Chapter 22 - Diabetes and Altered Mental Status

Central Nervous System (CNS)

The part of the nervous system made up of the brain and spinal cord that controls consciousness and mental status.

Peripheral Nervous System (PNS)

The part of the nervous system responsible for transmitting messages between the CNS and the rest of the body.

Sympathetic Nervous System

Division of the autonomic nervous system responsible for the "fight or flight" response.

-gut inactive and Pupils expand

Parasympathetic Nervous System

Division of the autonomic nervous system is responsible for "rest and digest" body functions.

-gut active and pupils shrink

Altered Mental Status (AMS)

Any deviation from a person's normal level of consciousness or cognitive function.

SNOT

A mnemonic used to remember common causes of altered mental status

Stroke, Seizure, Sugar

S (SNOT)

Narcotics

N (SNOT)

Oxygen

O (SNOT)

Toxins, Trauma, Temperature

T (SNOT)

AEIOU-TIPS

A mnemonic used to identify causes of altered mental status.

Alcohol

A (AEIOU-TIPS)

Epilepsy

E (AEIOU-TIPS)

Insulin (AEIOU-TIPS)

I (AEIOU-TIPS)

Overdose

O (Overdose)

Underdose

U (AEIOU-TIPS)

Trauma

T (AEIOU-TIPS)

Infection

I (AEIOU-TIPS)

Psychosis

P (AEIOU-TIPS)

Stroke

S (AEIOU-TIPS)

Glucose

A form of sugar that serves as the body's primary source of energy.

Insulin

A hormone produced by the pancreas that allows glucose to enter body cells.

Diabetes Mellitus (DM)

A metabolic disorder in which the body cannot properly use glucose for energy.

Type 1 Diabetes

Underproduction of insulin by pancreas

Synthetic Insulin

Supplements inadequate natural insulin for Type 1 Diabetes

Type 2 Diabetes

Inability of the body's cells to use insulin properly

Diet or Oral Diabetic medicaitons

Used to treat Type 2 diabetes

Hypoglycemia

A condition in which blood glucose levels are too low.

Hyperglycemia

A condition in which blood glucose levels are too high.

Diabetic Ketoacidosis (DKA)

A life-threatening condition caused by high blood glucose and dehydration resulting in acid buildup in the blood.

Glucometer

A device used to measure the amount of glucose in the bloodstream.

Oral Glucose

A medication used to raise blood sugar levels in patients experiencing hypoglycemia.

Cerebral Vascular Accident (CVA)

Another term for stroke; occurs when brain tissue is deprived of oxygen due to lack of blood flow.

Stroke/CVA causes

• Blockage of artery supplying blood to part of the brain

• Bleeding from a ruptured blood vessel in the brain

Additional Signs/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)

FAST exam

A stroke assessment tool

Facial droop

F (FAST)

Arm drift

A (FAST)

Slurred Speech

S (FAST)

Time critical

T (FAST)

Aphasia

Difficulty speaking or understanding speech due to brain damage.

hemorrhagic stroke

Bleeding from a ruptured blood vessel in the brain

Ischemic Stroke

• Blockage of artery supplying blood to part of the brain

Transient Ischemic Attack (TIA)

A temporary blockage of blood flow to the brain causing stroke-like symptoms that resolve within 24 hours.

Stroke Care

• Monitor airway

• Calm and reassure patient

• Consider oxygen

• Transport patient in semi-sitting position

• Transport to hospital with stroke management capabilities (minimum: CT scan)

Seizure

A sudden change in sensation, behavior, or movement caused by abnormal electrical activity in the brain.

Tonic-Clonic Seizure

A seizure involving unconsciousness and violent muscle contractions.

Tonic, Clonic, Postictal

Phases of Stroke

Tonic Phase (Stroke)

body rigid up to 30 seconds

Clonic Phase (Stroke)

body jerks violently for 1-2 minutes

Postictal Phase

The recovery phase after convulsions stop, often slow period of

regaining consciousness when the patient may be confused or drowsy.

Aura

A sensation or warning sign that occurs before some seizures.

• Patient may note smell, sound, or just a general feeling right before seizure

Status Epilepticus

• Two or more seizures lasting 5-10 minutes without regaining consciousness between them.

• High-priority emergency requiring immediate transport to hospital and possible ALS intercept

Sepsis

Infection, especially a severe, systemwide response to an infection

-one of most dangerous causes of AMS

Sepsis Signs/Symptoms

• AMS

• Tachycardia

• Tachypnea

• Hypotension

• Hyperglycemia

• Fever

Sepsis Treatment

• Recognition

• Consider oxygen

• Consider ALS

Vertigo and Lightheadedness

Dizziness

Synocope

• Brief loss of consciousness with spontaneous recovery

• Typically very short—a few seconds to a few minutes

• Patients often have some warning that syncopal episode (fainting spell) is about to occur

Causes of Dizziness and Syncope

• Hypovolemic = Low fluid/blood volume

• Metabolic

• Environmental/ toxicological

• Alcohol/Drugs

• Cardiovascular

• Bradycardia

• Tachycardia

Assessment: Dizziness and Syncope

• Are you on medication for this kind of problem?

• Did you have any other signs or symptoms?

• Did you witness any unpleasant sights or experience a strong emotion?

• Did anyone witness involuntary movements of the extremities (like seizures)?

Brain needs

Oxygen

Glucose

Water ➡️ O₂ + Glucose + H₂O = ATP ➡️ Lack of any = AMS

Hypoglycemia Causes

-Diabetic takes too much insulin

-Diabetic does not eat

-Diabetic over-exerts

-Diabetic vomits

Hypoglycemia Signs

-Rapid onset

-Pale, clammy skin

-Tachycardia

-Seizures

-AMS or unconsciousness

Hyperglycemia Causes

-Too little insulin(inability to produce insulin or insufficient injection quantity)

-Infection

-Stress

-Increased food intake

Hyperglycemia Signs

-Slow onset (days-weeks)

-Chronic Thirst and Hunger

-Frequent urination

-Nausea

-DKA

Diabetic Ketoacidosis (DKA) Signs/symptoms

-Profoundly altered mental status

-Rapid breathing

-Acetone (fruity) breath

-Shock from dehydration

Hypoglycemia (blood glucose levels)

< 80 mg/dL

Additional AMS Assessment Questions

How episode occurred, time of onset, duration, associated symptoms, any MOI or other evidence of trauma, any interruptions to episode, seizures, or fever

• DM Hx, history of previous episodes, intake, etc.

• Are they competent to refuse

Causes of Seizure

• Hypoxia

• Stroke

• Traumatic brain injury

• Toxins

• Hypoglycemia

• Brain tumor

• Congenital brain defects

• Infection

• Idiopathic

• Epilepsy

Physical AMS assessment

• Calloused Fingertips

• Glucose Monitor

• Contusions from an insulin injection

Significant AMS

< 50 mg/dL

Hyperglycemia (blood glucose levels)

140 mg/dL

Dehydration risk

200-300 mg/dL (prolonged)

High blood glucose levels

> 500 mg/dL

LOW Glucometer Reading

< 15 mg/dL extremely low

Oral Glucose Patient Requirements

✔ History of diabetes

✔ AMS

✔ Ability to swallow / protect airway

✔ Blood sugar < 60 mg/dL

Mimics

Symptoms of Stroke, intoxication and hypoglycemia all look very, very similar

Patient Care During Seizure

• 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

Patient Care after Seizure

• 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

• Seizure usually only 1-3 minutes long

• Patient breathing adequately may be given oxygen by mask or nasal cannula

• Treat injuries patient may have sustained during convulsions

• Transport

Underlying Cause

The reason may be far worse than the symptoms they cause