The Patient With An Altered Mental Status

The Patient With An Altered Mental Status
ECRN Mod IV 2009 CE Advocate Condell Medical Center Objectives by Jeremy Lockwood FFPM Mundelein Fire Department Prepared by Sharon Hopkins, RN, BSN, EMT-P

Objectives Upon successful completion of this module, the ECRN will be able to: 1. Identify components evaluated in determining a patient’s mental status and orientation. 2. Define altered mental status. 3. Identify the possible causes of altered mental status. 4. Identify signs and symptoms of altered mental status. 5. Identify elderly considerations related to altered mental status.

Objectives cont’d 6. Identify assessment procedures related to patients with altered mental status. 7. Describe how to obtain an accurate Glasgow Coma Scale assessment. 8. Describe the procedure to obtain a blood glucose determinant. 9. Identify the components of the Cincinnati Stroke Scale. 10. Identify Region X field treatment of patients with altered mental status.

Objectives cont’d 11. Describe methods of restraining the combative patient. 12. Identify the indications, contraindications, complications, and documentation when using the QuickTrach airway device. 13. Given a scenario obtain the GCS.

Normal Mentation To identify abnormal mental status, need to understand what is normal We all practice a number of means and ways to identify the mental status General appearance Orientation to person, place, and time AVPU Alert Responds to verbal stimuli Responds to painful stimuli Unresponsive

General Appearance Can gain important information looking at the “big picture” Observe hygiene Observe clothing Observe overall appearance Observe verbal and nonverbal behavior Facial expressions Tone of voice, volume, quality, speech pattern Eye contact Memory intact for recent and long-term events? Is the patient focused; paying attention?

Orientation to Person, Place, Time
Can be insulting to a patient to ask pointedly “what’s your name?” “who’s the president?” Often helpful to state: “Since I don’t know your condition very well, I need to ask some very basic questions.” Person – patient can state their name Place – patient can recognize they are at home, in a store, in an ambulance, at a hospital Time – patient can tell what year it is and time of year (by month or season) Especially for persons who do not work outside the house, it is easy to lose track of what day of the week it is. We all lose track even when we work outside the house. Oriented persons should be able to tell you what year it is and even the month.

AVPU A – alert meaning the patient is awake
“A” is not meant to indicate orientation; just level of awakeness V – responding to verbal stimuli only Any response including fluttering of eyelids is a positive response to calling the patient’s name or asking a command P – responding to “pain” Could also indicate responding to tactile stimuli so do not always need to inflict a painful stimuli Any response including fluttering of eyelids or any body twitch is a positive response U – unresponsive Patient is flaccid with no responses at all

Stimulating a Painful Response
Acceptable methods Pressing on supraorbital ridge (bone below eyebrow) Trapezium squeeze – twisting muscle where neck and shoulder meet Rubbing sternum with knuckles Pressing on finger nail bed Unacceptable methods Any technique that would leave bruising Discouraged methods Any stimuli that may cause movement of the c-spine in a trauma patient by pulling away from the stimuli

Altered Mental Status Patient not awake, not alert or not oriented
Patient not aware of their environment Patient not oriented to person, place, time Patient confused Patient unable to demonstrate an understanding of what is being said Most important is noting any change over the course of time in level of consciousness

Level of Consciousness
One of the first indicators to change when the level of perfusion is diminishing is level of consciousness FYI – The blood pressure is one of the last indicators to change when the level of perfusion diminishes

Possible Cause of Altered Mental Status
Many lists have been created Mnemonics have been created to trigger lists AEIOU-TIPS SMASHED EMS should think outside the box and look for all potential causes When you find one cause, keep looking in case there are more than one cause associated with the altered mental status

Thinking Outside The Box
How many squares do you see? No matter what everyone answers, they are all correct. The directions said to call out how many squares you see and that is what everyone does. This exercise emphasizes that we can all look at the same thing but can each have our own perspective of what we see.

Thinking Outside The Box
30 squares: 1 large 4 x 4 square 16 small 1 x 1 squares 4 – 3 x 3 squares in each corner 9 – 2 x 2 squares

Mnemonic - AEIOU-TIPS A – alcohol
E – endocrine, electrolytes, encephalopathy I – insulin O – opiates U – uremia T – trauma – head injury, blood loss (shock) I – intracranial, infection P – poisoning; psychiatric S – seizures; syncope

Mnemonic - SMASHED S – substrates, sepsis Hyper/hypoglycemia, thiamine
M- meningitis, mental illness (ie: psychosis) A – alcohol (intoxication/withdrawal) S – seizure, stimulants H- hyper/hypothyroidism, hyper/hypothermia, hypotension, hypoxia, hypercarbia E – electrolyte imbalance, encephalopathy D- drugs of any sort

A - Alcohol Includes beer, wine, and spirits
Alcohol is a psychoactive drug with depressant effects Decreases attention and slows reaction speed Short term effects: intoxication, dehydration, alcohol poisoning Long term effects: changes to metabolism in the liver and brain; possible addiction Binge drinking Men- 5 or more drinks in a row Women – 4 or more drinks in a row

A- Alcohol Evaluate Clarity of speech Ability to comprehend the conversation Gait Not all persons drinking alcohol have altered mental states EMS to contact Medical Control if the patient with alcohol “on board” wants to sign a release ECRN needs to involve MD in dialogue and decision making

E - Endocrine Endocrine system is an informational system much like the nervous system Chemical messengers, hormones, travel mainly via blood vessels to trigger responses Common conditions involving the endocrine system Diabetes mellitus Thyroid disease Obesity

E - Electrolytes Electrically conductive medium
Principally: sodium, potassium, calcium, magnesium, chloride Activates muscles and neurons Homeostasis of electrolytes regulated by hormones Generally kidneys flush out excess levels of electrolytes Electrolyte disturbance (ie: dehydration or overhydration) may lead to cardiac and neurological complications (ie: medical emergencies) Dehydration: exercise, diaphoresis, diarrhea, vomiting, intoxication, starvation Sodium – Na+ Potassium – K+ Calcium – Ca++ Magnesium – Mg++ Chloride – Cl-

E- Encephalopathy A syndrome of brain dysfunction
Brain function and/or structure is altered Causes Brain infection, tumor, increased intracranial pressure, exposure to toxins, radiation, tumor, poor nutrition, hypoxia, decreased blood flow to the brain Hallmark – altered mental status Common signs and symptoms include loss of cognitive function and subtle personality changes More signs and symptoms listed in the notes section Common signs and symptoms of encephalopathy: loss of cognitive function, subtle personality changes, inability to concentrate, lethargy, depressed consciousness, twitching, loss of muscle tone, nystagmus (rapid, involuntary eye movement), tremor, seizures, restless picking, abnormal respiratory patterns.

I - Insulin Diabetes mellitus
The brain is very dependant on a set glucose level to function If the glucose level falls, the brain cannot function normally Rapid change in behavior, level of consciousness when the blood sugar level drops All persons with altered level of consciousness need to have their blood sugar level checked

O - Opiates Used for pleasure and pain relief
Depresses body functions and reactions Taken in pill form, smoked, injected Single dose effect can last 3 – 6 hours Detection time lasts usually up to 2 days High physical and psychological dependence Develop physical symptoms, behavioral symptoms, health effects, increased pain tolerance With an increased pain tolerance, may perform risky behavior and not feel injured/pain even though you have been injured.

Examples of Opiates Codeine Darvocet Demerol Dilaudid Fentanyl Heroin
Hydrocodone Lorcet Lortab Methadone Morphine Percocet Percodan Oxycodone Oxycontin Ultram Vicodin

Signs and Symptoms - Opiates
Constricted pupils Sweating Nausea/vomiting/diarrhea Needle marks Loss of appetite Slurred speech Slowed reflexes Depressed breathing Depressed pulse rate Drowsiness Fatigue Mood swings Impaired coordination Depression Apathy Stupor Euphoria

U - Uremia Urea and waste products not eliminated from the blood
Accompanies kidney failure/renal failure Usually diagnosed when kidney function < 50% of normal Early symptoms: anorexia and lethargy Late symptoms: decreased mental acuity and coma

Causes of Uremia (besides kidney failure)
Increased production of urea in the liver High protein diet; GI bleed; drugs; increased protein breakdown (surgery, infection, trauma, cancer) Decreased elimination of urea Decreased blood flow through the kidneys (ie: hypotension); urinary outflow obstruction Dehydration Chronic kidney infections (chronic pyelonephritis)

T - Trauma Head injury Epidural bleed
Rapid bleeding with unresponsiveness often following a lucid interval Subdural bleed Slow bleeding with subtle changes Intracerebral bleed Ruptured blood vessel releases blood into brain tissue with resulting tissue edema Blood loss  shock Epidural bleeds – even though this is a rapid bleed with rapid onset of symptoms, surgery is often performed quickly and can reverse signs and symptoms. Subdural bleeds bleed so slowly that signs and symptoms may not show for hours or days after injury. The slower detection causes delay in recognition and therefore treatment.

I - Intracranial Tumor Symptoms/neurological deficits often point to the area of brain affected Right sided brain insult affects left sided body function Left sided brain insult affects right sided body function As you age the brain shrinks in the cranial vault. Subdural hematomas are slow bleeds from a venous source. There is room to bleed into the skull without necessarily putting any pressure onto brain tissue in the elderly and in chronic alcoholics. Often have subtle or no symptoms with head injury.

Intracranial cont’d Head injury
Pupillary changes reflect same side of brain insult Right pupillary change reflects right sided brain insult Left pupillary change reflects left sided brain insult Consider acute vs chronic condition Chronic conditions: Elderly with frequent falls Chronic alcoholism with frequent falls Subdural bleeds are very common in the elderly and other populations that have frequent falls. The bleeding is so slow and with the shrunken brain tissue, there is room to accommodate the slow bleed. Due to the slow nature of the bleeding, signs and symptoms are often very subtle as in subtle changes in personality.

I - Infection Meningitis Urinary tract infection (UTI) Sepsis
Bacterial is highly contagious Mask the patient and all medical personnel caring for patient Urinary tract infection (UTI) Elderly often do not present with high fevers Sepsis Newborns/very young infants will be very ill Encephalitis Pneumonia – viral and bacterial Liver abscess Bacterial meningitis – high fever, lethargy, irritability, headache, stiff neck, sensitivity to light, bulging fontanelles in infants (unless infant is dehydrated or crying). Encephalitis – acute inflammation of the brain.

P - Poisoning Drug overdose Intentional
Assume you are not getting the full story Mixing any meds with alcohol increases the risk of worsening conditions Accidental Assume young children will not be truthful (fear of being punished) EMS to bring in all containers Many drugs taken alone canbe dangerous enough but when mixed with alcohol, the depressant effect of alcohol compounds the problem.

P - Psychiatric Schizophrenia Bipolar Common mental health problem
Hallmark – significant change in behavior and loss of contact with reality Hallucinations, delusions, depression Bipolar Not particularly common mental health problem One or more manic episodes with or without subsequent or alternating periods of depression

S - Seizure Epilepsy Head injury Hypoglycemia Hypertensive crisis
Rapid increase in diastolic B/P >130mmHg Hypertensive disorder of pregnancy Formerly referred to as toxemia If Valium is used to stop the seizure in pregnancy, verbally remind the hospital staff. Valium crosses the placental barrier and can cause depressant effects on the fetus.

S- Syncope Brief loss of consciousness with spontaneous recovery
“Fainting” Typically a very short episode resolved when the patient lies flat (as in when they pass out) Often warning signs &/or symptoms Lightheadedness Vision changes Dizziness Sudden pallor Nausea Sweating Weakness

Causes of Syncope Hypovolemia – fluid &/or blood loss
Metabolic – alteration in brain chemistry Hypoglycemia Inner/ middle ear problem Environmental Room temperature, carbon monoxide Screen patient with RAD 57 tool if carbon monoxide suspected Toxicological – excessive alcohol Cardiovascular - dysrhythmias Ask patients what position they were in when they fainted. Any person who states they passed out while lying down (the treatment for syncope) passes out due to a cardiovascular problem until proven otherwise.

Elderly Considerations
Contributing factors to confusion Stress Fear of removal from their home Talking with strangers (ie: EMS, hospital staff) Answering questions they do not know the answers to

Elderly Considerations
Altered mental status possibly due to: Medical insult or traumatic head injury Heart rhythm disturbance; AMI Dementia Infection Related to prescription medications Decreased blood volume – shock Respiratory disorders and/or hypoxia Hypo/hyperthermia Decreased blood sugar level

Distinguishing Dementia From Delirium
Chronic, slow progression Irreversible disorder Impaired memory Global cognitive deficits Most commonly caused by Alzheimer’s Does not require immediate treatment Delirium Rapid in onset (hours to days), fluctuating course May be reversed esp if treated early Greatly impairs attention Focal cognitive deficits Most commonly caused by systemic disease, drug toxicity, or metabolic changes Requires immediate treatment Global cognitive deficits – more overall deficit not restricted to one area of the body Focal cognitive deficit – affects noted in a specific area of the body (ie: right extremity, left side of face)

Dementia Causes of this progressive disorientation Small strokes
Atherosclerosis Age related neurological changes Neurological changes Certain hereditary diseases (ie: Huntington’s) Alzheimer’s disease

Delirium Disorganized thinking with reduced ability to maintain attention and to shift attention Synonyms: Acute confusional state Acute cognitive impairment Acute encephalopathy Acute altered mental status

Patient Assessment ABC’s Is ventilation/breathing adequate?
Does supplemental oxygen need to be given? Room air contains 21 % O2 Nasal cannula delivers 24% - 44% O2 (2 – 6 L/min) Non-rebreather can deliver up to 100% O2 (12-15 L/min) Does the C-spine need to be controlled? Can the patient protect their own airway?

Patient Assessment Adequacy of circulation
What is the blood pressure? Does the blood pressure equate with the patient assessment? Is there a peripheral pulse? What is the peripheral pulse rate and quality? Do you need to gain IV access? Is IV access necessary? Is IV access needed as a precaution? If you can palpate a peripheral pulse (ie: radial pulse) the blood pressure is roughly, as a guideline, 80/systolic. If you can only palpate a carotid pulse, the blood pressure is roughly 60/systolic.

Patient Assessment Cardiac monitor Is there a dysrhythmia present?
What is the blood sugar level? Does the patient require isolation for potential infectious disease? History From the patient, caregiver, bystander History of present illness Pertinent past medical history

Patient Assessment Allergies Current medications
Use of drugs or other substances Physical exam Vital signs – B/P – P – R – SpO2 Hands-on assessment head to toe Skin exam Rashes? Evidence of infection?

Patient Assessment - Neurological
Evaluate appearance, behavior, attitude Thought disorders – logical and realistic? False beliefs/delusions? Suicidal/homicidal thoughts? Perception disorders? Hallucinations present? Mood and affect Insight and judgement – can patient understand circumstances and identify surroundings? Sensorium and intelligence – normal level of consciousness? Impaired cognition/intellectual functioning?

Neurological Assessment cont’d
Level of consciousness AVPU Pupillary response Ability to identify person, place, time Glasgow coma scale Scores 3 – 15 More important than any one score is the trend the score is making When checking pupillary response, ask the patient to focus on a set point (ie: “look at the tip of my nose”), with the light on bring the penlight from the side to in front of one pupil. Move the penlight out to the side and bring up and around to the opposite pupil. Bring the light in from the side checking for pupillary response.

Glasgow Coma Scale Evaluates wakefulness and awareness Wakefulness
The state of being aware of the environment Awareness A demonstrated understanding of what is being said

GCS Tips Always give the patient the best score possible
If the patient can move the right extremity and not the left, score for the movement of the right extremity Deteriorations will be noted faster as the score drops by awarding the highest points possible Pediatric component Used for the young patient who is not yet verbal due to age

Glasgow Coma Scale EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
4--Spontaneous 5--Oriented 6--Obeys 3—Verbal stimuli 4--Confused/ disoriented 5—Localizes/purposeful 2--Pain 3--Inappropriate words 4--Withdraws 1--None 2--Incomprehensible sounds 3--Abnormal flexion 2--Extensor posturing

GCS Score GCS 13 – 15 GCS 9 – 12 GCS <8 Mild brain injury
Moderate brain injury GCS <8 Severe brain injury Most patients with this score are in coma Evaluate for the need to assist in protecting the patient’s airway

Evaluating Eye Opening
Best response is obtained, if at all possible, before physical contact is made with patient This is not always possible when the C-spine needs to be controlled as c-spine control occurs immediately before other interaction with patient Patient gets credit if eyelids open even for a brief moment or just flicker Always consider need to control the C-spine over the verbal response of the GCS

Evaluating Verbal Response
5 – uses appropriate words/conversation 4 – speaks but is confused and disoriented 3 – speaking and you can understand the words spoken but the words do not contribute to the current conversation 2 – making sounds like grunts and moans; no intelligible words 1 – no response; no speech; no noise

Modifying GCS for Pediatrics
Adult GCS must be modified to match the developmental age of the young nonverbal child Best eye opening remains unchanged Best verbal response for non-verbal patient 5 – Smiles, coos, follows objects 4 – Irritable cry but is consolable 3 – Inappropriate crying; cries to pain 2 – Inconsolable, agitated; moans or groans to pain 1 – No response

Evaluating Motor Response
6 – Obeys commands 5 – Localizes/Purposeful movement Hits at you, grabs at your hands, pulling equipment off, pushing you away 4 – Withdraws from pain (unable to localize) 3 – Flexing with internal rotation and adduction of shoulders and flexion of elbows 2 – Extension with elbows straightened and possible internal shoulder and wrist rotation

Pediatric GCS Motor Response
Best motor response for non-verbal patient 6 – obeys commands May be difficult to determine if child understands 5 – localizes pain by withdrawing to touch stimuli 4 – withdraws to pain (more stimuli than touch) 3 – same – abnormal flexion 2 – same – abnormal extension 1 – no motor response; patient flaccid

GCS Practice (answers at end) Score the Following Patients:
The patient is watching you approach The patient speaks normally and answers questions The patient raises their arm when you ask to take their B/P Patient #2 The patient is looking around the environment The patient speaks normally but is confused When you ask the patient to raise their arm, they are slow to do so but eventually raises their arm

GCS Practice Patient #3 Patient #4
The patient’s eyes are closed and there is no movement even after squeezing the trapezius The patient groans when the trapezius is squeezed The patient flexes their arms to the chest wall Patient #4 Patient eyes open briefly when their name is called Patient groans while being pinched Patient does not follow commands and pushes you away whenever you try to treat the patient

Eyes are closed but open when calling the patient The patient yells “don’t” and “stop it” when being touched, assessed, and treated but is not speaking Patient pushes your hands away and is trying to pull off the cervical collar and IV Patient #6 Eyes open briefly when asked to open them The patient moans weakly when being touched The patient tries to pull away when care is being provided (ie: IV start)

Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyes The patient responds verbally saying their head hurts and the lights make it hurt worse Patient follows commands except for opening eyes Patient #8 Eyes are open looking straight ahead When asked what month it is, the patient responds “he, umm, he, my jacket, don’t…” Does not follow commands. Pulls one hand away and the other hand is pushing you away Patient #7 – eye muscle movement when being talked to gets a 3. Need to record results as you assess them. Appropriate to make a note in the comments section to explain why the patient’s eye opening is not “4”. Patient #8 When one hand withdraws (ie: jerks away) and one hand pushes you away (purposeful movement), award the highest score possible

GCS Practice – Pediatrics < 1y/o
Patient #9 (6 month old) Infant’s eyes flutter when touched Patient cries when gently touched; is consolable Patient withdraws when first touching them Patient #10 (9 month old) Eyelids flutter when the IO needle is placed Patient moans during the IO insertion and when deformed extremity is handled The patient pulls their arms tightly into their chest wall curling shoulders and wrists inward

GCS Answers Patient # 1 - 4, 5, 6 = 15 Patient # 2 – 4, 4, 6 = 14

Blood Glucose Level To be obtained in the field when:
Patient is known diabetic with diabetic related problem Patient has an altered level of consciousness for unknown reasons Patient is unresponsive (includes post-ictal patients) Consider the patient to have more than one problem at a time Make sure a 2nd or 3rd issue is not present once you find the first issue (ie: hypoglycemia) Be aware: Peds patients can drop their blood sugar level fast Patients can have simultaneous problems. Do full evaluations even after finding one problem. Pediatric patients under stress use large amounts of glucose form energy stores and can develop hypoglycemia quickly even in the absence of any diabetic disease.

Blood Glucose Monitor Machines calibrated for capillary specimen
Keep the site hanging dependently Can use side of finger tips or the forearm Once the site is wiped with an alcohol prep pad, let the site air dry before obtaining a sample Use a lancet to obtain a blood sample from the finger or forearm Patient should not sign a release until EMS can document a blood sugar level >60 in the field The side of the finger tip (calluses are more likely on the finger tip and lancets often are not able to adequately puncture the tough skin to get an adequate blood drop) can be used as a site. Puncture the ulnar side of the finger so the patient can more easily hold their hand to drop the blood sample on the strip. Any place on the forearm can be used as a site.

Stroke Care Most important question to ask:
Rapid detection of signs and symptoms with rapid diagnosis is essential Need to avoid delays 3 hour time limit to administer a fibrinolytic from time of first onset of signs and symptoms Increase risk of cerebral bleeding beyond a 3 hour time frame Most important question to ask: What time did symptoms begin?

Cincinnati Stroke Scale
Quick and simple evaluation tool Documentation Facial droop Right/left facial droop or no droop Arm drift Right/left arm drift or no drift Speech Clear or not clear

Facial Drooping Ask the patient to smile real big and show you their teeth Best way to see if a droop is present

Arm Drift With palms upward, there is a better chance to see a drift. If the eye are open and the patient sees their arm drifting, they may tend to correct it. Talk to the patient for the 10 seconds their eyes are closed (“you’re doing great; we’re almost done”) Demonstrate first and then have patient hold their hands out in front, palms up, for 10 seconds

Clarity of Speech Most likely you’ll know by now if there is a speech problem Can have the patient repeat after you any words or a sentence you give them “You can’t teach an old dog new tricks”

7 D’S Of Stroke Care Detection – of signs and symptoms
Dispatch – patient to call 911 Delivery – by EMS to the appropriate facility Door – emergent triage in the ED Data – appropriate tests Decision – to administer a fibrinolytic or not after diagnostic tests and assessment completed Drug – must administer the fibrinolytic within 3 hours of onset of symptoms Studies have shown that there is an increase in cerebral bleeds when the fibrinolytic is administered over 3 hours from onset of symptoms.

Quick Fixes of Altered Mental Status
Hypoglycemia – Dextrose Hypoxia – oxygen Pinpoint pupils – Narcan Seizures – Valium Dextrose if seizure due to hypoglycemia Cold – warm the patient up When walking into the scene for a patient with seizures and they are still having a seizure, quickly determine 2 questions: Does this patient have a history of seizures/epilepsy (think valium for stopping the seizure) Is this patient a diabetic? Obtain a glucose level and if <60, administer dextrose. Dextrose strength is dependent on patient age: <1 y/o gets D12.5%; 1 – 15 y/o gets D25%; >16 y/o gets D50%. If Valium is given to the pregnant patient with a seizure, make sure to verbally remind the hospital staff upon hospital arrival. Valium crosses the placental barrier and can depress the infant.

Combative Patient Talking down a patient is an art that requires effort and skill Need enhanced people skills of listening and observation Make sure the scene is safe Provide a calm and supportive environment Treat any existing medical conditions Do not confront or argue with the patient Provide realistic reassurance Respond to the patient in a direct, simple manner

2 Extremes of Behavioral Emergencies
Combative patient Fidgeting, nervous energy Voice getting louder Pacing Shouting, apparent anger Withdrawn patient Facing away from care provider Decreasing eye contact No eye contact or conversation Totally withdrawn

System Operating Guidelines – Use of Restraints
EMS personnel should contact Medical Control if possible before restraining patient May restrain patient first for patient and personnel safety All attempts must be made to avoid injury to patient and EMS personnel Do not compromise the patient’s ability to breath or further aggravate any injury or illness EMS to clearly document the behavior leading to use of restraints Handcuffs applied by police only Officer must accompany patient in the ambulance during transport if handcuffs are in place

Methods of Restraint Verbal de-escalation First method to employ
Avoids physical contact with the patient – safer Watch “personal space” 1.5 – 4 feet in the United States Keep open an “escape route” for yourself Personal space is defined as 1.5 to 4 foot distance from the person. This is the socially acceptable distance between strangers in the United States. Escape routes are means for the EMS provider to step away from harm’s way. Never place the patient between you and your exit route which is usually the doorway.

Methods of Restraint cont’d
Physical restraint Materials or techniques that will restrict the movement of a patient Soft restraints: sheets, wristlets, chest Posy Hard restraints: plastic ties, handcuffs, leathers Police must be in ambulance for transport if patient is in handcuffs Patients need frequent reassessment to evaluate for injury or possible neurovascular compromise or airway compromise Use a surgical mask placed loosely over the face to control spitting Avoid using hard restraints if at all possible. Never “hog tie” a patient with arms and legs tied together behind the back. CMC policy states that if the patient is in handcuffs, a police officer must be in the ambulance for transport. It is not acceptable to be given the handcuff key or to have the officer follow in their own car.

Physical Restraints EMS to not transport a restrained patient prone
Positional asphyxia may cause death Be prepared to protect the patient’s airway Do not secure straps to moving side rails Restraining thighs just above knees often prevents kicking Struggling against restraints may lead to severe acidosis and fatal dysrhythmias NEVER leave restrained patient unattended

Methods of Restraints cont’d
Chemical restraint Administration of specific pharmacological agents Decrease agitation Increase cooperation Not alter a patient’s level of consciousness Common agents used are haldol (in the ED) and/or benzodiazepines Diazepam (Valium) Lorazepam (Ativan) Midazolam (Versed)

Region X SOP - Severe Anxiety or Agitation
Valium 5 mg IVP slowly over 2 minutes Repeat as needed Maximum total dose is 10 mg In the absence of an IV, Valium 10 mg IM/rectally Watch for respiratory depression with administration of a benzodiazepine Have a BVM ready to use as a precaution

Documentation Tips All patients require a blood glucose level for altered mental status Documentation should reflect serial monitoring of the patient’s condition looking for changes GCS AVPU If restraints are used, document objectively and in detail the behavior that led to the need for restraints Document distal circulation of any restrained extremity Patients with altered mental status cannot sign a release in the field

Airway Control Measures
Region X EMS use the QuickTrach device ED tools available: ACMC – Quicktrach - Melker (especially being used for large necks - Surgical tray for surgical cric NLFH – QuickTrach - Melker - Arndt

Securing the Airway - QuickTrach
Indications Patient requires emergency assisted ventilation when all other conventional methods have failed Contraindications Tracheal transection Other less invasive maneuver allows ventilation >77# (35kg) – use 4.0mm ID device 22# – 77# (10 -35kg) use 2.0 mm ID <22# (10kg) – use needle cricothyrotomy

QuickTrach Device Connecting tube Syringe Flanges to attach ties
Stopper that is removed before final insertion

QuickTrach Procedure Patient positioned supine; neck hyperextended if no trauma) Cricothyroid membrane located and site cleansed Palpate the soft indentation between the thyroid and cricothyroid cartilages Larynx secured laterally between the thumb and forefinger Cricothyroid membrane punctured at a 900 angle The cricothyroid membrane is easier to find if you start from the base of the neck and run your fingertip upward. The first hard bone is the cricoid cartilage. The cricothyroid membrane is just above the cricoid cartilage.

Cricothyroid Membrane
Target area

QuickTrach cont’d Entry into the trachea confirmed by aspirating air thru the syringe If air is present, the needle is in the trachea Now angle changed to 600 with the tip pointing towards the feet and device advanced forward into the trachea to the level of the stopper Stopper to be snug against the skin Stopper reduces risk of inserting the needle too deeply Stopper removed

QuickTrach cont’d Needle and syringe held firmly, only the plastic cannula is slid into the trachea Advancement stopped when the flange rests snug against the neck Needle and syringe carefully removed Connecting tube attached to the cannula Can be preattached to BVM and then attached to cannula when needle and syringe are removed BVM attached to the connecting tube Patient can be bagged Cannula secured with the neck tape ties provided Suggest attaching one end of the neck ties prior to inserting the QuickTrach device – this leaves only one side to attach with the device in place with less maneuverability.

QuickTrach Complications
Puncture through of the trachea During bagging attempts surrounding tissue will expand due to leakage of air Inadvertent puncture of a blood vessel Formation of a hematoma under the skin and surrounding the airway External bleeding Inability to ventilate the patient There may be an obstruction at a more distal site

QuickTrach Documentation
Reason(s) an alternate airway devise was necessary Size of airway placed 4.0 mm for persons over 77# 2.0 mm for persons 22# - 77# Confirmation of airway placement Bilateral breath sounds Bilateral chest wall rise and fall

Melker Airway Device

Arndt Airway Device

Case Studies Read the following case studies How would you respond?
Can be a patient found by EMS Can be a walk-in Ed patient How would you respond? More information may be provided in the notes section

Case Study #1 57 year old patient found behind a garage unresponsive.
Breathing and has a radial pulse. Dry blood on lips. What are your impressions? How does your assessment proceed?

Case Study #1 Impression list Post-ictal from seizure Hypoglycemia
Alcohol intoxication Drug overdose Acute MI Stroke Head trauma

Case Study #1 Assessment Control c-spine while palpating neck area
Evaluate if respiratory assistance is needed Check quality, depth, rate of respirations, SpO2 Calculate GCS; obtain vital signs Consider IV-O2-monitor Assess for need for fluid challenge Assess cardiac rhythm; consider obtaining a 12 lead EKG Obtain a blood glucose sample

Case Study #2 Patient brought to ED by spouse
Patient dropping silverware at lunch, unable to sit up straight, unable to complete sentences Vital signs: 170/110; P – 64; R – 16; GCS -14 EKG monitor -

Case Study #2 What is your impression? What is the cardiac rhythm?
Atrial fibrillation How does this rhythm relate to any impressions? What assessments need to be done? Blood sugar level for all patients with altered level of consciousness Cincinnati stroke scale Patients in atrial fibrillation are at higher risk of dislodging an atrial clot that could travel to the brain and cause an ischemic stroke. Check if the atrial fibrillation is long standing. If the patient is on Coumadin as an anticoagulant.

Case Study #2 Cincinnati stroke scale
Ask the patient to smile real big showing you their teeth Ask the patient to put their hands out in front, palms up, and close their eyes Hold the position for 10 seconds Ask the patient to repeat a saying “You can’t teach an old dog new tricks”

When did the symptoms begin?
Case Study #2 What’s the most important question to ask the patient? When did the symptoms begin? The patient must receive treatment with fibrinolytics started within 3 hours of time of onset.

Case Study #3 An 18 year-old patient is found under the bleachers at school unresponsive with shallow respirations. AVPU - responds to painful stimuli Vital signs: 110/70; P – 110; R – 4; pupils constricted GCS – 8 What are your impressions?

Case Study #3 Impression list Drug overdose Head injury Hypoglycemia
Opiates – constricted pupils, depressed respirations Head injury Hypoglycemia Post-ictal

Case Study #3 Treatment Control c-spine
Consider c-spine injury until proven otherwise Secure airway Frequency to ventilate via BVM to support respirations? Once every 5 – 6 seconds Gain IV access Peripheral site? IO if peripheral unobtainable Evaluate cardiac rhythm Anyone with a GCS 8 or less is at risk for airway compromise and EMS should consider need to protect the airway (ie: intubate the patient).

Case Study #3 Medications to administer in the field (Region X EMS)
If blood sugar < 60 give 50 ml of 50% Dextrose As a diagnostic tool give Narcan 2 mg IVP every 5 minutes as needed for desired effect Maximum total of 10 mg Consider need to protect the airway with intubation following conscious sedation No indication for lidocaine Versed to relax the patient Morphine alternated with Versed to potentiate the effects of both medications Benzocaine if a blink reflex is present If a blink reflex is present, a gag is still present. Test by tapping the space between the eyes above the bridge of the nose or stroke the eye lashes. Look for any eyelid movement.

Case Study #4 EMS is called to the scene for an unknown medical emergency Police have secured the scene The patient is a 54 year-old male who is combative What are your impressions? What actions are indicated?

Case Study #4 Impressions Psychiatric problem Altered blood sugar
Head injury Electrolyte imbalance

Case Study #4 Action to take
Make sure the scene is safe and remains safe for the rescuers and the patient Will need a blood sugar at some point A cardiac monitor to evaluate rhythm could be important assessment information May need to restrain the patient for staff safety and patient safety

Case Study #4 Verbal de-escalation Soft restraints
Methods to restrain patients Verbal de-escalation Soft restraints Wrist and ankle restraints Chest posey or sheet Hard restraints with EMS in the field If police handcuff the patient, police must ride with the patient in the ambulance Police are not allowed to hand off cuff keys to EMS

Case Study #4 Documentation
Patient’s behavior in descriptive, objective terms that indicated the need for restraint If no time to contact Medical Control before restraining patient, EMS to contact Medical Control after the patient is restrained Document distal circulation, motion, and sensation periodically after restraining the patient

Case Study #5 32 year-old patient was found combative at work. This is very unusual behavior for this patient Vital signs: 110/70; P – 80; R – 18; skin damp Impression? Further assessment? Treatment?

Case Study #5 Impression Assessment Hypoglycemia Head injury
Drug / alcohol influence Assessment Blood sugar level Cardiac monitor Neurological evaluation

Case Study #5 Blood sugar was 25 Patient now alert and oriented
Treatment indicated 50 ml 50% Dextrose IVP Patient now alert and oriented Repeat blood sugar 56 Patient wants to sign a release. Can EMS allow a release to be obtained? No release until the blood sugar is >60 EMS to stay on the scene and continue to reassess as the patient takes in food or liquids

Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices 3rd Edition. Prentice Hall. 2009 Limmer, D. O’Keefe, M. Emergency Care. 10th Edition. Prentice Hall Region X SOP’s March Amended January 1, 2008. En.wikipedia.org/wiki/Endocrine_system En.wikipedia.org/wiki/Electrolyte_system En.wikipedia.org/wiki/Encephalopathy_system En.wikipedia.org/wiki/Opiate_system En.wikipedia.org/wiki/Uremia_system

Bibliography cont’d pdf staff.washington.edu/momus/PB/comachan.htm

The Patient With An Altered Mental Status

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