Download Unit 6 Altered Levels of Consciousness

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Unit 6 Altered Levels of Consciousness
Learners should be able to:
6.1 Define shock
Ref: AAOS 2009: Chapter 7
Shock occurs when the body’s tissues do not receive enough oxygenated blood.
6.2 State the primary causes of shock
To understand shock, think of the circulatory system as having three components: a working
pump (the heart), a network of pipes (blood vessels) and an adequate amount of fluid (the
blood) pumped through the pipes. Damage to any of the components can deprive tissues of
oxygen-rick blood and produce the condition known as shock.
6.3 List the signs and symptoms of shock
The signs of shock include the following:
 Altered mental status
 Agitation
 Anxiety
 Restlessness
 Confusion
 Pale, Cold and clammy skin, lips and nail beds
 Nausea and vomiting
 Rapid breathing
 Unresponsiveness (when shock is severe)
As a casualty deteriorates, their breathing and pulse rate will increase whilst their level of
consciousness will decrease. It is important to regularly assess these vital signs to recognise
whether your casualty’s condition is becoming worse.
6.4 Outline the treatment of a patient in shock
Even if there are no signs of shock, you should still treat seriously injured and suddenly ill
casualties for shock.
1. Place the casualty on his or her back
2. Raise the legs approximately 30cm (if spinal injury is not suspected). Raising the legs
allows the blood to drain from the legs back to the heart
3. Place blankets under and over the casualty to keep the casualty warm
6.5 Outline how monitoring vital signs can indicate the condition of a patient
Vital signs are outward signs of what is going on inside the body. They include pulse;
respiration; skin colour; temperature and condition (plus capillary refill in infants and
children) pupils and blood pressure.
Evaluation of these indicators can give valuable information. The first set of measurements
you obtain are called the baseline vital signs. You can gain even more valuable information
when you repeat the vital signs and compare them to the baseline measurements. This allows
you and other members of the patient’s health-care team to see trends in the patient’s
condition and to respond appropriately.
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Another sign that gives important information about a patient’s condition is mental status. It
is not considered one of the vital signs; however, whenever you take the vital signs, you
should also assess the patient’s mental status. (See initial assessment-unit one)
6.6 List the functions of the nervous system
http://en.wikipedia.org/wiki/Nervous_system
Anatomy of the Nervous System
If you think of the brain as a central computer that controls all bodily functions, then the
nervous system is like a network that relays messages back and forth from the brain to
different parts of the body. It does this via the spinal cord, which runs from the brain down
through the back and contains threadlike nerves that branch out to every organ and body part.
When a message comes into the brain from anywhere in the body, the brain tells the body
how to react. For example, if you accidentally touch a hot stove, the nerves in your skin shoot
a message of pain to your brain. The brain then sends a message back telling the muscles in
your hand to pull away. Luckily, this neurological relay race takes a lot less time than it just
took to read about it.
Considering everything it does, the human brain is incredibly compact, weighing just 3
pounds. Its many folds and grooves, though, provide it with the additional surface area
necessary for storing all of the body's important information.
The spinal cord, on the other hand, is a long bundle of nerve tissue about 18 inches long and
¾ inch thick. It extends from the lower part of the brain down through spine. Along the way,
various nerves branch out to the entire body. These are called the peripheral nervous system.
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Both the brain and the spinal cord are protected by bone: the brain by the bones of the skull,
and the spinal cord by a set of ring-shaped bones called vertebrae. They're both cushioned by
layers of membranes called meninges as well as a special fluid called cerebrospinal fluid.
This fluid helps protect the nerve tissue, keep it healthy, and remove waste products.
6.7 Define altered level of consciousness
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Not oriented
Doesn’t follow commands
Needs persistent stimuli to achieve state of alertness
Alterations in level of consciousness can be gauged on a continuum:
Fully Alert ------------------------- comatose
Altered levels of consciousness (ALC) are among the most common problems in general
medicine. It is estimated that over 5% of admissions to the emergency wards of large
municipal hospitals are due to conditions that cause a disorder of consciousness.
Altered levels of consciousness include a spectrum of disorders that range from mild
confusion to deep coma. It should be emphasized that these conditions are not disease entities
in themselves, but rather manifestations of a wide variety of disorders that may be transient or
prolonged, mild or profound. As yet, there has been no standard nomenclature to define and
classify the different states of ALC, although progress is being made in that direction. For
this reason, when confronted with such a patient, the physician should supply a description of
the patient’s condition and behaviour and the types of stimuli employed in attempts at
arousal. There is general agreement on the various levels of impaired consciousness and in
their definitions. This also requires definitions of normal consciousness and its normal
counterpart, sleep. The reaction of the patient to verbal and painful stimuli has been helpful in
determining the level of consciousness.
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Structural: brain lesions that destroy tissue or occupy space that is normally
occupied by the brain: Epilepsy; Tumors; Trauma
Cardiovascular: temporary or permanent interruption to the blood supply to the
brain, Shock ...
Metabolic: abnormally high or low levels of circulating metabolites: Hypoxia,
Hypoglycemia, Hyperglycemia, Renal failure (uremia), Liver failure, Infection
(sepsis)
Environmental: external factors that cause deterioration of central nervous system
function: Overdose, Toxins
Behavioral: abnormal mental status that results from internal factors: Psychiatric
disorders
6.8 List the causes of altered level of consciousness
A - alcohol, acidosis, anoxia
E - epilepsy, environment
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I - insulin (diabetes)
O - overdose
U - uremia (metabolic), underdose
T - trauma, toxins, tumors
I - infection (sepsis)
P - psychiatric disorders
S - stroke
GOLDEN RULE:
Altered level of consciousness is characteristic of nervous system dysfunction and warrants
thorough examination to rule out all possible causes.
http://www.lbfdtraining.com/Pages/emt/sectionb/aloc.html
6.9 Differentiate between concussion and compression
Concussion - a temporary disturbance of brain function caused by a blow to the head or
neck.
Signs & symptoms
• Partial or complete loss of consciousness, usually of short duration
• Shallow breathing
• Nausea and vomiting when regaining consciousness
• Casualty says she is ‘seeing stars’
• Loss of memory of events immediately preceding and following the injury
Compression – excess pressure on some part of the brain causes by a buildup of fluids inside
the skull.
Signs & symptoms
• Decreasing level of consciousness
• Unconsciousness from the time of injury, may be deeply unconscious
• Nausea and vomiting
• Unequal size of pupils
• One or both pupils don’t respond to light
http://www.cpr-pro.com/fa_head_injuries_firstaid.html
6.10 Define fainting
Fainting is loss of consciousness caused by a temporary lack of oxygen to the brain. Fainting
may be preceded by dizziness, nausea, or a feeling of extreme weakness. When a person
faints, the loss of consciousness is brief. The person will wake up as soon as normal blood
flow is restored to the brain. Blood flow is usually restored by lying flat for a short time. This
position puts the head on the same level as the heart so that blood flows more easily to the
brain. A fainting episode may be completely harmless and of no significance, but it can be a
symptom of a serious underlying disorder. No matter how trivial it seems, a fainting episode
should be treated as a medical emergency until the cause is determined.
6.11 List the signs and symptoms of a faint
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http://www.medicinenet.com/fainting/symptoms.htm
Fainting is the partial or complete loss of consciousness with interruption of awareness of
oneself and ones surroundings. When the loss of consciousness is temporary and there is
spontaneous recovery, it is referred to as syncope or, in nonmedical terms, fainting. Syncope
accounts for one in every 30 visits to an emergency room. It is pronounced sin-ko-pea.
Syncope is due to a temporary reduction in blood flow and therefore a shortage of oxygen to
the brain. This leads to lightheadedness or a "black out" episode, a loss of consciousness.
Temporary impairment of the blood supply to the brain can be caused by heart conditions and
by conditions that do not directly involve the heart.
Non-heart Causes: Syncope is most commonly caused by conditions that do not directly
involve the heart. These conditions include:
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Postural hypotension: Drop in blood pressure due to changing body position to a more
vertical position after lying or sitting;
Diseases of the nerves to the legs in older people (especially with diabetes or
Parkinson's disease) when poor tone of the nerves of the legs draws blood into the
legs from the brain.
High altitude.
Fainting after certain situations (situational syncope) such as: Blood drawing,
Urinating, Defecating , Swallowing or Coughing that trigger a reflex of the
involuntary nervous system that slows the heart and dilates blood vessels in the legs
and cause one to feel nausea, sweating, or weakness just before fainting.
Heart Causes: Heart conditions that can cause syncope or fainting due to temporary loss of
consciousness include:
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Abnormal heart rhythms (heart beating too fast or too slow).
Abnormalities of the heart valves
High blood pressure in the arteries supplying the lungs (pulmonary artery
hypertension).
Tears in the aorta (aortic dissection).
Widespread disease of the heart muscle
Medications can cause fainting by altering blood pressure or by affecting the heart.
6.12 Outline the treatment of a patient with altered level of consciousness
ALC is a medical emergency. As there is usually nothing an onlooker can do to treat the
cause, the best advice is to call 999 or 112 and get the person to the hospital as soon as
possible. It should be remembered, however, that even minor changes such as slurring words
or unsteadiness could be an early sign of impending problems that should be investigated. Do
not wait for the person to “pass out” before seeking medical care.
After contacting the ambulance, there are some things that can be done to help keep the
person safe until help arrives. For example, if the person does not respond when you shake
them or yell their name, check to make sure they are still breathing, and that they have a
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pulse. If they do not, begin cardiopulmonary resuscitation (CPR). If heat stroke is a
possibility, get the person into the shade or an air-conditioned area immediately. If there is
ice available (or even cold soft drink cans), place it in the groin area and under the neck. If
you know that the probable cause of ALC is type II diabetes, provide the person with sugar as
soon as possible. The best way to provide this sugar is through a paste that can be applied to
the gums (called Glucagon, among other things). If this paste is not available, regular table
sugar can also be placed under the lips and against the gums. The blood vessels in this area
are very close to the surface, and readily absorb the sugar, getting it into the blood system and
to the brain very quickly. If the person is having a seizure, do not touch them unless it is
absolutely necessary to help them avoid injury. If possible, open their collar, remove ties or
other constricting things from around the neck and unbutton their shirt. Never try to force
anything into the mouth. Remove from the area any objects such as chairs or tables that the
person might strike, thereby further injuring themselves. Do not attempt to restrain the person
in any way. When the seizure has stopped, place the person on their side in the recovery
position. Look around the area for any pill or chemical containers. This will give the
healthcare team valuable clues about overdose, poisoning, or medication interaction as cause
for the ALC.
Self care measures for ALC are general, and consist mainly of ways to prevent the various
causes of ALC. Carefully following the treatment regimens for diseases such as diabetes,
maintaining and using safety equipment, watching your diet for too much cholesterol, and
lowering your blood pressure if needed are all ways to care for yourself and prevent various
possible causes of ALC.
Your doctor is the best source of information on the drug treatment choices available to you.
Other therapies available for treating ALC are specific to the underlying condition.
Surgery is used to relieve pressure in the brain from a developing mass. A growing mass,
which can take many forms (i.e., bleeding from a stroke or aneurysm, abscess from an
infection, a tumor or swelling related to trauma), can press on the brain and cause ALC. If
this is the case, your doctor will order surgery to remove the offending mass.
If surgery is necessary, a craniotomy will most likely be done. A craniotomy is a surgical
method of cutting open the skull to gain access to the brain. After anesthesia is given and the
patient is asleep, the surgeon will cut a flap in the skin to expose the bone of the skull. They
will then usually drill a number of holes is the skull and use a specialized saw to connect
them. The bone flap is then removed, exposing the brain. What happens next will depend on
the underlying cause of ALC. If it is an aneurysm, then it may either be clipped, or a special
reinforcing fabric will be placed around it to keep it from getting bigger. If the cause is
bleeding into the brain or abscess, the surgical team will remove it from the area. In other
cases, a tumor may be removed.
Following surgery, the patient is usually admitted to an intensive care unit where vital signs
and pressure inside the skull can be closely monitored. Medications are usually given to limit
the chance for infection and seizures after surgery. The person will also be watched closely
for changes in level of consciousness and weakness or loss of speech that often signal
problems. Frequently the person will only stay in the ICU for about 24 hours. Depending on
the outcome, the person may be released home or sent to a rehabilitation hospital for further
treatment.
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6.13 Define diabetes and epilepsy and outline appropriate treatment
Diabetes is a condition that occurs when the body can't use glucose (a type of sugar)
normally. Glucose is the main source of energy for the body's cells. The levels of glucose in
the blood are controlled by a hormone called insulin, which is made by the pancreas. Insulin
helps glucose enter the cells.
In diabetes, the pancreas does not make enough insulin (type 1 diabetes) or the body can't
respond normally to the insulin that is made (type 2 diabetes). This causes glucose levels in
the blood to rise, leading to symptoms such as increased urination, extreme thirst, and
unexplained weight loss.
After a meal, a portion of the food a person eats is broken down into sugar (glucose). The
sugar then passes into the bloodstream and to the body's cells via a hormone (called insulin)
that is produced by the pancreas. Normally, the pancreas produces the right amount of insulin
to accommodate the quantity of sugar. However, if the person has diabetes, either the
pancreas produces little or no insulin or the cells do not respond normally to the insulin.
Sugar builds up in the blood, overflows into the urine and then passes from the body unused.
Over time, high blood sugar levels can damage:
 eyes - leading to diabetic retinopathy and possible blindness
 blood vessels - increasing risk of heart attack, stroke and peripheral artery obstruction
 nerves - leading to diabetic neuropathy, foot sores and possible amputation, possible
paralysis of the stomach, chronic diarrhea
 kidneys - leading to kidney failure
Diabetes has also been linked to impotence and digestive problems. It is important to note
that controlling blood pressure and blood glucose levels, plus regular screenings and checkups, can help reduce risks of these complications.
There are two main types of diabetes, Type I and Type II:
Type I diabetes or insulin-dependent diabetes (formerly called juvenile-onset diabetes,
because it tends to affect persons before the age of 20) affects about 10 percent of people
with diabetes. With this type of diabetes, the pancreas makes almost no insulin.
Type II diabetes or non-insulin-dependent diabetes. This was previously called "adult-onset
diabetes" because in the past it was usually discovered after age 40. However, with increasing
levels of obesity and sedentary lifestyle, this disease is now being found more and more in
adolescents - and sometimes even in children under 10 - and the term "adult onset" is no
longer used.
Type II diabetes comprises about 90 percent of all cases of diabetes. With this type of
diabetes, either the pancreas produces a reduced amount of insulin, the cells do not respond to
the insulin, or both.
There are three less common types of diabetes called gestational diabetes, secondary diabetes
and impaired glucose tolerance (IGT):
Gestational diabetes occurs during pregnancy and causes a higher than normal glucose level
reading.
Secondary diabetes is caused by damage to the pancreas from chemicals, certain
medications, diseases of the pancreas (such as cancer) or other glands.
Impaired glucose tolerance (IGT) is a condition in which the person's glucose levels are
higher than normal.
Causes and Risk Factors of Diabetes
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The cause of Type I diabetes is genetically based, coupled with an abnormal immune
response.
The cause of Type II diabetes is unknown. Medical experts believe that Type II diabetes has a
genetic component, but that other factors also put people at risk for the disease. These factors
include:
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sedentary lifestyle
obesity (weighing 20 percent above a healthy body weight)
advanced age
unhealthy diet
family history of diabetes
improper functioning of the pancreas
minority race (higher risk in Black, Hispanic, American Indian, westernized Asian and native Hawaiian
populations)
medication (cortisone and some high blood pressure drugs)
women having given birth to a baby weighing more than 9 lbs.
previously diagnosed gestational diabetes
previously diagnosed IGT
The warning signs and symptoms for both types are:
Type I: Frequent urination, increased thirst, extreme hunger, unexplained weight loss,
extreme fatigue, blurred vision, irritability, nausea and vomiting.
Type II: Any Type I symptom, plus: unexplained weight gain, pain, cramping, tingling or
numbness in your feet, unusual drowsiness, frequent vaginal or skin infections, dry, itchy
skin and slow healing sores.
Management of Type I Diabetes
Virtually everyone with Type I diabetes (and more than one in three people with Type II)
must inject insulin to make up for their deficiency.
Please be aware of the following problems that exist with insulin intake:
Hypoglycemia (low blood sugar) is sometimes called an insulin reaction or insulin shock. It
can occur suddenly in people using insulin if too little food is eaten, if a meal is delayed or in
the case of extreme exercise. Symptoms include feeling cold, clammy, nervous, shaky, weak
or hungry, and some people become pale, have headaches or act strangely.
Hyperglycemia (high blood sugar) occurs when too much food is eaten or not enough insulin
is taken. The warning signs are large amounts of sugar in the urine and blood, frequent
urination, great thirst and nausea.
Ketoacidosis (in its most severe form - diabetic coma) develops when insulin and blood
sugar are so out of balance that ketones accumulate in the blood. Symptoms include high
blood sugar or ketones in the urine, dry mouth, great thirst, loss of appetite, excessive
urination, dry and flushed skin, labored breathing, fruity-smelling breath and possible
vomiting, abdominal pain and unconsciousness.
In addition to daily injections of insulin, regular physical activity and a controlled diet are
essential.
There is no foolproof way to prevent diabetes, but steps can be taken to improve the chances
of avoiding it:
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Exercise. Studies of both men and women have shown that vigorous exercise, even if done
only once a week, has a protective effect against diabetes. Exercise not only promotes weight
loss but lowers blood sugar as well.
Lose weight. There is evidence that both men and women who gain weight in adulthood
increase their risk of diabetes. A study conducted at Harvard showed that adult women who
gained 11 to 17 pounds since the age of 18 doubled their risk of diabetes; those who gained
between 18 and 24 pounds almost tripled their risk. Fact: 90 percent of diabetics are
overweight.
Diet. The use of a diet low in calories and in saturated fat is an ideal strategy for preventing
Type II diabetes.
Stop smoking. Smoking is especially dangerous for people with diabetes who are at risk for
heart and blood vessel diseases.
Use alcohol in moderation. Moderation for men means no more than two drinks a day; for
women, one drink is the limit. Choose drinks that are low in alcohol and sugar such as dry
wines and light beers. If you use mixers, try to select one that is sugar free, such as diet
drinks, club soda, seltzer or water. If you take diabetic pills or insulin, alcohol can drop blood
glucose levels too far. Have the drink with a meal or snack.
Diabetic Emergencies
What to Look for
Low Blood Sugar
 Develops very quickly
 Anger, bad tempter
 Hunger
 Pale, sweaty skin
What to do
1.If uncertain about high or low sugar level,
give sugar
2.Repeat in 15 minutes if no improvement
3.Call 999 or 112 if conditions do not
improve
High Blood Sugar
 Develops gradually
 Thirst
 Frequent urination
 Fruity, sweet breath odour
 Warm and dry skin
What Is Epilepsy?
Epilepsy is a general term used for a group of disorders that cause disturbances in electrical
signaling in the brain. Like an office building or a computer, the brain is a highly complex
electrical system, powered by roughly 80 pulses of energy per second. These pulses move
back and forth between nerve cells to produce thoughts, feelings, and memories.
An epileptic seizure occurs when these energy pulses come much more rapidly-as many as
500 per second for a short time-due to an electrical abnormality in the brain. This brief
electrical surge can happen in just a small area of the brain, or it can affect the whole brain.
Depending on the part of the brain that is affected, the surge of electrical energy can cause:
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Changes in a person's sensations or state of consciousness.
Uncontrolled movements of certain parts of the body or of the whole body.
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These changes are known as an epileptic seizure. Epilepsy is also known as a seizure
disorder because the tendency is to have recurrent seizures. Epileptic seizures vary in severity
and frequency, and even in the time of day they occur. While some people may experience no
more than two or three seizures during their entire lifetime, others will have several seizures
in one day.
Does Everyone Who Has A Seizure Have Epilepsy?
A seizure is a symptom of epilepsy, but not all seizures are caused by epilepsy. A seizure not
related to epilepsy can be caused by a reaction to:
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A drug
A high fever
A severe head injury
Other disorders such diabetes, some heart conditions, and narcolepsy, among others.
Sometimes people have a single seizure for which no cause can ever be found.
What Brings On An Epileptic Seizure? Seizures can be sparked by a variety of stimuli,
including:
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Lights that flash at a certain speed
The flicker of a television screen or TV monitor
A sudden loud noise or repetitive sounds
Alcohol consumption
Cigarette smoking
Stress
Headache
Menstruation
Lack of sleep
Having a bad day
Some people with epilepsy have seizures only during their sleep.
But seizures can also occur seemingly for no reason at all.
How Is Epilepsy Treated?
Several treatments are available for epilepsy.The key to finding an effective treatment is an
accurate diagnosis of the type of epilepsy a person has.
Current treatment options can control seizures for about 80% of the people in the United
States who have epilepsy. Once a diagnosis of epilepsy is established, it is important to begin
treatment right away. The longer treatment is delayed, the more difficult the epilepsy is to
treat. (Medications, surgery, vagus nerve stimulation, diet...)
http://www.ehealthmd.com/library/epilepsy/EPI_treatment.html
Seizures
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What to Look for
Sudden falling
Unresponsiveness
Rigid body and arching of back
Jerky muscle movements
What to do
1.Prevent injury
2.Loosen any tight clothing
3.When the seizure has finished, place the
casualty in the recovery position
4.Call 999 or 112 if needed
6.14 Demonstrate the position used to treat a patient in shock
Reference: AAOS 2009: page 56 Diagrams
6.15 Demonstrate the recovery position
Reference: PHECC; CFR Training Manual: pages 19-20
6.16 Demonstrate the treatment of the patient with altered level of consciousness
See 6.12