Understanding Altered Mental Status and Diabetic Emergencies

Circulation and Hypoperfusion

Simultaneously, assess for indicators of hypoperfusion (inadequate blood flow to the tissues). If the circulatory system is failing to deliver oxygen and glucose to the RAS, mental status will deteriorate rapidly.

Determining Baseline Mental Status

A major challenge in assessing AMS is determining what is "normal" for the patient. This is known as the baseline mental status.

To categorize a patient's initial response quickly, responders use the AVPU scale:

• Alert: The patient is awake and responsive.
• Verbal: The patient responds only to spoken commands.
• Pain: The patient responds only to painful stimuli.
• Unresponsive: The patient does not respond to any stimuli.

Exam Tip: Determining baseline status can be particularly difficult in pediatric patients, as children answer questions and interact differently than adults.

For a more precise, quantitative measurement of a patient's level of consciousness, responders utilize the Glasgow Coma Scale (GCS). This tool allows for accurate documentation of changes in mental status over time, which is essential for communicating patient trends to hospital staff.

Diabetic Emergencies

Diabetes is a frequent cause of AMS. In a healthy body, the pancreas secretes insulin when blood glucose levels exceed 90 mg/dL. Insulin acts like a "key" that unlocks cells, allowing glucose (the body's primary energy source) to enter and be used for fuel.

In diabetic patients, this process fails in one of two ways:

• Type 1 Diabetes: The pancreas produces little to no insulin.
• Type 2 Diabetes: The body's cells become resistant to the insulin being produced.

Hypoglycemia vs. Hyperglycemia

When managing a diabetic emergency, you must differentiate between low and high blood sugar, though in the field, treating for low blood sugar is often the safest priority.

Field Management of Hypoglycemia

If a patient has a history of diabetes, presents with AMS, and is awake enough to swallow, you may administer oral glucose.

Warning: Never administer oral glucose to a patient who cannot protect their airway, as this poses a high risk of aspiration. If the patient is unconscious or unable to swallow, prioritize airway management and request Advanced Life Support (ALS).

Secondary Assessment and Other Causes

If the primary assessment is stable, proceed to the secondary assessment, which involves a comprehensive body system exam and a detailed history.

Key steps include:

• Interviewing bystanders: Ask what is "normal" for the patient and if they witnessed the onset.
• Reviewing medical history: Look for medic alert bracelets, wallet cards, or implanted insulin pumps.
• S.A.M.P.L.E. History: Specifically look for a history of diabetes and recent medication use.

Other Neurological Emergencies

Beyond diabetes, several other conditions can cause AMS:

1. Seizures: Caused by irregular electrical activity in the brain. A tonic-clonic seizure involves a rigid phase (tonic) followed by violent jerking (clonic). Status epilepticus (seizures lasting >10 minutes or multiple seizures in a row) is a high-priority emergency.
2. Stroke: Resulting from brain tissue death due to oxygen deprivation. This can be ischemic (a clot) or hemorrhagic (a bleed). Use the Cincinnati Prehospital Stroke Scale to assess for facial droop, arm drift, and abnormal speech.
3. Syncope: A brief loss of consciousness with spontaneous recovery. Causes range from cardiovascular issues (like bradycardia) to environmental factors (like heat stroke).

Critical Note: In cases of suspected stroke, the most important factor is the time of onset. Rapid transport to a facility capable of managing stroke is the priority.