, injury, or disease and not a disease itself. Covers Objective: 19.8 Point to Emphasize: Seizures result from the disorganized firing of neurons in the brain. A seizure is not a disease in itself but rather a sign of some underlying defect, injury, or disease. continued on next slide

Seizure Disorders Two types of seizures Partial Generalized Affect only one part, or one side, of brain; patient may not lose consciousness. Generalized Affect entire brain and affects the consciousness of the patient Covers Objective: 19.8 continued on next slide

Seizure Disorders Tonic-clonic seizure Unconsciousness and major motor activity Tonic phase Body rigid up to 30 seconds Clonic phase Body jerks violently for 1 to 2 minutes. Covers Objective: 19.8 continued on next slide

Seizure Disorders Tonic-clonic seizure Some seizures preceded by aura Postictal phase After convulsions stop; often slow period of regaining consciousness. Some seizures preceded by aura Sensation patient has just before it is about to happen Patient may note smell, sound, or just a general feeling right before seizure. Covers Objective: 19.8

Causes of Seizures Hypoxia Stroke Traumatic brain injury Toxins Hypoglycemia Covers Objective: 19.9 continued on next slide

Causes of Seizures Brain tumor Congenital brain defects Infection Metabolic Idiopathic Covers Objective: 19.9 Discussion Topic: List and discuss the causes of seizures. Knowledge Application: Have students work in small groups. Assign each group a specific cause of seizure. Have the group research the cause and discuss the pathophysiology behind the seizure. continued on next slide

Causes of Seizures Epilepsy Measles, mumps, and other childhood diseases Eclampsia Heat stroke Covers Objective: 19.9

Patient Assessment What was person doing before seizure started? Exactly what did person do during seizure? How long did seizure last? What did person do after seizure? Covers Objective: 19.10 Point to Emphasize: Assessment of seizures must include looking for the underlying cause. continued on next slide

Patient Assessment If you are present when a convulsive seizure occurs: Place patient on floor or ground. Loosen restrictive clothing. Remove objects that may harm patient. Protect patient from injury, but do not try to hold patient still during convulsions. Covers Objective: 19.10 Talking Points: Never place anything in the mouth of a seizing patient. Many objects can be broken and obstruct the patient's airway. Knowledge Application: Ask students to research the local stroke care protocol. Discuss local procedures for caring for a stroke patient. continued on next slide

Patient Assessment After convulsions have ended Protect airway. If no possibility of spine injury, position patient on side. If patient is cyanotic, ensure open airway and provide artificial ventilations with supplemental oxygen. Covers Objective: 19.10 continued on next slide

Patient Assessment After convulsions have ended Patient breathing adequately may be given oxygen by mask or nasal cannula. Treat injuries patient may have sustained during convulsions. Transport. Covers Objective: 19.10 continued on next slide

Patient Assessment Status epilepticus Two or more convulsive seizures in a row without regaining full consciousness or a single seizure lasting more than 10 minutes High-priority emergency requiring immediate transport to hospital and possible ALS intercept Covers Objective: 19.10

Types of Seizures Not all seizures present as generalized tonic-clonic. Partial seizures Uncontrolled muscle spasm or convulsion while patient is fully alert Complex partial seizure Often preceded by an aura Covers Objective: 19.8 continued on next slide

Types of Seizures Generalized seizures Tonic-clonic seizure Absence (petit mal) seizure Brief, without dramatic motor activity Temporary loss of concentration or awareness May go unnoticed by everyone except the patient and knowledgeable members of their family Covers Objective: 19.8

Stroke Death or injury of brain tissue from oxygen deprivation Causes Blockage of artery supplying blood to part of the brain Bleeding from a ruptured blood vessel in the brain Covers Objective: 19.11 Point to Emphasize: Stroke refers to the death or injury of brain tissue as a result of a lack of oxygen. This can be caused by an arterial blockage or from bleeding from a ruptured blood vessel. Discussion Topic: Describe the pathophysiology of stroke. How is brain tissue affected? continued on next slide

Stroke Signs One-sided weakness (hemiparesis) very common Difficulty speaking or complete inability to speak Headache caused by bleeding from ruptured vessel Less common, but very important Covers Objective: 19.11 continued on next slide

Stroke Other signs and symptoms Confusion Dizziness Numbness, weakness, or paralysis Usually on one side of body Loss of bowel and/or bladder control Impaired vision High blood pressure Covers Objective: 19.12 continued on next slide

Stroke Other signs and symptoms Difficult respiration or snoring Nausea or vomiting Seizures Unequal pupils Headache Loss of vision in one eye Unconsciousness Uncommon Covers Objective: 19.12 continued on next slide

Stroke Communicating with a stroke patient Often difficult to communicate with a stroke patient Damage to brain can cause partial or complete loss of the ability to use words. Aphasia General term meaning difficulty in communication Covers Objective: 19.12

Transient Ischemic Attack Small clots temporarily block circulation to part of brain. Causes stroke-like symptoms Symptoms resolve when clots break up. Complete resolution of symptoms without treatment within 24 hours, but usually much sooner Covers Objective: 19.12

Patient Assessment Cincinnati Prehospital Stroke Scale Stroke patient more likely to show abnormal response. Ask patient to grimace or smile. Covers Objective: 19.12

Assessment: Stroke Covers Objective: 19.12 2. Assess for speech difficulties. A stroke patient will often have slurred speech, use the wrong words, or be unable to speak at all. © Daniel Limmer

Patient Assessment Cincinnati Prehospital Stroke Scale Ask patient to close eyes and extend arms straight out in front for 10 seconds. Covers Objective: 19.12

Assessment: Stroke Covers Objective: 19.12 3. Assess for arm drift by asking the patient to close her eyes and extend her arms, palms up, for 10 seconds. A patient who has not suffered a stroke can usually hold her arms in an extended position with eyes closed.

Assessment: Stroke Covers Objective: 19.12 3. Assess for arm drift by asking the patient to close her eyes and extend her arms, palms up, for 10 seconds. A stroke patient will often display arm drift or palm rotation. That is, one arm will remain extended, but the arm on the affected side will drift downward or turn over.

Patient Assessment Cincinnati Prehospital Stroke Scale Ask patient to say something. "You can't teach an old dog new tricks." Covers Objective: 19.12 Point to Emphasize: A patient who demonstrates any one of the three findings of the Cincinnati Prehospital Stroke Scale has a 70 percent chance of having an acute stroke.

Patient Care For conscious patients who can maintain airway Calm and reassure patient. Monitor airway. Administer high-concentration oxygen is oxygen saturation is below 94 percent of if signs of hypoxia or respiratory distress present. Transport. Covers Objective: 19.12 Point to Emphasize: Assessment and care of stroke patients includes identification of when symptoms began and rapid transport to an appropriate facility. continued on next slide

Patient Care For unconscious patient or patient who cannot maintain airway Maintain open airway. Provide high-concentration oxygen. Transport. Covers Objective: 19.12 continued on next slide

Patient Care Transport suspected stroke patient to hospital with capabilities for managing stroke patient. Capabilities must include CT scan at minimum. Covers Objective: 19.12 continued on next slide

Patient Care Determine and document exact time of onset of symptoms. Document contact information if person other than patient provides time of onset. Covers Objective: 19.12 Discussion Topic: Describe the treatment of a patient having an identified stroke. What are the critical elements of appropriate care?

Dizziness and Syncope Can indicate serious or life-threatening problems May be impossible to diagnose true cause of syncope Covers Objective: 19.13 Point to Emphasize: Altered mental status also can result from syncope, hypovolemia, and other metabolic causes. continued on next slide

Dizziness and Syncope Dizziness Common term meaning different things to different people Vertigo Sensation of surroundings spinning around you Light-headedness Sensation you are about to pass out (presyncope) Covers Objective: 19.13 continued on next slide

Dizziness and Syncope Syncope Brief loss of consciousness with spontaneous recovery Typically very short A few seconds to a few minutes Patients often have some warning that a syncopal episode (fainting spell) is about to occur Covers Objective: 19.13

Causes of Dizziness and Syncope Cardiovascular causes Bradycardia and tachycardia can cause decreased cardiac output and syncope. Vasovagal syncope is thought to be the result of stimulation of the vagus nerve, which signals the heart to slow down. Decreased cardiac output causes syncope. Covers Objective: 19.13 continued on next slide

Causes of Dizziness and Syncope Hypovolemic causes Low fluid/blood volume causes dizziness or syncope, especially when patient attempts to sit up or stand. Source of bleeding may not be obvious. Metabolic and structural causes Alterations in brain chemistry or structure can lead to diminished level of consciousness. Covers Objective: 19.13 continued on next slide

Causes of Dizziness and Syncope Metabolic and structural causes Inner and middle ear problems also cause dizziness or syncope. Environmental/toxicological causes Alcohol and drugs can cause fluctuations in consciousness. Other causes In half of the cases, no cause is ever found. Covers Objective: 19.13

Patient Assessment Rapidly identify and treat life threats. Gather important information that will assist in overall treatment. Ask: Have you had any similar episodes in the past? What do you mean by "dizziness"? Covers Objective: 19.14 continued on next slide

Patient Assessment Ask: Did you have any warning? When did it start? How long did it last? What position were you in when the episode occurred? Are you on medication for this kind of problem? Covers Objective: 19.14 continued on next slide

Patient Assessment Ask: Did you have any other signs or symptoms; nausea? Did you witness any unpleasant sight or experience a strong emotion? Did you hurt yourself? Did anyone witness involuntary movements of the extremities, like seizures? Covers Objective: 19.14 Knowledge Application: Have students work in small groups. Using a programmed patient, have groups practice assessing patients with altered mental status. Include scenarios on stroke, seizures, and other causes of altered mental status.

Patient Care Administer oxygen based on oxygen saturation levels and patient’s level of distress. Call for ALS. Loosen tight clothing around neck. Lay patient flat. Treat associated injuries patient may have incurred from fall. Covers Objective: 19.14 Discussion Topic: Discuss causes of altered mental status beyond stroke and seizure. What other disorders can affect the reticular activating system? Class Activity: Have students complete group research projects. Assign a cause of altered mental status and have groups research pathophysiology, care, and current advancements in treatment.

Think About It Is the seizure or syncope a symptom of a larger problem? Covers Objective: 19.13 Talking Points: Often seizures and syncope point to a larger problem. Although they may be the patient's chief complaint, always look for a larger problem that may be causing these issues. Problems such as cardiac dysrhythmias, stroke and sepsis can all cause seizures and syncope and may be far worse problems than the symptoms they cause.

Transient Ischemic Attacks Video Covers Objective: 19.11 Video Clip Transient Ischemic Attacks Differentiate between a stroke and a transient ischemic attack. What are some causes of a transient ischemic attack? Does a patient with a history of transient ischemic attacks have an increased risk for having a stroke? Explain. What emergency care should be provided to a patient suspected of having a TIA? Why should a patient who appears to have fully recovered from a transient ischemic attack on an EMT's arrival still be examined by an emergency room physician? Click on the screenshot to view a video on the topic of transient ischemic attacks. Back to Directory

Chapter Review

Chapter Review Diabetic emergencies are usually caused by poor management of the patient's diabetes. Diabetic emergencies are often brought about by hypoglycemia, or low blood sugar. The chief sign of this hypoglycemia is altered mental status. continued on next slide

Chapter Review Whenever a patient has an altered mental status, a history of diabetes, and can swallow, administer oral glucose. Seizures may have a number of causes. Assess and treat for possible spinal injury, protect the patient's airway, and provide oxygen as needed. continued on next slide

Chapter Review You should gather information about the seizure to give to hospital personnel. A stroke is caused when an artery in the brain is blocked or ruptures. continued on next slide

Chapter Review Signs and symptoms of stroke commonly include an altered mental status, numbness or paralysis on one side, and difficulty with speech. For stroke patients, ensure an open airway and provide supplemental oxygen. Determine the exact time of onset of symptoms and transport promptly. continued on next slide

Chapter Review Dizziness and syncope (fainting) may have a variety of causes. In the case of syncope, administer oxygen, loosen clothing around neck, and place patient flat with raised legs if there is no reason not to. Treat any injuries and transport.

Remember Determine if the patient's altered mental status is being caused by hypoxia. In a patient with a hypoglycemic emergency, determine whether the mental status will allow the administration of oral glucose. continued on next slide

Remember Assess the seizure patient to determine the need for artificial ventilation. Determine when the symptoms of the stroke began.

Questions to Consider List the chief signs and symptoms of a diabetic emergency. Explain how you can determine a medical history of diabetes. Explain what treatment may be given by an EMT for a diabetic emergency and the criteria for giving it. Talking Points: Symptoms of a diabetic emergency include altered mental status, pale sweaty skin, and tachycardia. These symptoms can vary depending on whether the emergency is caused by hyper- or hypoglycemia. A history of diabetes can be obtained by the patient or family. Insulin and other anti-diabetic medications can indicate diabetes as well. Medic alert jewelry can also point to the disease. Treatment for a diabetic emergency includes transport, allowing the patient to eat if appropriate, and administration of oral glucose. continued on next slide

Questions to Consider Explain the care that should be given to a conscious and to an unconscious patient with suspected stroke. Explain the care that should be given to a patient who has experienced dizziness or syncope. Talking Points: Stroke patients should receive airway management when necessary. High flow oxygen and rapid transport are also important. Syncope and dizziness often point to a more significant underlying problem. Always complete a thorough patient assessment. Transport the patient lying flat and administer high concentration oxygen.

Critical Thinking A 62-year-old male is witnessed to have a tonic-clonic seizure. You find him actively seizing. His skin is pale and moist and slightly cyanotic. Discuss the immediate treatment necessary. Talking Points: Cyanotic skin demonstrates the need for immediate airway management and high concentration oxygen. Once the airway has been secured, the primary assessment must be completed. Rule out life-threatening causes of the seizure like hypoxia, hypoglycemia, and stroke.