Altered Consciousness Flashcards
Two acute complications of diabetes:
Hyperglycemia
Hypoglycemia: blood glucose less than 50 mg/dL
Manifestations of arteriosclerosis in chronic complications of diabetes:
Heart: angina and MI CNS: stroke/CVA Kidneys: glomerulosclerosis Lower extremities: gangrene High blood pressure
Manifestions of microangiopathy in chronic complications of diabetes:
Eye: diabetic retinopathy (leading cause of blindness)
Kidney: arteriolar nephrosclerosis
Extremities: gangrene
Neuropathy
Classification of type 1 diabetes:
- destruction of beta cells of pancreas (autoimmune)
- more common in adolescents, usually non obese
- circulating and exogenous insulin required
- more severe than type 2
Classification of type 2 diabetes:
- genetic interactions regulated by weight, exercise, diet, and stress but is not immune
- patients endogenous insulin prevents ketoacidosis but does not meet increased needs
3 (triad) symptoms of undiagnosed diabetes:
- polydipsia (thirst)
- polyphagia (appetite)
- polyuria (urination)
Important dental considerations for Type 1 diabetic:
- early appts
- normal dietary habits
- use a short lasting anesthetic
For a pre-op IV sedation diabetic type 1 patient:
Do not eat; hold insulin and schedule early in morning
For a surgical post-op diabetic patient:
- reduce insulin if food is reduced
- check glucose more often
- antibiotics for type 1 and 2 if extensive surgical procedure
Clinical SYMPTOMS of hyperglycemia in T1 diabetic:
- the three polys (polydipsia, polyphagia, polyuria)
- weight loss
- headache, blurred vision, mental stupor
- fatigue to diabetic coma
Clinical SIGNS of hyperglycemia in T1 diabetic:
red, hot, and dry face
deep and rapid respirations, rapid heart rate, hypotensive
fruity, sweet breath- diabetic ketoacidosis
Early stage of hypoglycemia:
- difficult conversation, calculations, mood change
- hunger, nausea
Advancing early stage of hypoglycemia:
- skin is cold and wet (hyperglycemia was hot, dry)
- sweating, goosebumps (piloerection), tachycardia, anxiety, resembles intoxication
Late stage of hypoglycemia:
- unconscious due to hypoglycemic come or insulin shock
- seizures
- hypotension
Blood glucose normal levels (what level does your brain need and at what level do you exceed renal absorption?):
50-150 mg/dl
brain needs 50 mg/dl
above 180 mg/dl, exceeds renal absorption
What occurs when glucose exceeds 180 mg/dl?
Glucose is excreted in the urine. It causes the excretion of water, Na, K –> polyuria, polydipsia and dehydration
What occurs in the absence of glucose (or when there’s not insulin to help uptake glucose into cells)?
muscle breaks down ketone bodies, acetone is a by-product that causes fruity breath; diabetic ketoacidosis
What happens when ketones exceed proper blood levels?
metabolic acidosis (7.3 and below), ketones excreted
What does the body due to compensate for a metabolic acidosis and what are these called?
respiratory alkalosis (hyperventilate) Kussmaul's respirations
Management of a hyperglycemic patient:
p: Supine
abc: Airway most important
d: Activate EMS, O2
Management of conscious, hypoglycemic patient:
(patient seems intoxicated) If conscious: p: upright abc: d: oral glucose (orange juice, soda, candy bar) patient CAN go home with escort
Management of conscious but unresponsive hypoglycemic patient:
patient refuses to ingest oral carbs or can't ingest 1. Activate EMS 2a. 50 ml of 50% dextrose IV (ONLY IV) or 2b. 1 mg glucagon IM or IV Monitor vitals every 5 mins 3. Discharge with EMS
Management of unconscious hypoglycemic patient:
p: supine
abc: airway most important, no chest compressions
d: activate EMS
-administer IV 50% dextrose
-IM or IV glucagon
- .5mg of epinephrine (unless they have CV disease)
- decorative icing as last resort
Oral carbs once consciousness is regained, be prepared for hypoglycemic seizures, discharge with EMS
What is the end stage of untreated hypothyroidism and what is a drug used to treat hypothyroidism?
myxedema coma
Synthroid- L-thyroxine
Symptoms of hypothyroidism:
- parasthesia
- weakness and fatigue
- cold intolerance
- constipation and weight gain
Signs of hypothyroidism:
- pseudomyotonic reflex
- Hypothermia with dry, scaly skin and puffy eyelids
- menorrhagia (abnormal periods)
- hoarse voice, thick tongue, slow speech
Three types of drugs to be cautious in prescribing to patient with hypothyroidism:
- Opioid analgesics 2. Sedative-hypnotics 3. Antianxiety
Another name for hyperthyroidism:
Graves disease
Symptoms of hyperthyroidism:
- weight loss and weakness
- nervousness and sweating
- loose stools
- heat intolerance (hypo is cold intolerance)
Signs of hyperthyroidism:
- tachycardia, wide pulse pressure
- fever, warm, moist, soft skin
- tremor
- exophthalamos and staring
3 treatments for hyperthyroidism:
- Propylthiouracil
- subtotal thyroidectomy
- radioactive iodine ablation of gland
characterization of thyroid storm:
- hyperpyrexia (really high fever)
- sweating, stupor, coma
- agitated and disoriented
- A Fib and tachycardia
use of anesthetics in hyperthyroid patient:
anesthetics with vasoconstrictors, but use the least concentrated effective solution and smallest volume; AVOID atropine; contraindicated to use racemic epinephrine for gingival retraction
Management of thyroid patients:
P -conscious: upright -unconscious: supine ABC D- if patient does not become conscious with positioning, activate EMS, administer O2, vitals, IV infusion
2 common causes of cerebral infarction (CVA) and two patients at higher risk:
- Atherosclerosis and thrombosis (81% of CVAs) (embolisms account for 7%) (intracranial hemorrhage 13%)
- patients with high BP and diabetes mellitus
Common sites for embolism:
Heart (A. fib, MI, prosthetic and path valves) Neck veins (carotid bifurcation)
Characterize the two types of intracranial hemorrhages:
- subarachnoid- w/in subarachnoid space
- intracerebral- w/in brain parenchyma
Occurs most often when BP is elevated
two sources of intracranial hemorrhage:
- ruptured arterial aneurysms
2. hypertensive vascular disease
Predisposing factors for cerebrovascular accident:
- high BP (greatest risk)
- diabetes
- cardiac enlargement
- hypercholesterolemia
- smoking
- history of CVA
When can a patient have elective dental treatment following a CV accident?
- after 6 months, but if there is emergency, treat with medications and invasive procedures at hospitals
- morning appts, use local with epi with caution, oral or nitrous sedation
- be cautious of anticoagulants
manifestations of transient ischemic attack:
1/2. abrupt onset but rapid recovery
- transient numbness and weakness of contralateral extremities (“pins & needles”)
- transient monocular blindness
manifestations of infarction:
- gradual onset (TIA is abrupt onset)
- TIA precedes
- headache limited to side of infarction
- paralysis on one side of body (facial asymmetry) (pupils uneven in size)
- difficulty breathing, swallowing, unable to speak or slurred speech (aphasia)
- loss of bladder/bowel control
manifestations of embolism:
-abrupt onset with mild headache before signs and symptoms
manifestations of cerebral hemorrhage:
- abrupt onset of signs and symptoms (seconds)
- sudden and VIOLENT headache (your brain is bleeding, duh)- localized becoming generalized
- nausea and vomiting
- chills and sweating
- dizziness and vertigo
- half of patients lose consciousness
management of CV accident (page 12-13)
P: Conscious- upright or semi-supine
ABC: BLS as needed
Vitals: Elevated BP, pulse rate normal or elevated and bounding; monitor every 5 mins
D: Activate EMS, O2, No CNS depressants (so NO nitrous oxide)– read page 13
