1. 19
Diabetic Emergencies and Altered Mental Status

2. 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.

3. 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

4. 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.

5. 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

6. 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

7. 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?

8. 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.

9. 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?

10. 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.

11. 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.
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12. 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

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

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

15. 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

16. 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?

17. 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?"

18. 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.

19. 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.

20. 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

21. 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.

22. 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.

23. 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?

24. 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?
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25. 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?

26. 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.
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27. 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

28. 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.
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29. 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
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30. 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
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31. Diabetic Emergencies Hyperglycemia Results Profound dehydration
Excessive waste products released into system
Diabetic ketoacidosis (DKA)
Covers Objective: 19.5
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32. Diabetic Emergencies Diabetic ketoacidosis
Profoundly altered mental status
Shock (caused by dehydration)
Rapid breathing
Acetone odor on breath
Covers Objective: 19.5

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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
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39. 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
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40. 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?

41. 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.

42. 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

43. 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.
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44. 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

45. 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

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

47. 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.
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48. Hypoglycemia and Hyperglycemia Compared
Breath
The hyperglycemic patient typically has acetone breath, but not all patients exhibit this sign.

49. 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.
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50. 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.

51. 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

52. 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

53. 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

54. 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
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55. 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
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56. 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

57. Causes of Seizures Hypoxia Stroke Traumatic brain injury Toxins
Hypoglycemia
Covers Objective: 19.9
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58. 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

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

60. 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

61. 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

62. 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
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63. 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
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64. 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

65. 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
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66. 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

67. 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

68. 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
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69. 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
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70. 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
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71. 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

72. 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

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

74. 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

75. 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

76. 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.

77. 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.

78. 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.

79. 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

80. Patient Care
For unconscious patient or patient who cannot maintain airway
Maintain open airway.
Provide high-concentration oxygen.
Transport.
Covers Objective: 19.12
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81. 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
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82. 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?

83. 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

84. 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
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85. 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

86. 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
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87. 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
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88. 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

89. 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
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90. 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

91. 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.

92. 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.

93. 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.

94. 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.
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95. Chapter Review

96. 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.
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97. 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.
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98. 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.
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99. 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.
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100. 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.

101. 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.
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102. Remember
Assess the seizure patient to determine the need for artificial ventilation.
Determine when the symptoms of the stroke began.

103. 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.
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104. 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.

105. 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.