1. Altered Mental Status Coma and Reduced GCS Emergencies Franko Haller, Medical English VI franko@me.com December 2010 Mentor: A. Žmegač Horvat

2. Imagine yourself... - A1 highway - early August - foreign tourists - high-traffic season

3. A 112-call - 65 year old female - LOC - bus tour - exit Brinje, direction South - English speaking tour with Croatian guide *

4. What can you expect? - 65 year old female - LOC - bus tour - exit Brinje - English speaking tour with Croatian guide ALMOST anything!

5. How to approach the patient? D DANGER

6. How to approach the patient? R RESPONSE AVPU assessment A - ALERT V - responds to VOICE P - responds to PAIN U - UNRESPONSIVE

7. How to approach to a patient? DR ABC DANGER, RESPONSE, AIRWAY, BREATHING, CIRCULATION

8. What can you see? - 65 year old female - group of 15 Canadians D - no danger to provider/emergency team R - reduced LOC; not alert, does not respond to voice stimuli, responds to pain stimulus on sternum AVPU A - open, patent B - normal breathing, RR 18/min C - strong, 98 bpm, BP 120/80

9. SAMPLE history S - signs & symptoms A - allergies M - medications P - past medical history L - last oral intake E - events preceding this acute emergency

10. SAMPLE history S - signs & symptoms: tired and cranky, complained of lightheadedness A - allergies: no known allergies M - medications: metformin and other drugs for her diabetes P - past medical history: known diabetic, history of a stroke 5 years ago L - last oral intake: breakfast 3 hours ago E - events preceding this acute emergency: severe and sudden headache minutes before she lost consciousness

11. What should you do next? Check blood glucose Establish an i.v. access (50 ml of 50% glucose/dextrose flushed with NS) Check pupils Check reflexes Reevaluate ABCs (consider oropharyngeal airway) Determine GCS

12. What should you do next? Blood Glucose 1.1 mmol/L on glucometer Establish an i.v. access (50 ml of 50% glucose/dextrose flushed with NS) Check pupils - fixed and dilated, symmetric Check reflexes - diminished, symmetric Reevaluate ABCs - unchanged

13. Coma and decreased GCS THINK ABOUT * no focal neurology: low O2, high CO2, hypotension, metabolic (glucose, Na+, Ca++, K+, acidosis, alkalosis, renal, liver failure), hypothermia, pyrexia, malignant hypertension overdose: opiates, benzos, alcohol, insulin, some oral hypoglycemics * focal neuro findings: CVA, tumor, hematoma, trauma, hypoglycemia * meningism: meningitis, encephalitis, SAH

14. Glasgow Coma Scale (GCS) = or < 8 requires intubation E2 V3 M5 total GCS 10

15. Acute confusion Confusion Off-legs Acopia Dementia Delirium Psychosis acute deficit in thinking, memory, orientation or awareness medical slang for acute inability to walk in the elderly medical slang for elderly patients no longer coping at home chronic deficit in thinking, memory and/or personality acute onset confusion with hallucinations or illusions hallucinations or illusions without confusion

16. Acute confusion THINK ABOUT EMERGENCIES acute chronic ASK ABOUT low O2, high CO2, MI, sepsis, intracranial bleed, meningitis, encephalitis, raised ICP, CVA, arrhythmia; common: infection, metabolic, head injury, alcohol withdrawal/intoxication, post-ictal, Korsakoff’s dementia history from family, relatives, friends, nurses PMH: lung, hear, liver, kidney, epi, dementia, psych DH: benzos, opiods, steroids, NSAIDs, B-blockers, psych drugs, alcohol, recreational drugs

17. Acute confusion THINK ABOUT EMERGENCIES Look for Obs Investigations cyanosis, pulse (HR and rhythm), bronchial breathing, creps, abdo pain, signs of head injury, neck stiffness, photophobia, focal neurology, pupils, papilloedema, tone and reflexes GCS, temp, HR, BP, RR, O2 sats urine dipstick, middle stream, culture, swab blds FBC, U+E, LFTs, CRP, glucose, Ca++, cardiac markers, blood cultures, amylase, TFT, B12 level, ABG ECG, CXR, CT, LP if CT normal

18. Acute confusion Abbreviated Mini- Mental (10-point test) 8 or more is normal in an elderly patient

19. Thank you for your attention Literature: 1. Oxford Handbook for The Foundation Programme; Hurley, Dawson, Sanders, 2nd E, Oxford University Press, 2008 2. Oxford Cases in Medicine and Surgery; Guiding Your Through Diagnosis; Farne, Norris, Smith, Oxford University Press, 2010