Lesson 6: Altered Consciousness

What is the most common cause of altered consciousness in the dental setting?

ingestion or administration of drugs

What is pharmacosedation?

the use of drugs to calm someone down; does not have to be a prescription medication

What are predisposing factors of altered consciousness?

1. ingestion or administration of drugs
2. alcohol
3. benzodiazepines

If a patient walks into the dental office "under the influence" of alcohol for other drugs, what should you do?

1. postpone treatment
2. advise against self-administration of drugs

What three systemic problems can lead to altered consciousness?

1. diabetes mellitus
2. thyroid gland dysfunction
3. cerebrovascular accident (CVA)

What is diabetes?

A group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.

________ is the 8th leading cause of death in the U.S.

diabetes

80% of diabetics are __ years or older.

45

T/F: Morbidity and mortality from diabetes are most often related to its vascular chronic complications.

TRUE

What are the vascular chronic complications associated with diabetes?

1. atherosclerosis
2. diabetic microangiopathy (neuropathy)
3. increased incidence of periodontal disease

What is atherosclerosis?

the build up of plaque inside the arteries

T/F: Heart disease and stroke account for approximately 65% of deaths in individuals with diabetes.

TRUE

What is diabetic microangiopathy?

disease/dysfunction of one or more peripheral nerves, leading to numbness and weakness

What occurs due to diabetic neuropathy?

a. retinopathy
b. gangrene
c. nephropathy

What is the leading cause of blindness in ages 20-74?

retinopathy

T/F: In diabetic patients, gangrene affects the upper extremities. Leg amputations are 15-40x greater for a diabetic.

first statement is FALSE; second statement is TRUE

What is insulin?

a hormone made by your pancreas that allows your body to use sugar (glucose) from carbohydrates in the food that you eat for energy, or to store glucose for future use

What is the main function of insulin?

keeping your blood sugar level from getting too high or too low

What are predisposing factors of diabetes?

a. genetic disorder
b. environmental factors such as diet and toxins
c. primary destruction of Islets of Langerhans in the pancreas
d. endocrine condition such as hyperpituitarism or hyperthyroidism
e. the administration of steroids resulting in iatrogenic diabetes

List the types of diabetes.

a. Type 1 Diabetes Mellitus
b. Type 2 Diabetes Mellitus
c. Gestational Diabetes
d. Impaired Glucose Homeostasis/Impaired Glucose Tolerance
e. Uncontrolled Diabetes or Not Diagnosed

T/F: Type 1 Diabetes is formerly known as Insulin Dependent Diabetes Mellitus (IDDM) and is genetic or hereditary. It is seen more commonly in adults.

first statement is TRUE; second statement is FALSE (it is seen more in adolescents)

What role does insulin play in Type 1 Diabetes?

circulating insulin is absent and requires exogenous insulin

T/F: Most Type 2 Diabetics are dependent on insulin.

FALSE; most Type 2 diabetics are not dependent on insulin

How is Type 2 Diabetes managed?

controlled by diet, exercise, and/or medication

T/F: Obese percentage of Type 2 diabetes is 80%. Non-obese percentage of Type 2 Diabetes is 10%.

both statements are TRUE

Is the progression of Type 2 Diabetes slow?

Yes; there are minimal symptoms or asymptomatic for years with slow disease progression

What is another term for "Impaired Glucose Homeostasis"?

Prediabetes

What is "prediabetes"?

when blood sugar levels are higher than normal, but not high enough to meet the classification for diabetes

What are the repercussions of uncontrolled or undiagnosed diabetes?

a. decreased ability to fight infection
b. changes in structure and function of the blood vessels
c. inadequate blood supply to the heart

What is gestational diabetes?

abnormal result of oral glucose tolerance test during pregnancy

T/F: Women with gestational diabetes have an increased risk of developing Type 2 Diabetes.

TRUE

Name the 2 acute complications of diabetes.

1. Hyperglycemia
2. Hypoglycemia

What is hyperglycemia?

excess glucose in the blood leading to diabetic coma

What are the possible causes of hyperglycemia?

a. person who is undiagnosed
b. diabetic who fails to take medication
c. diabetic who takes insufficient medication

What is hypoglycemia?

abnormally low blood glucose levels

What are the possible causes of hypoglycemia?

a. omission or delay of meals
b. excessive exercise
c. overdose of insulin
d. accidental ingestion of wrong medication

What will the physical status of a hyperglycemic be?

flushed, dry skin, BP decreased, signs of dehydration

What will the physical status of a hypoglycemic be?

cold and wet ("clammy"), BP increased, more common acute complications

List common drugs used to treat Type 1 Diabetes.

1. rapid acting - apidra, humalog, novalog
2. short acting - regular, novalin r, humalin r
3. long acting - lantus, levimir, humulin u, exubera (inhaled)

List common drugs used to treat Type 2 Diabetes.

1. biguanides - metformin (glucophage)
2. thiazolidinediones
3. sulfonylureas (glucotrol)
4. meglitinides
5. glucosidase inhibitors

Name the 8 common oral complications of uncontrolled diabetes.

1. xerostomia
2. poor healing
3. increased incidence and severity of caries
4. candidiasis
5. gingivitis
6. periodontal disease
7. periapical abscesses
8. burning mouth syndrome

Should you utilize shorter acting or longer acting anesthetics for Type 1 Diabetics?

shorter acting

What blood glucose levels are acceptable for treatment?

70-175 mg/dL

What range of blood glucose levels are more likely to become hypoglycemic?

What range of blood glucose levels should be evaluated carefully prior to treatment with a medical consult?

>240 mg/dL

What is the A1c test?

measures the average blood glucose over the past 2-3 months

What A1c is considered normal for healthy adults?

What should be the target A1c for a diabetic patient?

What are the classic symptoms of hyperglycemia?

1. polyuria
2. polydipsia
3. polyphagia
4. blurred vision
5. loss of strength
6. marked irritability
7. headache
8. drowsiness
9. malaise
10. dry mouth and skin
11. kussmaul's respirations
12. fruity, sweet odor in the breath

What are Kussmaul's respirations?

deep, labored, either slow or rapid breathing pattern

What are the early symptoms of hypoglycemia?

1. changes in mood
2. hunger
3. nausea
4. decreased conversation

What are the later symptoms of hypoglycemia?

1. sweating
2. tachycardia
3. piloerection
4. increased anxiety
5. bizarre behavior (belligerence, poor judgement, uncooperative)
6. unconsciousness (seizures, hypotension)

T/F: Treat ALL diabetic emergencies as HYPOGLYCEMIA until shown otherwise.

TRUE!!

How should you manage a diabetic emergency in a conscious patient?

1. terminate the dental procedure
2. position patient sitting upright
3. CABs as indicated
4. definitive care - nasal cannula
5. administer oral carbohydrates (primary) - orange juice or soda or Glutose (paste/gel) - administer 3-4 oz doses over 5-10 minutes
6. recovery - observe pt for 1 hour before dismissal, if uncertain of stability, call for ride home

How should you manage a diabetic emergency in an unresponsive, conscious patient with hypoglycemia?

1. terminate the dental procedure

2. position patient sitting upright

3. CABs as indicated

4. definitive care - nasal cannula

5. administer oral carbohydrates (primary treatment)

6. summon EMS if carbohydrate does not reverse signs and proceed to secondary treatment (Glucagon 1 mg IM or IV do if EMS delayed 40 minutes or more)

7. could administer 50 ml of 50% dextrose IV if available

8. monitor vital signs every 5 minutes

9. transport to hospital for check

How should you manage a diabetic emergency in an unconscious patient with hypoglycemia?

1. terminate the dental procedure 2. position patient supine 3. CABs as indicated 4. definitive care - non-rebreather bag 5. summon EMS 6. administer oral carbohydrates (primary = glutose rubbed in vestibule) (secondary = glucagon IM or IV ONLY if EMS is delayed by 40 minutes or more) 7. seizures may occur follow procedure for seizure 8. recovery and discharge (upon regaining consciousness can give an oral carbohydrate, EMS to transport to hospital)

How should you manage a diabetic emergency in an unconscious patient with hyperglycemia?

1. terminate the dental procedure
2. position patient supine
3. CABs as indicated
4. definitive care - non-rebreather bag
5. summon EMS
6. IV infusion of 5% dextrose and water or normal saline
7. recovery and discharge

Can insulin be administered by the dental office staff to the patient in a diabetic emergency?

NO! it must be administered carefully and monitored by a medical professional only

Where is the thyroid gland?

on either side of the trachea

Which hormones does the thyroid gland produce?

thyroxin (T4), triiodothyronine (T3), and Calcitonin

What ASA status is someone with controlled hypothyroidism?

ASA II

What ASA status is someone with controlled hyperthyroidism?

ASA II if controlled
ASA III if exhibit clinical manifestations

T/F: Epi in gingival retraction cords is contraindicated in patients with hyperthyroidism. One retraction cord has about 3 cartridges worth of epi.

first statement is TRUE; second statement is FALSE (contains 12 cartridges worth of epi)

What are the two types of thyroid dysfunction?

hypothyroidism and hyperthyroidism

What is hypothyroidism?

body's tissues do not receive an adequate supply of thyroid hormones occurring as a result of thyroid failure (primary), pituitary gland dysfunction (secondary), or hypothalamus dysfunction (tertiary)

What is the end stage of hypothyroidism?

myxedema coma

T/F: Myxedema coma has a 50% mortality rate.

TRUE

What is hyperthyroidism?

heightened thyroid gland activity associated with excessive quantities of thyroid hormone

What are alternative names for hyperthyroidism?

a. thyrotoxicosis
b. toxic goiter
c. basedow's disease
d. graves' disease
e. parry's disease
f. plummer's disease

Which crisis can occur if hyperthyroidism is left untreated?

thyroid storm which can be acute and life-threatening

What are the predisposing factors for hypothyroidism?

a. idiopathic atrophy of thyroid
b. thyroidectomy or ablation following radioactive iodine therapy
c. iodine deficiency
d. inherited enzyme defect
e. hashimoto's disease (hashimoto's thyroiditis)

What are the clinical manifestations of cretinism?

a. mental retardation
b. ossification of bones
c. neurologic damage
d. skin and lips are thick
e. face is broad and puffy
f. flat nose

What are the dental implications of hypothyroidism in children?

a. poor tooth development
b. delayed tooth eruption
c. large tongue

What is the clinical evidence of hypothyroidism in adults?

a. weakness & fatigue
b. sudden weight gain (5-10 pounds)
c. upon progression: slowing of speech, hoarseness, anhidrosis, decreased taste/smell, dyspnea, anginal pain
d. myxedema --> puffy eyelids/face
e. orange-red skin color
f. thickened tongue

What are the predisposing factors for hyperthyroidism?

1. diffuse enlargement of the thyroid gland and the presence of antibodies against different fractions of the thyroid gland (Graves Disease)
2. tumors, malignancies, carcinomas

What is the clinical evidence of hyperthyroidism?

a. diaphoresis
b. exopthalmos
c. increased BP, occasional paroxysmal atrial fibrillation
d. experience mitral valve prolapse significantly more than general population
e. very sensitive to catecholamines (epi)
d. anxiety is hormonally induced, not psychological

List common thyroid replacement medications for hypothyroidism.

levothyroxine (Levo-T, Synthroid, etc.)

Name common anti-thyroid drugs for hyperthyroidism.

methimazole (Tapazole), propylthiouracil

What are the emergency signs and symptoms of hypothyroidism?

a. paresthesia
b. loss of energy
c. intolerance to cold
d. muscular weakness
e. pain in muscles and joints
f. inability to concentrate and forgetfulness
g. drowsiness
h. dry, scaly skin
i. puffy eyelids
j. hoarse voice
k. myxedema coma

What are the emergency signs and symptoms of hyperthyroidism?

a. weight loss
b. palpitations
c. dyspnea, edema
d. chest pain
e. nervousness and psychosis
f. elevated fever
g. tachycardia
h. congestive heart failure
i. exophthalmos
j. thyroid storm

What are the symptoms of thyroid storm?

a. hyperpyrexia (above 106.7 F)
b. excessive sweating
c. nausea
d. vomiting
e. abdominal pain
f. cardiovascular disturbances
g. heart failure with pulmonary edema

What is the management of thyroid dysfunction emergency in an unconscious patient with either hypo or hyper thyroidism?

1. terminate dental procedure
2. position supine
3. CABs
4. definitive care - non-rebreather bag
5. call EMS
6. IV 5% dextrose if available
7. EMS transport to hospital

What is a cerebrovascular accident?

focal neurological disorder caused by destruction of brain substance as a result of intracerebral hemorrhage, thrombosis, embolism, or vascular insufficiency

What are the three types of strokes?

1. occlusive
2. hemorrhagic
3. transient ischemic attack (TIA)

What are the occlusive strokes?

a. lacunar infarct - from poorly controlled HBP or diabetes
b. cerebral infarct - death of brain tissue from ischemia

What are hemorrhagic strokes?

results from bleeding of the arteries; major sources of apoplexy

a. subarachnoid hemorrhage (SH)

b. intracerebral hemorrhage (IH)

Define apoplexy.

unconsciousness or incapacity resulting from a cerebral hemorrhage or stroke

Define aneurisms.

excessive localized enlargement of an artery caused by a weakening of the artery wall

What is a transient ischemic attack?

tiny, recurrent strokes that usually last less than 30 minutes; they are a sign of CV disease; can be often treated with aspirin

What are predisposing factors for strokes?

a. HBP
b. diabetes
c. cardiac enlargement
d. hypercholesteremia
e. oral contraceptives
f. smoking
g. family history and genetics
h. physical inactivity

What is the ASA status of someone who had a CVA more than 6 months ago?

ASA III

What is the ASA status of someone who had a CVA within the past 6 months?

ASA IV

What are the clinical manifestations of CVA?

neurological
a. paralysis on one side of the body
b. difficulty breathing and swallowing
c. inability to speak or slurred speech
d. loss of bladder and bowel control
e. pupils are inequal in size
f. flushed face and bounding pulse

T/F: Infarction symptoms are gradual onset. Embolism symptoms are abrupt.

both TRUE

T/F: The symptoms and signs for hemorrhage as well as transient ischemic attack are abrupt.

TRUE

What is the management of CVA in a conscious patient?

a. terminate procedure b. position patient in semi fowler recommended head and trunk raised 30 degrees c. CABs d. monitor vital signs e. definitive care - nasal cannula f. summon EMS

What is the management of CVA in an unconscious patient?

1. terminate dental procedure
2. position patient supine upon loss of consciousness
3. CABs
4. monitor vital signs every 5 minutes (BP elevated, pulse may be normal)
5. definitive care - non rebreather bag, if BP goes up --> semi-fowler position to relieve intracranial pressure, supine if CPR needed, 5% dextrose IV/water/saline if possible
6. summon EMS

What are the symptoms of hemorrhage?

a. sudden violent headache
b. nausea and vomiting
c. chills and diaphoresis
d. dizziness and vertigo
e. neurological signs/symptoms
f. loss of consciousness

What are the symptoms of transient ischemic attack?

a. transient numbness and weakness of extremities
b. transient monocular blindness
c. consciousness may be unimpaired, although processes may be dulled

What are the symptoms of infarction?

a. TIA frequently preceding
b. headache, usually mild
c. neurological signs/symptoms
d. transient monocular blindness