Chapter 21- Diabetic Emergencies & Altered Mental Status

A form of sugar, the body’s basic source of energy
Glucose

Also called “sugar diabetes” or just “diabetes”, the condition brought about by decreased insulin production or the inability of the body cells to use insulin properly
Diabetes mellitus

A hormone produced by the pancreas or taken as a medication by many diabetics
Insulin

Fainting
Syncope

A prolonged seizure or when a person suffers two or more convulsive seizures without regaining full consciousness
Status epilepticus

Low blood sugar
Hypoglycemia

A medical condition that causes seizures; with proper medication, many of these patients no longer have seizures
Epilepsy

High blood sugar
Hyperglycemia

A sudden change in sensation, behavior, or movement; the most severe form produces violent muscle contractions called convulsions
Seizure

A condition of altered function caused when an artery in the brain is blocked or ruptured, disrupting the supply of oxygenated blood or causing bleeding into the brain
Stroke

The relationship of glucose to insulin is often described as:
A lock-and-key mechanism

You are treating a 27-year-old female who has a condition that you suspect has been brought about by a decrease in insulin production. This condition is known as:
Diabetes mellitus

Your patient has a history of diabetes. You were called to her home because her family noticed her mental status was altered. The most common medical emergency for the diabetic patient is called:
Hypoglycemia

You are treating a diabetic patient who seems to have overdone his exercise routine today. He is a little confused about where he is and the day of the week. The most medical condition he had developed is called:
Hypoglycemia

The hypoglycemia that EMT’s see in the field has many causes. Which of the following is NOT a cause of hypoglycemia?
The patient ate a box of candy too fast

If sugar is not replenished quickly for the diabetic patient who has developed hypoglycemia, the patient:
May have permanent brain damage

You are treating a patient who is unconscious for an unknown reason. The clues that a patient is a diabetic include what?
A medical identification bracelet; the presence of insulin in the refrigerator; information provided by family members

In the patient with an altered mental status, the EMT should always consider what before proceeding with the secondary assessment and transport
An airway or breathing problem

An intoxicated appearance and uncharacteristic behavior are typical of:
Diabetic emergency

Your patient has a history of diabetes and takes medication by injection daily. Diabetics often present the EMT with what signs and symptoms?
Cold, clammy skin; anxiety; combativeness

For the EMT to consider administering oral glucose, the patient must have an altered mental status, have a:
History of diabetes, and be awake enough to swallow

You are treating a diabetic patient who has low blood sugar, as documented by a glucometer. When reassessing the patient after you administered oral glucose, you note the patient’s condition has not improved. What action should you take?
Consult medical direction about whether to administer more glucose

When it is time to transport the diabetic patient who does not respond to painful stimuli, which position is most appropriate?
Recovery

Which statement about children with diabetes is MOST correct?
Children are more at risk than adults for developing hypoglycemia

Which of the following would MOST likely indicate an alteration in the patient’s blood sugar level?
Change in mental status

Your patient is going to need oral glucose. Before and after administering the medication, you should make sure to:
Document the mental status of the patient

A patient is very confused and disoriented. Before deciding the patient has a behavioral problem, the EMT should consider what?
A potential head injury; a brain tumor; hypoxia

A trade name for oral glucose is:
Insta-glucose

People with diabetes routinely test the level of sugar in their blood using a(n):
Glucose meter

Complication of diabetes include:
Kidney failure; heart disease; blindness

The reading on the device that diabetes routinely test the level of sugar in their blood is reported in:
Milligrams of glucose per deciliter of blood

If the diabetic is symptomatic and has a sugar level below what, he is considered hypoglycemic?
80

If the diabetic is symptomatic and has a sugar level above what, he is considered hyperglycemic?
120

You are assessing a patient who just had a seizure. The MOST common cause of seizures in adults is:
Not taking prescribed antiseizure medication

Seizures are commonly caused by what?
A high fever; a brain tumor; an infection

Which of the following is NOT a characteristic of an idiopathic seizure?
Last longer than 10 minutes

You are responding to a call for a 37-year-old male patient who has had a seizure. Convulsive seizures may be seen with:
Epilepsy or hypoglycemia

You are interviewing the family members of a patient who just had a seizure. The best-known condition that results in seizures is:
Epilepsy

Most members of the general public associate what seizure with epilepsy.
Generalized tonic-clonic

When obtaining the medical history of the seizure patient, interview the bystanders to find out what?
How long the seizure lasted; what the patient did after the seizure; what the patient was doing prior to the seizure

You are treating a patient who is actively seizing. He is rapidly becoming cyanotic. After convulsions end, what action should you take?
Provide artificial ventilations supplemental with oxygen

On your arrival at the scene, you notice that a bystander has placed a tongue blade in the corner of a seizure patient’s mouth. What should you do?
Carefully remove the object from the patient’s mouth

A seizure will normally last about how many minutes?
1 to 3 minutes

You are treating an elderly patient who has just had two back-to-back seizures without regaining consciousness. This is a serious condition called what and the treatment will include what?
Status epileptic; ALS meds

If you suspect a conscious 49-year-old female has had a stroke, you should transport her in what position and pay close attention to her what?
Semi-sitting; airway

When assessing your 53-year-old male patient, you determine he is having difficulty saying what he is thinking even though he clearly understands you. This condition found in stroke patients is called:
Expressive aphasia

When assessing your 42-year-old female patient, you determine that she can speak clearly but cannot understand what you are saying. This is called:
Receptive aphasia

Your patient is a suspect stroke patient. A common sign you would expect to find in this patient is:
Headache

You are treating a 58-year-old male patient who you suspect may be having a stroke. The signs and symptoms this patient presents with might include:
Vomiting; seizures; loss of bladder control

The 62-year-old male patient who presented with a number of the signs and symptoms of a stroke was taken to the ER yesterday. When talking with your Medical Director about the call, he tells you that the signs and symptoms were completely resolved within the past 24hrs. This patient was most likely suffering a(n):
Transient ischemia attack (TIA)

You are treating a patient who passed out while waiting in a long line to get into a concert. When a patient faints, the medical term to describe this is usually a(n) what and the treatment would involve what?
Syncopal episode; oxygen administration

When assessing your 45-year-old female patient, she says that she feels lightheaded. Lightheadedness, or dizziness, is a symptom that is often due to :
Poor perfusion to the brain

What happens when the autonomic nervous system engages?
Blood constricts, heart pumps fast and breathing rate increases

What are the signs and symptoms that develop outside the body of the hypoglycemic patient?
Confused, stupor, unconscious, seizures,

As the blood sugar level creeps up, what does the patient complain of?
Dehydration & hypovolemic shock

What is the acetone or fruity smell on the diabetic’s breathe due to?
The production of ketones

What are the three phases of a seizure?
1. Tonic- body becomes rigid (30seconds); breathing may stop; patient may bite tongue or become incontinent
2. Clonic- body jerking (1-3minutes); may foam at the mouth or drool; face/lips may be cyanotic
3. Postictal- convulsions stop; patient drowsy and tired

What are the signs and symptoms of a diabetic emergency?
– rapid onset of altered mental status
– intoxicated appearance, staggering, slurred speech, and unconscious
– elevated heart rate
– cold, clammy skin
– hunger
– seizures
– uncharacteristic behavior
– anxiety
– combativeness

What are some reasons that diabetics become hyperglycemic?
– not taken enough insulin deficiency
– forgotten to take insulin
– overeaten
– an infection that has upset glucose/insulin balance

What are the five categories of causes for dizziness and syncope?
– Hypovolemic
– Metabolic and structural
– environmental/toxicological
– cardiovascular
– other causes

Requirements to Maintain Mental Status:
• Oxygen to perfuse brain tissue
• Glucose to nourish brain tissue
• Water to keep brain tissue hydrated

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)

What is one of the most common
causes of altered mental status?
Hypoxia

Facts about Glucose:
• Form of sugar
• Body’s basic source of energy
• Body cells require glucose to remain alive and create energy
• Glucose molecule is large
• Will not pass into cell without insulin

Facts about Insulin:
• 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

Facts about Diabetes Mellitus:
• Two types
• Type 1
– Underproduction of insulin by pancreas
• Type 2
– Inability of body’s cells to use insulin properly

Facts about Type 1 Diabetes:
• 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

Facts about Type 2 Diabetes:
• 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

Facts about Hypoglycemia: Signs:
• Very rapid onset
• May present with abnormal behavior mimicking drunken stupor
• Pale, sweaty skin
• Tachycardia
• Seizures

Results of Hypoglycemia:
• Starvation of brain cells
• Altered mental status
• Unconsciousness
• Permanent brain damage

Causes of Hyperglycemia:
• Decrease in insulin
– May be due to body’s inability to produce insulin
– May exist because insulin injections not given in sufficient quantity
• Infection
• Stress
• Increasing dietary intake

Signs of Hyperglycemia:
• Develops over days or weeks
• Chronic thirst and hunger
• Increased urination
• Nausea

Results of Hyperglycemia
• Profound dehydration
• Excessive waste products released into system
• Diabetic ketoacidosis (DKA)

Diabetic Ketoacidosis: Signs and Symptoms
• Profoundly altered mental status
• Shock (caused by dehydration)
• Rapid breathing
• Acetone odor on breath

Blood glucose measurement:
– Less than 60-80 mg/dL in symptomatic diabetic: hypoglycemia
– Less than 50 mg/dL: significant alterations in mental status
– Over 140 mg/dL: hyperglycemia
– Over 200-300 mg/dL for prolonged time: dehydration, other more serious symptoms
– 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

Facts about Seizure Disorder:
• 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

Facts about Tonic-Clonic Seizure:
• Unconsciousness and major motor activity
• Tonic phase—body rigid up to 30 seconds
• Clonic phase—body jerks violently for 1-2 minutes
• Postictal phase—after convulsions stop; often slow period of regaining consciousness

Facts about an Aura:
• 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

Facts about a Partial Seizure:
• Not all seizures present as generalized tonic-clonic
• Partial seizure: uncontrolled muscle spasm or convulsion while patient is fully alert

Causes of Seizure:
• Hypoxia
• Stroke
• Traumatic brain injury
• Toxins
• Hypoglycemia
• Brain tumor
• Congenital brain defects
• Infection
• Idiopathic
• Epilepsy

When 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

Facts about Status Epilepticus:
• Two or more convulsive seizures lasting 5-10 minutes or more without regaining full consciousness
• High-priority emergency requiring
immediate transport to hospital and
possible ALS intercept

Facts about 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
• One-sided weakness (hemiparesis): very common
• Headache caused by bleeding from
ruptured vessel: less common, but very important

Signs and Symptoms of Stroke:
• Confusion
• Dizziness
• Numbness, weakness, or paralysis
(usually on one side of body)
• Loss of bowel or bladder control
• Impaired vision
• High blood pressure• Difficult respiration or snoring
• Nausea or vomiting
• Seizures
• Unequal pupils
• Headache
• Loss of vision in one eye
• Unconsciousness (uncommon)

Facts about Transient
Ischemic Attack (TIA):
• 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 (usually much sooner)

Facts about Dizziness:
• Common term meaning different things to different people
• Vertigo: sensation of surroundings
spinning around you
• Lightheadedness: sensation you are about to pass out (pre-syncope)

Facts about Syncope:
• Brief loss of consciousness with
spontaneous recovery
• Typically very short—a few seconds to a few minutes
• Patients often have some warning that syncope episode (fainting spell) is about to occur

Causes of Dizziness and Syncope:
• Hypovolemic
• Metabolic
• Environmental/ toxicological
• Cardiovascular

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
• Inner and middle ear problems also cause dizziness or 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

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