Signs and symptoms
- Presence of insulin stored in the refrigerator.
- Bruising at insulin injection site on the abdomen.
- Abnormal blood glucose level.
- Normal blood glucose is 80-120 mg/dl.
- Hyperglycemia, >120 mg/dl, caused by a lack of insulin. High blood sugar level even after long time without food.
- Severe hyperglycemia
- Excess urination, with glucose in urine, leads to dehydration.
- Frequently thirst, urination and hunger.
- Fruity or acetone odor in breath.
- Hypoglycemia, <60 mg/dl, caused by over administration of insulin.
- Severe hypoglycemia triggers epinephrine release.
- Pale, cool and clammy skin.
- Warm sensation.
- Dehydration caused by excess glucose in the urine that causes large water loss through osmosis.
Frequent thirst, urination, and hunger.
- Patient skipped a meal, medication, or had unusually vigorous activity.
General altered mental status
- Anxiousness or combativeness.
- Trauma that indicates injury to the central nervous system.
- Mechanism of injury indicates trauma such as falls, even if it's from a medical condition.
- Unequal pupils that indicate head injury.
- Discoloration around the eyes.
- Discoloration behind the ears.
- Flexion or extension.
- Drug abuse.
- Pinpoint pupils.
- Dilated pupils.
- Suspect hazardous gas or poisoning if multiple patients have altered mental status.
- Inadequate breathing, which leads to hypoxia.
- Signs of hypoxia.
- Shock and hypoperfusion.
- Cool and clammy skin with pallor.
- Look for internal bleeding such as rigidity and tenderness in the abdomen.
- Look for external bleeding.
- Edema in the lower extremities or posterior sacral region which indicates congestive heart failure.
- Extreme tachycardia >160 that prevents the proper refilling of blood to the left ventricle.
- Inadequate perfusion, heart rate, blood pressure.
- Seizure signs
- Bitten lips or tongue.
- History of seizures.
- Stroke: weakness or paralysis on one side.
- Stabilize the spine if you suspect the mechanism of injury indicates trauma such as a fall.
- Open and maintain airway because patients with altered mental status can not protect their airway.
- Clear any obstructions in the airway, as it may be the cause for the altered mental status from hypoxia.
- PPV if breathing is inadequate.
- All altered mental status patients must receive high flow oxygen to ensure adequate perfusion to the brain.
- Place in recovery position to avoid aspirations.
- Oral glucose for hypoglycemic patient.
- Do not administer glucose for patients with head injury or stroke, because when glucose moves into the brain, it will increase the osmotic pressure of the brain and cause any swelling to worsen.
- Rehydration treatment for those dehydrated from hyperglycemia. Follow medical direction.
Medical conditions and mechanisms
- Conditions that can cause altered mental status.
- Drug abuse or poisoning.
- Head trauma.
- Shock, hypoxia, hypoperfusion.
- Type I diabetes: acquired during childhood. Pancreas does not produce any insulin. Patient need to have daily insulin intake.
- Type II diabetes: developed in adulthood. Either the pancreas does not secrete enough insulin or the body does not respond to insulin secretions. Patient takes oral hypoglycemic drugs that stimulate insulin production and the body's response to it.
- Hyperglycemia in diabetic patient is when there's a lack of insulin, blood sugar level rises. While brain cells can access this blood glucose without insulin, the body cells are starving because they can't get the blood glucose without insulin. In a normal person, blood glucose rises after a meal (to 120-140 mg/dl), but falls afterwards. Diabetic patients with inadequate insulin have high blood sugars even after an 8-12 hour fast. Symptoms are slow to show because the brain is getting enough oxygen, and it takes a long time for DKA or HHNS to kick in.
- Diabetic ketoacidosis (DKA) occurs after long period of severe hyperglycemia. Caused by metabolism of fat, which makes an acid byproduct. Leads to altered mental status and eventually coma. Commonly seen in type I diabetics. The ketone bodies produced during their metabolism cause their breath to smell fruity or of an acetone odor.
- Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is similar to DKA, but occurs in type II diabetics, who can manage to secrete some insulin, which helps to prevent the metabolism of fat. Thus, no acidosis occurs, but the patient is still dehydrated, which leads to altered mental status and seizures.
- Hypoglycemia in diabetic patient is when blood glucose level is too low. This can be caused by administration of too much insulin. When the body cells take up all the blood sugar, there's none left for the brain. Therefore, the patient suffers from altered mental status. Symptoms occur very fast because the brain is very sensitive and as soon as it doesn't get enough sugar, symptoms will kick in.
- Insulin: chemical secreted by the pancreas that promotes cells to take up blood glucose, and thus, lowers blood glucose level.
- Glucagon: chemical secreted by the pancreas that promotes the release of glucose into the blood stream, and thus, raises blood glucose level.
- Epinephrine (adrenalin): released by the adrenal glands that stops insulin release and promotes release of glucose into the blood.
- The 3 Ps of diabetes:
- Polydipsia: frequent thirst.
- Polyuria: frequent urination.
- Polyphagia: feeling hungry.
- IDDM: insulin-dependent diabetes mellitus, or type I.
- NIDDM: non-insulin-dependent diabetes mellitus, or type II.