Module 5: Altered Consciousness

Altered consciousness is a clinical finding—not a diagnosis. It refers to a change in the mental state that can affect perception, cognition, and awareness. 70

First response to any change in consciousness approach;

1. Stop care: cease dental treatment immediately

2. Position & Assess: position the patient appropriately; assess responsiveness

3. Assess C-A-B: Circulation, Airway, Breathing

4. Definitive Management: Provide condition-specific care and activate EMS when indicated.    

Diabetic Emergencies

• The most likely altered-consciousness emergency you will encounter in the dental setting is hypoglycemia.

1. HYPOglycemia - low glucose; sudden onset, adrenergic signs, behavior change.

2. HYPERglycemia - high glucose; gradual onset, dehydration, systemic illness.

• Insulin helps lower blood glucose - too much leads to hypoglycemia.

• Glucagon helps raise blood glucose - the bodys natural counter-regulatory hormone.

• The brain needs a steady glucose supply - too little causes rapid behavioral and consciousness changes.

Before Treatment: Ask Questions

1. When did you last eat - what did you last eat?

2. What is your usual glucose range?

3. Have you ever needed help for severe hypoglycemia?

4. When did you last take insulin or diabetes medication?

5. Do you use a CGM or have a glucometer with you?

6. Do you carry glucose tablets or prescribed glucagon?

Blood glucose below 70 mg/dL is considered low. Four common factors; medication, food, activity, alcohol / Illness.

Conscious Patient with Suspected Hypoglycemia

15-15 rule: administer 15 grams of fast-acting carbohydrates, wait 15 minutes, and then recheck blood glucose levels. If the blood glucose remains low, repeat the process.

Severe Hypoglycemia: Cannot Swallow or Unconscious

1. Activate EMS / Call 911

2. Support CBAs; provide BLS as needed

3. Administer oxygen per training/protocol

4. Use prescribed glucagon if trained or permitted

5. Monitor continuously until EMS assumes care

High glucose emergencies typically develop over hours to days - not minutes. Four common factors; Missed or insufficient insulin relative to glucose load, Illness, stress, carbohydrate intake.

Recognizing Significant Hyperglycemia (gradual onset + dehydration + systemic illness signs)

1. Increasing thirst (polydipsia) and frequent urination (polyuria)

2. Nausea, vomiting, abdominal discomfort may occur

3. Fruity/acetone breath - may indicate diabetic ketoacidosis (DKA)

4. Dry mouth/ dehydration signs; fatigue, weakness, blurred vision

5. Deep or labored breathing

6. Progressive confusion, drowsiness, or decreased consciousness = severe - activate EMS

Clinical Check: Diabetes

A patient with diabetes becomes shaky and confused 20 minutes into treatment. They took their usual insulin and ate only a few bites of breakfast. They are awake, sweating, trembling, irritable, and can swallow.

1. What emergency is most likely? Hypoglycemia: The patient's symptoms suggest a significant drop in blood sugar levels due to insufficient food intake relative to their insulin dosage.

2. What is your immediate treatment? Administer a rapid-acting source of glucose, such as oral glucose gel, or give the patient some juice or a sugar-containing snack to raise their blood sugar levels quickly.

3. What finding would change this to EMS-level? If the patient becomes unresponsive or unable to swallow, this could necessitate EMS-level intervention due to the risk of airway obstruction or severe hypoglycemia requiring intravenous glucose administration.

Thyroid Dysfunction

1. Severe hypothyroidism can lead to myxedema coma (profound slowing of all body systems)

2. Severe hyperthyroidism can lead to thyroid storm (dangerous acceleration of all body systems)

• Signs of thyroid dysfunction may include unexplained weight fluctuations, cold intolerance, changes in energy levels, altered mood, and cognitive disturbances, which can further impact overall consciousness.

Myxedema Coma: Recognition

• Altered mental status: confusion

• Hypothermia (subnormal temperature)

• Bradycardia

• Hypotension

• Slow / inadequate ventilation

Myxedema Coma: Response

1. Stop treatment; activate EMS immediately

2. Keep the patient warm; avoid unnecessary temperature extremes

3. Assess and support airway, breathing, and circulation

4. Monitor vital signs and level of responsiveness continously

5. Provide BLS and oxygen as indicated by training and protocol

6. Prepare for further deterioration while waiting for EMS arrival

Hyperthyroidism: What Might You Notice Before an Emergency?

• Acceleration of body functions

• Heat intolerance / sweating; tremor

• Nervousness / irritability; tachycardia or palpitations

• Weight loss despite appetite; frequent bowel movements

• History of Graves disease or antithyroid medication

• Increased sensitivity to heat and complaints of excessive sweating, often linked to hyperthyroid conditions.

• Nausea, vomiting, diarrhea may occur

• Possible heart failure, hypotension, or cardiovascular collapse

Thyroid Storm: Response

1. Stop dental treatment immediately

2. Activate EMS / Call 911

3. Assess and support ABC’s; oxygen/BLS as indicated

4. Position for comfort while maitaining airway and circulation

5. Monitor vital signs continously; collect emergency history

6. Transer for definitive medical management

Clinical Check: Thyroid Emergency

A patient with Graves disease becomes acutley ill during treatment: very anxious, confused, HR 148/min, hot and sweaty skin, temperature of 103 F, nausea and increasing agitation.

1. Which thyroid emergency fits this pattern? This presentation is consistent with Thyroid Storm, a life-threatening condition characterized by severe hyperthyroidism and marked clinical symptoms.

2. What is your first action after stopping treatment? Contact EMS

3. What information should you give EMS? Patient's history of Graves disease and recent treatment, Current vital signs: heart rate (HR 148/min), temperature (103 F), Clinical symptoms: anxiety, confusion, hot and sweaty skin, nausea, and increasing agitation, Time of onset for current symptoms and any previous episodes if applicable.

Stroke / Cerebrovascular Accident

• Sudden neurologic change; any abrupt focal deficit is a stroke until proven otherwise.

• B.E.F.A.S.T.

• Call 911

Stroke Clues

• Face drooping: Ask the person to smile; does one side of the face droop?

• Arm weakness: Ask the person to raise both arms; does one arm drift downward?

• Speech difficulty: Ask the person to repeat a simple phrase; is their speech slurred or strange?

• Suden severe headache

• Sudden visual disturbance in one or both eyes

• Sudden dizziness, trouble walking, or loss of coordination

Stroke Response

1. Stop treatment

2. Call 911

3. Time; document symptom onset or last known to be well

4. ABC’s: Assess airway, breathing, circulation

5. Position; mimimize unnecessary movement

6. Monitor vital signs and responsiveness, be ready for deterioration

*****Hypoglycemia can mimic a stroke*****