hey welcome to the module 6 exam review video part three this one will hopefully go by a lot quicker than the previous two as even though we have a lot of topics they don't really go as in depth um we'll try to make this quick let's get started so the first thing we'll talk about is altered mental status U my biggest takeaway about altered mental status is that you all have to recognize anyone with AMS is in a potential life-threatening situation right so if you're patient is not acting normally or is unable to act normally and they are confused or they're unresponsive or they only are responsive to verbal or painful stimuli we just need to recognize that your patient is critical there are many causes of alter menal status I'm not going to list them all you know here it's bullet pointed a bunch of them but honestly think of anything and everything uh that could be severe enough it's going to lead to altern metal status when you do encounter a patient with ultral status then we kind of want to make sure that we take c-spine precautions especially if they are found somewhere that a person is typically not going to lay down so like they're found on the side of the highway or on the floor of their kitchen we have to consider that they ended up on the floor in a dangerous manner we don't know how they got there right so make sure you take C spine and then you're going to manage their ABCs because if you have a person who is altered and unable to respond well they're not likely to protect their own Airway as well so go through the ABCs maintain their Airway suction if you have to try to keep their spo2 above 94% if they have signs of respiratory failure then go ahead and ventilate them and keep them supine while you transport them since your altered patient is a critical one you want to reassess them every 5 minutes and again you're just looking for changes in their mental status staying on top of their ABCs and recording your vital signs when you can to establish those Trends in the meantime you want to do a thorough secondary assessment you want to go head to toe we're looking for any and all reasons that is potentially causing your patient to be unresponsive or altered since they are unable to reliably tell you themselves so you know we want to work with speed and efficiency managing the ABCs and transporting but we do want to be thorough through all our sample history looking for any other physical signs that could give us Clues as to what could be wrong never assume that just one thing is wrong with your patient right we could have comorbidities or C or different things acting upon uh the patient together and with that we are now going to go ahead and dive into stroke so a stroke patient is when you have a deficiency in the nervous system function and we call this a neurological deficit so if you recall when you did your spinal mobilization stations and you're checking can you wiggle your fingers can you feel me touching you we're all looking for those neurological deficits there and if there is a deficit then something is wrong with the central nervous system meaning the brain or spinal cord you are dealing with an acute stroke we need to remember the pneumonic from the AHA of fast where F stands for facial droop a stands for arm drift s stands for slur speech and then T stands for time and that time could either be the last time normal seen normal for the patient or time to get to the hospital or time is brain but we do need to understand and remember the pneumonic fast for your exam we should also understand that there are two main types of stroke uh one is either caused by a blockage or clot we call that an es schic stroke the other one is caused by a rupture or a bleed known as a hemorrhagic stroke so in the field we cannot distinguish between the two types therefore we must get them to a hospital with a cath lab so that they can you know take a picture and identify what type of stroke we're dealing with if we are dealing with an esemicolonr and basically that just stands for clot Busters right you can administer a drug that's going to go in there and break up the clot and restore blood flow um the key takeaway that last bullet point is that aib or atrial fibrillation is typically uh a history finding that it will precipitate or lead to an es schic stroke when we're talking about hemorrhagic strokes this can result into a rupture of a weakened artery so think about your aneurysms um or even your dissections but typically in aneurysm when it comes to the brain uh high blood pressure can you know typically lead to this so these are our leading factors just recall that we are not going to give our patients aspirin if they're suffering from a stroke because again we can't differentiate between es schic or hemorrhagic if you give aspirin and it turns out to be a hemorrhagic stroke then you are going to cause more harm than good often time your stroke patients will suffer paralysis affecting one side of the face or body versus the other here's just a slide to depict you know what that that facial droop could potentially look like I really want you guys to be familiar with the difference between a stroke and a transin schic attack otherwise known as tias um there are at least one or two questions on your exam that has you kind of identifying whether this is a Tia or not and so the definition is that you have the same signs and symptoms of a stroke whether it's facial dro arm drift slurge speech or all of the above and the symptoms will resolve in less than 5 minutes okay just keep in mind that if your patient is experiencing tias and it goes away it doesn't mean that your patient you know is all better and they should just stay home we have to understand that this is a risk factor that they are more likely to experience a full-blown stroke um within the next couple days or so whenever you're assessing whether your patient has a stroke or Tia we want to note where the patient is found meaning like is this a potential trauma patient or is this purely medical so if your patient was found you know on on a kitchen chair or something with these neurological deficits we can sort of safely assume that this is a stroke if they are found like at the base of the stairs and they might have some bruising to their head and eyes well then now you know that this is more likely like a head bleed due to trauma um again just assess your patients we're always going to harp on those ABCs so look for inadequate breathing abnormal breathing patterns and then manage it with the BVM as you see fit uh for this last bullet point we are going to recall just like with your acute myocardial infarcts your Mis you don't want to administer too much oxygen to a stroke patient so we want to stay above 94% but any time we get to 100 or you know we're saturated at 100% then we increase that risk of re profusion injury due to the free radicals that we're creating for the purpose of this exam we typically go over the Cincinnati prehospital Stroke Scale since this is what we typically use in Louisiana I know the textbook States a few others or mentions a couple other stroke scales you can review them as you know you see fit for the nrmt but I'm pretty sure at National Registry they won't really cater to one scale versus the other so since they know that difference States and different systems go by you know different rules but here's the Cincinnati preh hospital Stroke Scale for you guys to just kind of look over and study for this exam while managing your Strokes or tias you want to check a blood glucose level um sometimes having a low blood sugar will mimic a stroke and it's going to be very embarrassing if you bring your patient in calling in a stroke and it turns out that their blood sugar was just too low uh we also want to make sure that if the patient is unable to protect themselves or protect their extremities they were not just leaving it you know dangling off the side of the stretcher as you you know push them through the door and we also want to make sure that we establish rapid transport to the correct facility so your highest level stroke center that is in within reasonable driving distance uh should be your goal here and we want to reassess our patient every 5 minutes because just because they showed up with a certain set of neurological deficits we want to make sure that it's not getting worse or we're having more deficits or it's improving and now you're considering that this patient is having a TIA instead of a stroke all right the next topic and this is the only slide I have on headaches for the exam I didn't really cover headaches too much um for National Registry or the final you may want to review uh this topic again but for the purpose of this video I'm just going to talk about headaches here on the slide you have various types cluster headaches tension headaches uh migraines you know go back and read over what type of headache is what but I'm letting you know now for this exam we're not going to really touch on it the next chapter we're diving into our seizures and syncable episodes so a seizure is defined as a sudden and temporary alteration in brain function caused by electrical discharges in the brain I think seizures are something that any ENT should be able to recognize and I'm sure you all have watched you know a TV show or Hollywood this is probably one of the more uh you know pronounced depictions out there when we categorize our seizures we might call them either primary or secondary seizures and so the primary seizure is when you know the cause is unknown or it's genetics or it's just something that involves uh you know the the state of the patient already these patients are typically you know they've had some history of seizures somewhere and they they know that they have seizures they they are very comfortable with how to manage themselves after a seizure so you know we just we're just there to support and initiate transport if they want to the secondary seizure is a little bit more dangerous where it can be occurring from an underline cause and there are several causes whether you have you know some kind of trauma or a lack of oxygen or lack of glucose and I think when it comes to their patients with primary seizures because they're so used to primary to the seizures occurring normally for them they often you know lose side lose track of the fact that it could be caused by something else so I think as EMS providers whenever you encounter your patients experiencing a seizure and if they're trying to blow you off you know be thorough with your assessment do the detective work try tried to you know rule out all causes just to make sure that the seizure wasn't caused by some underlying you know issue for this exam you really need to know the definition of status epilepticus and this is a life-threatening emergency this is the most dangerous seizure you could have uh by your textbook it's defined as two or more sequential seizures without a full recovery of Consciousness between them or it's a continuous seizure that last longer than 30 minutes now obviously we're not going to sit there for you know 27 28 minutes and think it's not status yet so you know the rule is that if the seizure has lasted longer than 5 minutes it more than likely will develop into status so if the seizure has been going on for longer than 5 minutes it's safe to say this is status epilepticus and we need to initiate transport for this slide I want to highlight what a tonic clonics seizure is in the terms of tonic versus clonic so when we say a tonic seizure that means your your patient has excessive muscle tone so think tonic to tone if they are tensed up and stretching out or you know they seem like they're contracted in and they're you know holding this this weird posture then you're dealing with the tonic seizure when your patient has a clonic seizure then we're thinking of a convulsive seizure so that's your typical you know shape in or spasms of the of the body and limbs to where you know they have uncontrolled movements and a tonic clonic seizur is when you have you know the presentation of both where they start off in that tonic State and then proceed into a clonic seizure um your patient is never awake or aware through any of this so whenever you have patients trying to fake seizures and they describe what they were doing how they got to the floor or you know what happened to them then you know it's not a true seizure or at least not a true tonic clonic seizure all your tonic clonic seizures will occur with you know without any awareness and most patients won't even recall any events of what happened tonic clonic seizure there are a list of stages here we want to Define aura for your exam and your aura is when you're you have like a warning sign so different patients have different auras they may have a certain taste or sight or Sensation that kind of warns them that a seizure is about to take place and this is something a patient deals with on the regular they know what their Aura is they can often describe it to you or you know take measures to protect themselves as as they occur uh the next phase is the loss of consciousness and then you go into your tonic phase with that muscle rigidity or intense muscle tone and then you go into your relaxed phase or hyper I mean your tensed up phase or your hypertonic phase going into your clonic phase where you have convulsion and then your postictal state we want to be able to Define what a postictal state is for your exam and that's literally just the the stage where your patient is recovering so they're coming out of their seizure but they their mental status is still altered they may be unresponsive or they're just confused and disoriented sometimes they're a little bit combative but over time their mental status is going to progressively improve here I have a bulleted list of other types of generalized seizures I'm not going to go into too much details about each um I think you should review all of these for you know the possible final or nrmt exam only ones I'll really highlight is maybe the absence seizure which is known also as a petite M seizure and it's most common in kids um these are character ized by like a sudden sensation or like they lose Consciousness really quickly and then they just have this like they're not talking they're just staring off into space and it it doesn't last long you know they end after maybe like 15 20 seconds the other one I'm going to highlight is the febr seizure where if your patient is experiencing a severely high fever that it starts to damage the brain then and you're going to see you know a seizure as a result and again these are most common in your pediatric patients um so we'll just go ahead and highlight absence and febril seizure there for you guys to carry forward but again if you're reviewing for the nrmt and final I would try to be familiar with all of these when we talk about partial seizures then they involve abnormal movements of one area of the body your patient can be in typically is awake and aware so they will kind of know what's going on and it may just involve one body part or will spread to other areas honestly I've never seen this in the field uh and if it has happened it's a very rare condition or people just don't call 911 for it cuz they're aware of it but um just know that partial seizures do exist and some people you know it'll just be a very strange experience for them but don't write them off uh similar to any patient experiencing altered metal status we don't always know the cause for seizure so you want to look for evidence of trauma or poisoning or even potential medical history if the patient is postal they will be confused and you know may not be able to respond appropriately but you just got to give them time if they are actively seizing then you must move objects away from them and that is uh pretty key in the management of seizures otherwise do not restrain them you kind of just have to let the seizures play out and protect their head as best you can you may want to lay them on their Sid so that if they vomit uh they can you know they can expel out to the ground and not up into their own Airway um insert an oral nasal adjunct if you can and if you need to and just make sure that they're oxygen stays above 94% so if you have a patient who is excessively convulsing and you're having trouble getting a mask or something on them then just blow by oxygenation will work here um the last bit here is to also make sure that you check a blood glucose level because if you have a low blood sugar that could cause a seizure or the seizure activity was St so strenuous that it used up a lot of the blood glucose and then you might have to replace it afterwards I just threw this slide in here to you know Drive the point that we are protecting the season patient from injury by moving furniture and objects away and just so that yall can be you know familiar with that phrasing so that when you see it on the exam you know what to answer all right so a Syncopy or a syncable episode is any sudden temporary loss of consciousness I think the lay in terms for this would just be fainting so if your patient had fainted then they had a snable episode um a lot of times people call like they interchange the definitions of Syncopy for a seizure like they see someone drop and they say oh he had a seizure when it's just a synal episode I have this table here to help you guys differentiate between the two but you know if you can witness a seizure it'll probably be very obvious you know that it's a seizure versus a syncable episode so make sure you do your history if the patient isn't able to respond to you then ask bystanders more so to describe what happened as opposed to you know what they think happened and uh you know here you might want to keep things with your open-ended questions and if you're not getting the answers you need then you use your Clos into questions to pull specific details so management of a syncable episode very similar to your altered mental status or uh seizure patients you want to do your ABCs do a thorough head to toe keep them supine uh make sure that you consider all causes so you know you know this really hand inand with alter mental status we don't know what caused them to faint so we want to make sure that we look for any or all causes and encourage transport if we do happen to get them back um one thing that often occurs is if your patient has a snable episode they end up on the ground and after you're laying on the ground for you know a few moments they they wake up again but if they sit up or stand up too quickly you know they have another snable episode so it's it's not on the slide but I just want you guys to kind of think about why that's the case right so if your patient is fainting from standing or sitting but they are able to regain Consciousness while laying down then it's most likely due to the positioning the patient that is helping them peruse better right so just like our shock patients We Lay Them supine so that we can peruse to the brain and vital organs more easily and it's the same concept here for your patient experiencing a syncable episode all right the last chapter we'll talk about is diabetic emergencies I know we've talked a little bit before about checking the blood sugar of various patients uh in all the previous chapters but now we're diving into why that's so important uh recall from A&P or module 2 that glucose is basically the energy that we use to or the molecule we provide to break down from energy so it is the primary energy source for your cells and without it your cells cannot function with glucose uh regulation of the blood glucose level is critical to normal cell function and your brain cells use up the most glucose for energy so whenever you have a low blood glucose one of the earliest signs is that altered menal status and if you have a very long time of low blood glucose then you're going to lead to the death of those cells on the opposite Spectrum if there is too much glucose then you can pull some water into the cell as it crosses that cell membrane and that's going to make head injuries or Strokes even worse um also with a high blood sugar that glucose has to be excreted through the urine and as it is excreted pulls excessive water with it so that's going to lead to dehydration now insulin is the main hormone that controls blood glucose levels and we should recall that insulin is produced from the pancreas so when insulin is secreted it kind of signals to the cells that now is the time to pick up glucose from the bloodstream so you have all this glucose just circulating in the bloodstream and without insulin to tell the cells you know to bring it inside it's going to stay in the bloodstream here we have a couple images to help depict this so on the left side you can see that with insulin the channel opens for glucose to enter and then they metabolize it into energy on the other side on the right if you don't have insulin then glucose will stay in the bloodstream and so your your blood glucose level will start to get high but your cell still needs energy somehow um so what they do is they metabolize fat to produce energy instead and I a lot of you guys are thinking oh that's awesome but you also have to consider the byproducts of burning that fat is not always good for the body and so this is kind of the premise to producing Ketone bodies and part of the keto diet but we'll talk more on that later so the way insulin regulates your body or your blood glucose levels is we typically have a range a normal range that is between 70 to 120 if you have a hard time remember remembering that then we often say the trick is to think of what your normal blood pressure is 120 over 80 120 over 70 and that is your normal range for blood glucose anything higher than 120 is you know too too much blood sugar anything lower than 70 is too low um but again as you eat a meal and your increased blood glucose levels get higher then insulin will secrete as a result and this insulin will trigger yourself to uptake that blood glucose and so your levels will drop um if you're in between meals like you haven't eaten for a very long time and you don't have any circulating blood sugar then a hormone called glucagon is secreted instead and this is kind of the uh the trigger to break down your fat stores this slide is reiterating some things from the last one what your normal readings are and we have the new terms hypoglycemia versus hyperglycemia and hopefully we know these uh prefixes by now that hypo means below and Hyper means above or Too High um when you're assessing your patient it is important to know the last time the patient ate or drank something um just to kind of give some reference onto uh whether the patient is uh you know maintaining their blood glucose well enough or not so when we talk about diabetes uh diabetes is a disturbance in the metabolism of carbohydrates fats and proteins and this can either result from a lack of production of insulin from the pancreas or an inability of the cells to respond to that insulin insulin sorry if the patient doesn't manage their diabetes then they will typically have a higher blood glucose level and so we have the three PS of diabetes which is polydipsia which is an increased level of thirst polyurea which is an increased amount of urine production and polyphasia which is an increased hunger so if you think about the what we talked about earlier the glucose molecules pulling water with it as you excrete it in your urine the excessive glucose it's going to pull water with it causing you to urinate more frequently but as you urinate more frequently you become more dehydrated so you achieve poly dipsia which is increased thirst um at the same time you have an increased blood glucose level because the insulin isn't telling your cells to take it into the into the into the cell itself and because the cells are constantly starved of glucose and they're having to break down fat stores to produce energy they kind of signal to your brain that hey we need sugar or we need glucose and we're hungry so you get the three PS of diabetes diabetes we label diabetes into two types and type one diabetes is where your pancreas does not secrete insulin on its own usually this is some kind of genetic or autoimmune disorder where your immune cells have attacked the the cells that produce insulin and your patients have to rely on taking insulin in order to regulate blood glucose so we often say your type one patients are insulin dependent um these patients are more prone to diabetic keto acidosis or dka which again we'll talk more about later when we talk about type 2 diabetes this is when your cells have become resistant or they're not responding to the insulin anymore and therefore they're not taking in you know the blood glucose just because they they've become immune to the response to it and it's not so much that they require insulin some of them do take insulin still but majority of these patients will have to regulate their their blood sugar through diet and exercise and just kind of like limiting the amount of blood sugar is available so that their body can regulate itself more easily when we talk about our hypoglycemic emergencies these are patients with the low blood sugar and it's usually due to a patient that either takes insulin but they either forgot to or they didn't eat enough or you have a patient that's just kind of fasting and then you know they take insulin anyways um sometimes a patient will take too much insulin so if you think about your geriatric patients that they may have forgotten they took a dose of insulin so they take another um you know this is the usual causes of hypoglycemia for the purpose of your exam you do need to know the assessment findings of hypoglycemia like if you look at a patient how can you tell if they are hypoglycemic versus hyperglycemic um first off you're going to have that onset of altered mental status right so they might exhibit some bizarre behavior uh and that's due to their low blood sugar we always say you know you're not you when you're hungry so grab a Snickers other signs and symptoms occur from the release of epinephrine and so you're going to see patients present with this you know deretic or sweating and they're going to have this pale cool clammy skin um along with you know weakness if the patient has been hypoglycemic for several minutes then we're going to see some brain cell dysfunction and again the Alter Metal status with confusion or drowsiness they may be completely unresponsive or you might even see them exhibit seizures or stroke like symptoms which is why we always rule out a blood glucose for those emergencies when when you are providing emergency care for these hypoglycemic patients uh they are typically unresponsive or unable to follow commands so they may not be able to protect their own Airway therefore we want to establish an open Airway if we have to provide positive pressure ventilations go ahead and do so otherwise again we're just trying to keep oxygen above 94% we want to check their blood glucose level and then we may want to request ALS if the patient is confused but they're responsive and they're able to swallow or protect their own Airway you know follow commands then we can administer a tube of oral glucose so these are the patients that you know they're they're not quite gone whe they're running a little bit slow a little bit bizarre but they're able to pretty much do what you ask and you know most of these patients are recognizing that their blood sugar is low and um they're going to be more than Cooperative to eat or you know take the oral glucose I do want to backtrack a little bit about the unresponsive patients that you should not just pour or squeeze oral glucose into a patient that can't protect their Airway but your book will mention that there is you know a method that we can employ where you take a small Pearl drop of glucose onto your finger and you just smear it along their gums and on their cheeks um is it going to work very quickly no but it's often better than doing nothing while you're waiting for ALS and so for those patients that can't protect their Airway we want a paramedic or ALS on scene to start an IV and administer the dextrose through the through the vein but again if there's a long transport time or it's too long for IV access you can start smearing some glucose on their gums and cheeks you know check it every 5 minutes or so and it'll take a long while but again it's better than letting your patient just stay hypogly glycemic without doing anything so talking more about oral glucose it is a gel it's absorbed very quickly um a lot of students like to ask does it taste good I don't really think so some of the newer Brands reportedly taste better but you know it's each their own uh your patient if they have alter menal status and they are low in blood sugar and they can swallow then they can eat the whole tube and you're going to give them the entire tube again if there's any question on whether the patient can protect their own Airway we don't really want to squeeze like a whole tube in there um instead you want to just you know smear it across the gums uh for a patient that is alert oriented will just kind of squeeze a bit of it in between their cheek and gum so that you know they can swallow it on their own when we switch gears talking about hypoglycemia this is high blood glucose levels caused by relative lack of insulin or response to insulin um so the key one I'm going to highlight here is dka diabetic keto acidosis and what happens with dka is your body is not receiving or the cells of your body is not receiving glucose and therefore it has to break down fat stores for energy well in the process of breaking down those fat stores it is creating what we call Ketone bodies and these Ketone B IES are acidic in nature and uh you know damaging in large amounts so we typically say that a patient is in dka when their blood sugar is above 350 um without insulin again they can't move glucose into the cells so they starve and now they are burning that fat producing those Ketone bodies this doesn't happen very quickly it often progresses over a few days um and in the process of this buildup of Ketone bodies and excessive blood sugar you know they're going to become more dehydrated and you might see like poor skin turer or uh or they're going to develop what we call kousal respirations where they're breathing very hard and very fast as they breathe really deep and rapidly with that kousal respiration you know they're what's happening is their body is trying to blow off carbon dioxide to reduce the acid explode inside the body and so if they continue to hyperventilate then they'll reduce the amount of carbonic acid and thus reduce the total amount of acid in the body um but again signs and symptoms related to this you're can have dehydration uh excessive thirst excessive uh urination you're going to have signs of dehydration your patient may appear dry you know they have dry skin instead of sweaty skin skin and they're going to be flushed in appearance so managing a patient in dka same principles manage your ABCs um check their blood sugar level if you're unsure of their condition I would honestly call Medical Direction here and let them guide you on what to do next for the purpose of this exam I didn't really talk about hypoglycemic hyperosmolar non totic syndrome but it's basically a hyperglycemic patient without the production of Ketone bodies so management is basically the same you know ABCs check the blood sugar level contact medical direction for guidance if you have to if you want to know more details about hhns I would review it just in case nrt asks you some questions regarding this so in general whenever you are dealing with a patient with alter menal status and a history of diabetes we want to make sure that we are checking their blood sugar um we want to see if the administration of glucose is improving anything if they're hypoglycemic uh just keep in mind that Administration with oral glucose is not a very fast procedure and it could take as long as 20 minutes uh you want to be aggressive in checking their blood sugar just to see their Trends if it's going up or if it's going down and if you're patient is hypoglycemic meaning that they're on the high side of things and again we're really just managing their ABCs and transporting them to the hospital um so this slide will conclude my review video part three I hope it wasn't too long and uh we highlighted all the key points I try to you know give youall some tidbits throughout all three videos on what will assuredly be on the exam and what isn't going to be on the exam to try to save you some study time um again though a lot of the materials that I did Skip or say not to worry about this exam we want to make sure that we try to at least review those items in case the national registry exam brings them up so with that I wish you luck