Pathophysiology and Current Management Practices - Case Study Example

Introduction Emergency medical facilities and the paramedics provides care to sustain life during the pre-hospital environment, at the point of injury or illness and usually in an emergency situations. This is very important activity especially during the assessment and the initial medical care, and care on the route to the hospital usually in an ambulance. It is important to note that paramedics provide medical care for trauma and emergency situations. In this regard, accurate pathophysiology diagnoses is therefore very important to ensure effective treatment or medication for the patient, thus the understanding of underlying pathophysiological mechanisms for a diagnoses is important (Heardman, 2014 p.30). This paper outlines three differential diagnoses for a case, their respective pathophysiology and current management practices for those diagnoses. The case diagnosed in this paper is about a 62 year old man who collapsed at a shopping centre at about 10:30 am after feeling extremely dizzy. The man who is also living alone had experienced an episode of falling from stairs eight months ago without any major injury. Although the man is a wake and sitting on the ground, he shows signs of drowsiness and disoriented and has difficulty in talking. The man insists on going home even though his eyes suddenly move upwards and in a few seconds he begins a seizure. The key symptoms in this case are drowsiness, difficulty in talking, dizziness, difficulty in talking and seizure. The history such as episodes of falling, age, time of incident and the fact the he lives alone are also crucial and important information in obtaining accurate differential diagnoses. This paper will discuss hypoglycaemia, hypotension and stroke including their pathophysiology pre-hospital management and medication, complications that may arise and current research and knowledge gaps. The rationale for these three diagnoses for this condition have been based on the key diagnostic signs presented by the patient that include; drowsiness, difficulty in talking, dizziness, and seizure as well as the past medical history of the patient. 2.0 Differential Diagnosis- Hypoglycemia Due Failure of the Counterregulatory Hormone 2.1 Pathophysiology of Hypoglycaemia The brain metabolism relies primarily on glucose to supply energy necessary for metabolism. When levels in blood drop below a certain levels normally 0.55nm, subtle reduction in the mental efficiency of the brain occurs and results into the impairment of judgment resulting into symptoms like seizures (Stefanova & Hill, 2013 p.45). Small quantities of glucose can be derived from the stored glycogen within the astrocytes; however brain is dependent to greater extent on the continual supply of glucose from the blood. Glucose from the blood diffuse into the interstitial cells, then into the central nervous system (CNS) and finally into the neurons. Within the CNS, energy is required for synthesis of signals and conveyance of information to the muscles (Guthrie & Guthrie, 2009 p.75). This explains the emergence of symptoms such as drowsiness, difficulty in talking, dizziness, and seizure. Generally lack of enough glucose supply to the brain would result into confusion and in severe cases it is preceded with dizziness and drowsiness, seizure and finally the patient can go into a coma. The nervous, metabolic and hormonal systems often respond to falling glucose level supplied to the brain. These systems function through adaptive system through the provision of alternative fuels, gluconeogenesis or glycogenolysis. During low blood sugar levels in blood circulation, sympathetic nervous system including the adrenal medulla are activated thus glycogen that is stored in the liver is converted into glucose through glycogenolysis process and blood glucose levels is restored (Stefanova & Hill, 2013 p.46). However, this is only possible in individuals who are capable of regulating their blood sugar. In hypoglycaemic individuals, normal regulation of blood sugar is impaired and thus individuals experience episodes of low blood sugar after hours of taking meals. This is because the absorbed glucose from digested foods is depleted and there is need to convert glycogen to glucose for use by the brain. In severe cases of hypoglycaemic individuals, blood glucose concentrations can go to less than 45mg per 100 ml and may cause neuroglycopenc symptoms such as impaired thinking, blurred vision, confusion, unconsciousness, seizures and finally coma (Guthrie & Guthrie, 2009 p.76). The fact that the 62 year old lives in a house alone means, he may have missed a meal last night thereby leading to low blood sugar. This is reinforced by the fact that he had similar episode of falling in the past though with minor injuries Hypoglycaemia can be insulin-dependent or insulin independent. Insulin dependent hypoglycaemia is caused by too much insulin within the body which may be as a result of intake of too much drugs used to treat hyperglycaemia or presence of insulin secreting tumour within islets of Langerhans (Goldstein, 2009 p.216). This results into the activation of insulin receptors thus blood glucose is reduced. Insulin-independent hypoglycaemia is attributed to disorders that cause impairment of glycogenolysis process such as starvation, adrenal insufficiency, severe infections, severe liver disease or infections. 2.2 Paramedic Clinical Practice Interventions And Rationale Hypoglycaemia is a life threatening medical emergency that must be dealt with immediately to avert coma or death of the patient. Comprehensive assessment of the patient including past medical history as well as evaluation of the patient’s blood sugar levels is crucial and should be done as soon as possible. Initially quick acting carbohydrates are administered followed by long acting carbohydrates. Administration of oral glucose is recommended for patients with low LOC who can swallow safely. Figure 1: step by step guideline for medical management of hypoglycaemia Can Swallow Cannot Swallow Source Stefanova & Hill, 2013 p.45 The paramedics must first assess the patient if they can swallow well by carefully giving small amounts of water and confirming that they are awake and capable of following commands before giving 25grams of oral glucose (Aehlert, 2011 p.956). Other sources of glucose apart from oral glucose can be cake icing, orange juice with sugar added and plain chocolate bar. However, oral administration of glucose often takes longer hours to raise the blood glucose levels to normal. Continuous monitoring of the patient while they consume glucose ensuring they do not aspirate is also important. When blood glucose is found to be below 60 md/dl and the patient is not able to take oral glucose safely, pre-hospital management recommends two medications: the administration of dextrose 25% (D50) and glucagon (Goldstein, 2009 p.219-220). However, paramedics must first establish IV access which should be within a large vessel to accommodate IV catheter. This is because D50 is viscous and there is need to have it absorbed by the body. As stated by Guthrie & Guthrie (2009 p.75), the administration of D50 should be done carefully since it can result into severe damage to the nerves, muscles and skin and in some cases may result to death. D50administered is expected to begin raising blood glucose in between 30 seconds to 2 minutes. Sometimes vascular access may not be possible, in this condition it is recommended that you administer 0.5 mg of glucagon either intramuscularly or subcutaneously (Aehlert, 2011 p.957). This would restore blood sugar levels within 20 minutes, however, when action is slow, administration of glucagon can be repeated. Paramedics should promptly transport the patient to the hospital and continue monitoring the patient closely for any changes in symptoms while on the way to medical hospital. The patient should be placed in cardiac monitor and oxygen saturation monitored for vital signs and glucose level (Goldstein, 2009 p.221). 2.3 Future Intervention and In hospital Management Recovery of the patients with hypoglycaemia often takes shorter time depending on the severity of the condition. The patient may recover fully while on the way to the hospital with blood glucose levels above 7 mmol/L, thus admission would not be necessary (Khunti et al, 2013 p. 159). However, it is important to make arrangements so that there is prompt follow up by the hypoglycaemic team. Full discharge can only take place after there is full recovery of the cerebral function. However, when the doctors recommend admission to the hospital either when the patient is in a coma, the patient will be admitted in an ICU. At the hospital the doctors will try to analyze the root cause of hypoglycaemia. Prolonged coma especially after achieving the right glucose levels after more than 60 minutes calls for additional assessment. It is important to assess neurological deficits and consider head injury, intracranial infection, poisoning with alcohol or drugs, cerebral oedema infarction (Guthrie & Guthrie, 2009 p.75). This 62 year old would be admitted for over 24 hours for close monitoring because he lives alone and the possibility of recurrent hypoglycaemia is possible. If the history of the patient reveals recurrent hypoglycaemia, doctors may also recommend pancreatic transplantation especially for disabling recurrent hypoglycaemia (Rathmann et al 2013 p.56). Comprehensive education on nutrition, medication and meals would also be given before discharge. 2.4 Current Research and Trends Glucagon is the most commonly used counterregulatory hormone that is used in many severe hypoglycaemia. However, research has shown that this hormone response to hypoglycaemia is often lost in many C-peptide negative individuals (Rathmann et al, 2013 p.59). Restoration of this response is however the key to effective response to reduce the risk of severe hypoglycaemia. In this regard, amino acids have been used in many experiments since they have potential to stimulate release of glucagon from the pancreatic alpha cells. As stated by Brod et al (2010 p.1289), taken orally, amino acids have proved to enhance glucagon response to hypoglycaemia. However, this technology has never been implemented since amino acids have been known to stimulate release of glucagon during euglycaemia thus have deleterious effects on overall glycaemia control. 2.5 Conclusions Hypoglycaemia is a serious life threatening condition that may lead to death of a patient if the condition is not managed in time. Emergency management should therefore aim at restoring normal blood sugar to avert key diagnostic symptoms that affect the normal functioning of the brain. The role of paramedics is paramount since they open leads for further treatment of the patient. It is therefore important to note that without emergency management, the patient is likely to die. 3.0 Differential Diagnosis- Hypotension due to Failure of the Autonomous Nervous System 3.1 Pathophysiology of Hypotension Approximately five hundred to seven hundred millilitres of blood is momentarily shifted to the lower part of the body whenever one assumes an upright position thus arterial pressure reduces as a result of reduction in central blood. During this time normal complex reflexes comes in to rapidly initiate cardiovascular, muscular and neurohumoral responses in order to maintain the blood pressure. However, when the upright position is assumed for long time in the absence of the normal circulatory reflexes normally controlled by the autonomous nervous system, there is tendency for blood to pool in the lower part of the body resulting into the fall of the cardiac pressure and output which finally deprives the brain of the normal blood supply (Mager, 2012 p.52). This condition results into symptoms associated with reduced blood supply to the central nervous system such as light-headedness, blurred vision, confusion, dizziness, weakness, fainting, and drowsiness. In normal individuals, the low blood pressure is easily detected by baroreceptors located on the thorax and initiates the reflex constriction process of arterioles and the veins that brings blood pressure to normal. Figure 2: pathophysiology of hypotension Source: Franzini et al, 2013 p.152 Autonomic nervous system plays a critical role in continuously regulating the blood pressure using the elaborate network of nerves, receptors and hormones in order to balance the effect of parasympathetic nervous system and Sympathetic nervous system that tends to lower and raise blood pressure respectively. Normal individuals are therefore capable of maintaining normal blood pressure in many disease states and within a wide range of activities due to rapid compensation abilities of the autonomic nervous system. The sympathetic nervous system plays a vital role in the regulation of the upright position in human beings. Stimulation of the sympathetic nervous system results into increased cardiac contractility and heart rate. These activities finally lead to the constriction of arterioles and peripheral veins (Metzler et al, 2013 p.2215). 3.2 Paramedic Clinical Practice Interventions and Rationale The first action for paramedics will be to take blood pressure in order to confirm hypotension condition of the patient. Secondly they will restore the balance of blood volume within the body so as to avert the symptoms. This will be achieved by laying the old man on his back in a supine position then gently raising his legs high enough above the level of their heart. This would enhance flow of blood from the lower arterioles and veins back to the heart which will increase blood pressure. According to Metzler et al (2013 p.2217), it is best to incline the entire patient as a unit which allows for the elevation of the lower extremities and reclining of the torso. Continue monitoring the blood pressure while you take the patient to the hospital for further medication. Sometimes low blood pressure does not respond to positioning and the cause may not be known immediately. In such situations administration of intravenous IV fluids is be recommended initial therapy (Schroede et al, 2013 p.12670). The rationale behind this prehospital medication is to replenish body fluids with normal saline in order to reverse the condition while the patient is taken to the physician to determine another cause. However, this can only be administered to hypotensive patient if it is suspected that the condition is resulting from dehydration, hypovalemia, severe infections, and allergic reactions or vomiting. In this case, the 62 year old may be hypotensive as a result of dehydration due to the fact that he is staying alone in the house thus may have not eaten for long time. However, care must be taken to ensure that complications do not arise from too much fluid infused into the body. 3.3 Future Interventions and In-hospital Management Hospital medication is necessary for this patient especially if the condition is not restored completely by the paramedics. In many cases that result to admission of the patient, there is often need for comprehensive assessment of the patient to certain the root cause. In many cases, severe hypotension results from heart insufficiency, severe infection or multiple organ failure (Franzini et al, 2013 p.151). In this regard, the doctors can administer medications that improve the ability of the heart to pump more blood while further diagnosis is done. In this regard, dobutamine, norepinephrine and dopamine can be administered to increase the ability of the heart to pump more blood (Medow et al, 2012 p.17). As stated by Khalid et al (2014 p.57), these medications work by stimulating the adrenergic nervous system thus resulting into contractibility of the heart and with constriction of the blood vessels the force is increased and blood supply to the brain is enhanced. 3.4 Current Research, Trends and Gaps Identification and understanding of the pathophysiology of hypotension has resulted into the research and development of new drugs and non-pharmacological measures to counter the condition. Research has shown that when individuals are exposed to polypharmacy, diuretics and amantadine was common among PD patients with orthostatic hypotension. The recent drugs being developed are mainly geared at treatments agents that aggravate hypotension. Researchers are also warning that patients should try as much as possible to avoid large meals, sudden change in posture, hot baths, vasodilating medications and alcohol. 3.5 Conclusions Hypotension is a medical condition that can easily be managed by paramedics if accurately diagnosed. While the symptoms show potential diagnostic signs, it is important to rule out other conditions before administering medication. Even though the patient may insist on going back home after receiving glucose stabilizing agents, it is important to visit hospital in order to get comprehensive medication including other lifestyle changes that could deal with the root course. Nevertheless, paramedics play crucial role in averting adverse health effects that could rise from complication thus enhance life. 4.0 Differential Diagnosis- Stroke Due to Deprivation of Nutrients and Oxygen 4.1 Pathophysiology of Stroke The brain requires enough supply of oxygen and nutrients for its cell metabolism and for energy in order to function properly. When arteries are blocked, auto-regulatory mechanism aid in maintaining cerebral circulation until collateral circulation develops to transport blood to the affected area. This compensatory mechanism is sometimes overworked especially if the cerebral blood flow remains impaired thus last longer, leading to deprivation of oxygen leading to the infarction of the brain tissue. In this regard, brain cells cease to function because it is unable to engage in anaerobic metabolism, cannot store glycogen and cannot store glucose resulting into thrombotic stroke (Wardlaw, 2010 p.174). Figure 3: Pathophysiology of stroke Source: Moustafa& Baron, 2008 p.S45 Due to lack of supply of oxygen and nutrients, some of the neurones that are supplied by the affected blood vessels die resulting into cerebral infarction and increase in intracranial pressure. The injured cells accumulate water, calcium and sodium which results into a vicious cycle of further damage as shown in figure 3. This damage of the neurons inhibits their normal function and the patient will experience symptoms such as weakness, confusion, numbness, dizziness, loss of vision and difficulty in talking (Moustafa & Baron, 2008 p.S45). 4.2 Paramedic Clinical Practice Interventionsand Rationale Administration of basic life support system is vital as the first step in the prehospital management of patients who has suffered from stroke (Moustafa & Baron, 2008 p.S46). This should be followed with close assessment of the condition and if there is bulbar dysfunction or those experiencing seizures, the patients’ airways should be protected. Continue monitoring the vital signs as well as neurologic assessments and endotracheal intubation (Camerlingo et al, 2013 p.333). On the way to the hospital, monitor pulse oximetry and administer supplementary oxygen and ventilator assistance if the patient is hypoxic. Securing the airways forms the most important action that would be done at the emergency response while the patient is being taken to the hospital. As stated by Wardlaw (2010 p.174), securing the airway is very important in preventing complication arising from aspiration pneumonia even though there is no evidence of research on the utility of the airway. In order to improve effectiveness of the airway, endotracheal tube should be placed in order to supplement nasopharyngeal or orpharyngeal with the view of increasing efficiency and improving recovery all the way to the hospital. 4.3 Future intervention and In-hospital Management At the hospital, the patient is first taken at the emergency room before admission at the ICU. At the emergency room, special procedures will be followed as soon as the patient arrives. First, the patient will be taken through a comprehensive physical examination including tests to know the cause and the extent of the stroke (Camerlingo et al, 2013 p.334). ACT scan is one of the most important tests that must be done at the hospital to detect the type of stroke the patient has had. This is important since the type of stroke would determine the best subsequent treatments that will be administered to the patient. Other tests will also continue after ACT to determine the extent and the exact vessels and nerves that have been affected. The patient will have intravenous IV line inserted, oxygen supplement, while monitoring of the body fluid and blood pressure balance is monitored closely. This is because stroke may result into complications due to increased pressure in the brain thus it is critical to monitor headache, drowsiness and confusion which are the key symptoms of increased pressure in the brain (Sander, 2013 p.37). It is important to avoid anything that is swallowed until it is clear that the patient can take. According to Gropen et al (2014 p.387), if the ACT scan show blood clots, emergency drug therapy such as T-PA (Activase) and Intra-arterial t-PA can be administered to burst the clots. However, a patient receiving t-PA should be monitored closely in the ICU since it may result into bleeding (Sander, 2013 p.38). 4.4 Current research and Trends Current research has been focused on the development of drugs that can protect the brain cells from dying. According to Johansson (2011 P.148) researchers are testing drugs that can either stop or slow down brain cells from dying as well as the use of Constraint-induced movement therapy (CIMT). This is based on the fact that brain cells dying very fast and if there is no concrete medication within three hours of strake a patient is likely to die. Researchers hope that a new drug would be developed would reduce the disabling effects of stroke. CIMT is a method in which splint is applied to normal hand about ninety percent of the day in order to force use of the paretic hand together with “shaping” by which the tasks are made progressively more difficult. 4.5 Conclusions Stroke is one of the leading causes of death in many countries across the world, and number third cause of death in the United States of America. Stroke also causes permanent disability and results into billions of dollars in medication and loss of productivity. The role of paramedics in averting these advert effects is therefore very crucial in the management of stroke. Accurate diagnoses and emergency management within the shortest time possible could help save life. Meanwhile, current research and emerging medication is expected to enhance medical therapy for patients with stroke. References Aehlert, S, 2011, Paramedic Practice Today: Above and beyond (volume 1), Burlington: Jones and Bartlett Publishers. 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