Presentation on theme: "The Patient With An Altered Mental Status"— Presentation transcript:
1The Patient With An Altered Mental Status ECRN Mod IV 2009 CEAdvocate Condell Medical CenterObjectives by Jeremy Lockwood FFPM Mundelein Fire DepartmentPrepared by Sharon Hopkins, RN, BSN, EMT-P
2ObjectivesUpon 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.
3Objectives cont’d6. 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.
4Objectives cont’d11. 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.
5Normal MentationTo identify abnormal mental status, need to understand what is normalWe all practice a number of means and ways to identify the mental statusGeneral appearanceOrientation to person, place, and timeAVPUAlertResponds to verbal stimuliResponds to painful stimuliUnresponsive
6General AppearanceCan gain important information looking at the “big picture”Observe hygieneObserve clothingObserve overall appearanceObserve verbal and nonverbal behaviorFacial expressionsTone of voice, volume, quality, speech patternEye contactMemory intact for recent and long-term events?Is the patient focused; paying attention?
7Orientation 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 namePlace – patient can recognize they are at home, in a store, in an ambulance, at a hospitalTime – 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.
8AVPU A – alert meaning the patient is awake “A” is not meant to indicate orientation; just level of awakenessV – responding to verbal stimuli onlyAny response including fluttering of eyelids is a positive response to calling the patient’s name or asking a commandP – responding to “pain”Could also indicate responding to tactile stimuli so do not always need to inflict a painful stimuliAny response including fluttering of eyelids or any body twitch is a positive responseU – unresponsivePatient is flaccid with no responses at all
9Stimulating a Painful Response Acceptable methodsPressing on supraorbital ridge (bone below eyebrow)Trapezium squeeze – twisting muscle where neck and shoulder meetRubbing sternum with knucklesPressing on finger nail bedUnacceptable methodsAny technique that would leave bruisingDiscouraged methodsAny stimuli that may cause movement of the c-spine in a trauma patient by pulling away from the stimuli
10Altered Mental Status Patient not awake, not alert or not oriented Patient not aware of their environmentPatient not oriented to person, place, timePatient confusedPatient unable to demonstrate an understanding of what is being saidMost important is noting any change over the course of time in level of consciousness
11Level of Consciousness One of the first indicators to change when the level of perfusion is diminishing is level of consciousnessFYI – The blood pressure is one of the last indicators to change when the level of perfusion diminishes
12Possible Cause of Altered Mental Status Many lists have been createdMnemonics have been created to trigger listsAEIOU-TIPSSMASHEDEMS should think outside the box and look for all potential causesWhen you find one cause, keep looking in case there are more than one cause associated with the altered mental status
13Thinking 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.
14Thinking Outside The Box 30 squares:1 large 4 x 4 square16 small 1 x 1 squares4 – 3 x 3 squares in each corner9 – 2 x 2 squares
15Mnemonic - AEIOU-TIPS A – alcohol E – endocrine, electrolytes, encephalopathyI – insulinO – opiatesU – uremiaT – trauma – head injury, blood loss (shock)I – intracranial, infectionP – poisoning; psychiatricS – seizures; syncope
17A - Alcohol Includes beer, wine, and spirits Alcohol is a psychoactive drug with depressant effectsDecreases attention and slows reaction speedShort term effects: intoxication, dehydration, alcohol poisoningLong term effects: changes to metabolism in the liver and brain; possible addictionBinge drinkingMen- 5 or more drinks in a rowWomen – 4 or more drinks in a row
18A- AlcoholEvaluateClarity of speechAbility to comprehend the conversationGaitNot all persons drinking alcohol have altered mental statesEMS to contact Medical Control if the patient with alcohol “on board” wants to sign a releaseECRN needs to involve MD in dialogue and decision making
19E - EndocrineEndocrine system is an informational system much like the nervous systemChemical messengers, hormones, travel mainly via blood vessels to trigger responsesCommon conditions involving the endocrine systemDiabetes mellitusThyroid diseaseObesity
20E - Electrolytes Electrically conductive medium Principally: sodium, potassium, calcium, magnesium, chlorideActivates muscles and neuronsHomeostasis of electrolytes regulated by hormonesGenerally kidneys flush out excess levels of electrolytesElectrolyte disturbance (ie: dehydration or overhydration) may lead to cardiac and neurological complications (ie: medical emergencies)Dehydration: exercise, diaphoresis, diarrhea, vomiting, intoxication, starvationSodium – Na+Potassium – K+Calcium – Ca++Magnesium – Mg++Chloride – Cl-
21E- Encephalopathy A syndrome of brain dysfunction Brain function and/or structure is alteredCausesBrain infection, tumor, increased intracranial pressure, exposure to toxins, radiation, tumor, poor nutrition, hypoxia, decreased blood flow to the brainHallmark – altered mental statusCommon signs and symptoms include loss of cognitive function and subtle personality changesMore signs and symptoms listed in the notes sectionCommon 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.
22I - Insulin Diabetes mellitus The brain is very dependant on a set glucose level to functionIf the glucose level falls, the brain cannot function normallyRapid change in behavior, level of consciousness when the blood sugar level dropsAll persons with altered level of consciousness need to have their blood sugar level checked
23O - Opiates Used for pleasure and pain relief Depresses body functions and reactionsTaken in pill form, smoked, injectedSingle dose effect can last 3 – 6 hoursDetection time lasts usually up to 2 daysHigh physical and psychological dependenceDevelop physical symptoms, behavioral symptoms, health effects, increased pain toleranceWith an increased pain tolerance, may perform risky behavior and not feel injured/pain even though you have been injured.
24Examples of Opiates Codeine Darvocet Demerol Dilaudid Fentanyl Heroin HydrocodoneLorcetLortabMethadoneMorphinePercocetPercodanOxycodoneOxycontinUltramVicodin
25Signs and Symptoms - Opiates Constricted pupilsSweatingNausea/vomiting/diarrheaNeedle marksLoss of appetiteSlurred speechSlowed reflexesDepressed breathingDepressed pulse rateDrowsinessFatigueMood swingsImpaired coordinationDepressionApathyStuporEuphoria
26U - Uremia Urea and waste products not eliminated from the blood Accompanies kidney failure/renal failureUsually diagnosed when kidney function < 50% of normalEarly symptoms: anorexia and lethargyLate symptoms: decreased mental acuity and coma
27Causes of Uremia (besides kidney failure) Increased production of urea in the liverHigh protein diet; GI bleed; drugs; increased protein breakdown (surgery, infection, trauma, cancer)Decreased elimination of ureaDecreased blood flow through the kidneys (ie: hypotension); urinary outflow obstructionDehydrationChronic kidney infections (chronic pyelonephritis)
28T - Trauma Head injury Epidural bleed Rapid bleeding with unresponsiveness often following a lucid intervalSubdural bleedSlow bleeding with subtle changesIntracerebral bleedRuptured blood vessel releases blood into brain tissue with resulting tissue edemaBlood loss shockEpidural 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.
29I - IntracranialTumorSymptoms/neurological deficits often point to the area of brain affectedRight sided brain insult affects left sided body functionLeft sided brain insult affects right sided body functionAs 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.
30Intracranial cont’d Head injury Pupillary changes reflect same side of brain insultRight pupillary change reflects right sided brain insultLeft pupillary change reflects left sided brain insultConsider acute vs chronic conditionChronic conditions:Elderly with frequent fallsChronic alcoholism with frequent fallsSubdural 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.
31I - Infection Meningitis Urinary tract infection (UTI) Sepsis Bacterial is highly contagiousMask the patient and all medical personnel caring for patientUrinary tract infection (UTI)Elderly often do not present with high feversSepsisNewborns/very young infants will be very illEncephalitisPneumonia – viral and bacterialLiver abscessBacterial 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.
32P - Poisoning Drug overdose Intentional Assume you are not getting the full storyMixing any meds with alcohol increases the risk of worsening conditionsAccidentalAssume young children will not be truthful (fear of being punished)EMS to bring in all containersMany drugs taken alone canbe dangerous enough but when mixed with alcohol, the depressant effect of alcohol compounds the problem.
33P - Psychiatric Schizophrenia Bipolar Common mental health problem Hallmark – significant change in behavior and loss of contact with realityHallucinations, delusions, depressionBipolarNot particularly common mental health problemOne or more manic episodes with or without subsequent or alternating periods of depression
34S - Seizure Epilepsy Head injury Hypoglycemia Hypertensive crisis Rapid increase in diastolic B/P >130mmHgHypertensive disorder of pregnancyFormerly referred to as toxemiaIf 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.
35S- 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 symptomsLightheadedness Vision changesDizziness Sudden pallorNausea SweatingWeakness
36Causes of Syncope Hypovolemia – fluid &/or blood loss Metabolic – alteration in brain chemistryHypoglycemiaInner/ middle ear problemEnvironmentalRoom temperature, carbon monoxideScreen patient with RAD 57 tool if carbon monoxide suspectedToxicological – excessive alcoholCardiovascular - dysrhythmiasAsk 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.
37Elderly Considerations Contributing factors to confusionStressFear of removal from their homeTalking with strangers (ie: EMS, hospital staff)Answering questions they do not know the answers to
38Elderly Considerations Altered mental status possibly due to:Medical insult or traumatic head injuryHeart rhythm disturbance; AMIDementiaInfectionRelated to prescription medicationsDecreased blood volume – shockRespiratory disorders and/or hypoxiaHypo/hyperthermiaDecreased blood sugar level
39Distinguishing Dementia From Delirium Chronic, slow progressionIrreversible disorderImpaired memoryGlobal cognitive deficitsMost commonly caused by Alzheimer’sDoes not require immediate treatmentDeliriumRapid in onset (hours to days), fluctuating courseMay be reversed esp if treated earlyGreatly impairs attentionFocal cognitive deficitsMost commonly caused by systemic disease, drug toxicity, or metabolic changesRequires immediate treatmentGlobal cognitive deficits – more overall deficit not restricted to one area of the bodyFocal cognitive deficit – affects noted in a specific area of the body (ie: right extremity, left side of face)
40Dementia Causes of this progressive disorientation Small strokes AtherosclerosisAge related neurological changesNeurological changesCertain hereditary diseases (ie: Huntington’s)Alzheimer’s disease
41DeliriumDisorganized thinking with reduced ability to maintain attention and to shift attentionSynonyms:Acute confusional stateAcute cognitive impairmentAcute encephalopathyAcute altered mental status
42Patient Assessment ABC’s Is ventilation/breathing adequate? Does supplemental oxygen need to be given?Room air contains 21 % O2Nasal 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?
43Patient 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.
44Patient Assessment Cardiac monitor Is there a dysrhythmia present? What is the blood sugar level?Does the patient require isolation for potential infectious disease?HistoryFrom the patient, caregiver, bystanderHistory of present illnessPertinent past medical history
45Patient Assessment Allergies Current medications Use of drugs or other substancesPhysical examVital signs – B/P – P – R – SpO2Hands-on assessment head to toeSkin examRashes? Evidence of infection?
46Patient Assessment - Neurological Evaluate appearance, behavior, attitudeThought disorders – logical and realistic?False beliefs/delusions?Suicidal/homicidal thoughts?Perception disorders?Hallucinations present?Mood and affectInsight and judgement – can patient understand circumstances and identify surroundings?Sensorium and intelligence – normal level of consciousness? Impaired cognition/intellectual functioning?
47Neurological Assessment cont’d Level of consciousnessAVPUPupillary responseAbility to identify person, place, timeGlasgow coma scaleScores 3 – 15More important than any one score is the trend the score is makingWhen 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.
48Glasgow Coma Scale Evaluates wakefulness and awareness Wakefulness The state of being aware of the environmentAwarenessA demonstrated understanding of what is being said
49GCS 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 extremityDeteriorations will be noted faster as the score drops by awarding the highest points possiblePediatric componentUsed for the young patient who is not yet verbal due to age
50Glasgow Coma Scale EYE OPENING VERBAL RESPONSE MOTOR RESPONSE 4--Spontaneous5--Oriented6--Obeys3—Verbal stimuli4--Confused/ disoriented5—Localizes/purposeful2--Pain3--Inappropriate words4--Withdraws1--None2--Incomprehensible sounds3--Abnormal flexion2--Extensor posturing
51GCS Score GCS 13 – 15 GCS 9 – 12 GCS <8 Mild brain injury Moderate brain injuryGCS <8Severe brain injuryMost patients with this score are in comaEvaluate for the need to assist in protecting the patient’s airway
52Evaluating Eye Opening Best response is obtained, if at all possible, before physical contact is made with patientThis is not always possible when the C-spine needs to be controlled as c-spine control occurs immediately before other interaction with patientPatient gets credit if eyelids open even for a brief moment or just flickerAlways consider need to control the C-spine over the verbal response of the GCS
53Evaluating Verbal Response 5 – uses appropriate words/conversation4 – speaks but is confused and disoriented3 – speaking and you can understand the words spoken but the words do not contribute to the current conversation2 – making sounds like grunts and moans; no intelligible words1 – no response; no speech; no noise
54Modifying GCS for Pediatrics Adult GCS must be modified to match the developmental age of the young nonverbal childBest eye opening remains unchangedBest verbal response for non-verbal patient5 – Smiles, coos, follows objects4 – Irritable cry but is consolable3 – Inappropriate crying; cries to pain2 – Inconsolable, agitated; moans or groans to pain1 – No response
55Evaluating Motor Response 6 – Obeys commands5 – Localizes/Purposeful movementHits at you, grabs at your hands, pulling equipment off, pushing you away4 – Withdraws from pain (unable to localize)3 – Flexing with internal rotation and adduction of shoulders and flexion of elbows2 – Extension with elbows straightened and possible internal shoulder and wrist rotation
56Pediatric GCS Motor Response Best motor response for non-verbal patient6 – obeys commandsMay be difficult to determine if child understands5 – localizes pain by withdrawing to touch stimuli4 – withdraws to pain (more stimuli than touch)3 – same – abnormal flexion2 – same – abnormal extension1 – no motor response; patient flaccid
57GCS Practice (answers at end) Score the Following Patients: The patient is watching you approachThe patient speaks normally and answers questionsThe patient raises their arm when you ask to take their B/PPatient #2The patient is looking around the environmentThe patient speaks normally but is confusedWhen you ask the patient to raise their arm, they are slow to do so but eventually raises their arm
58GCS Practice Patient #3 Patient #4 The patient’s eyes are closed and there is no movement even after squeezing the trapeziusThe patient groans when the trapezius is squeezedThe patient flexes their arms to the chest wallPatient #4Patient eyes open briefly when their name is calledPatient groans while being pinchedPatient does not follow commands and pushes you away whenever you try to treat the patient
59GCS Practice Patient #5 Patient #6 Eyes are closed but open when calling the patientThe patient yells “don’t” and “stop it” when being touched, assessed, and treated but is not speakingPatient pushes your hands away and is trying to pull off the cervical collar and IVPatient #6Eyes open briefly when asked to open themThe patient moans weakly when being touchedThe patient tries to pull away when care is being provided (ie: IV start)
60GCS Practice Patient #7 Patient #8 Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyesThe patient responds verbally saying their head hurts and the lights make it hurt worsePatient follows commands except for opening eyesPatient #8Eyes are open looking straight aheadWhen 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 awayPatient #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 #8When one hand withdraws (ie: jerks away) and one hand pushes you away (purposeful movement), award the highest score possible
61GCS Practice – Pediatrics < 1y/o Patient #9 (6 month old)Infant’s eyes flutter when touchedPatient cries when gently touched; is consolablePatient withdraws when first touching themPatient #10 (9 month old)Eyelids flutter when the IO needle is placedPatient moans during the IO insertion and when deformed extremity is handledThe patient pulls their arms tightly into their chest wall curling shoulders and wrists inward
63Blood Glucose Level To be obtained in the field when: Patient is known diabetic with diabetic related problemPatient has an altered level of consciousness for unknown reasonsPatient is unresponsive (includes post-ictal patients)Consider the patient to have more than one problem at a timeMake 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 fastPatients 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.
64Blood Glucose Monitor Machines calibrated for capillary specimen Keep the site hanging dependentlyCan use side of finger tips or the forearmOnce the site is wiped with an alcohol prep pad, let the site air dry before obtaining a sampleUse a lancet to obtain a blood sample from the finger or forearmPatient should not sign a release until EMS can document a blood sugar level >60 in the fieldThe 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.
65Stroke Care Most important question to ask: Rapid detection of signs and symptoms with rapid diagnosis is essentialNeed to avoid delays3 hour time limit to administer a fibrinolytic from time of first onset of signs and symptomsIncrease risk of cerebral bleeding beyond a 3 hour time frameMost important question to ask:What time did symptoms begin?
66Cincinnati Stroke Scale Quick and simple evaluation toolDocumentationFacial droopRight/left facial droop or no droopArm driftRight/left arm drift or no driftSpeechClear or not clear
67Facial DroopingAsk the patient to smile real big and show you their teethBest way to see if a droop is present
68Arm DriftWith 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
69Clarity of SpeechMost likely you’ll know by now if there is a speech problemCan have the patient repeat after you any words or a sentence you give them“You can’t teach an old dog new tricks”
707 D’S Of Stroke Care Detection – of signs and symptoms Dispatch – patient to call 911Delivery – by EMS to the appropriate facilityDoor – emergent triage in the EDData – appropriate testsDecision – to administer a fibrinolytic or not after diagnostic tests and assessment completedDrug – must administer the fibrinolytic within 3 hours of onset of symptomsStudies have shown that there is an increase in cerebral bleeds when the fibrinolytic is administered over 3 hours from onset of symptoms.
71Quick Fixes of Altered Mental Status Hypoglycemia – DextroseHypoxia – oxygenPinpoint pupils – NarcanSeizures – ValiumDextrose if seizure due to hypoglycemiaCold – warm the patient upWhen 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.
72Combative PatientTalking down a patient is an art that requires effort and skillNeed enhanced people skills of listening and observationMake sure the scene is safeProvide a calm and supportive environmentTreat any existing medical conditionsDo not confront or argue with the patientProvide realistic reassuranceRespond to the patient in a direct, simple manner
732 Extremes of Behavioral Emergencies Combative patientFidgeting, nervous energyVoice getting louderPacingShouting, apparent angerWithdrawn patientFacing away from care providerDecreasing eye contactNo eye contact or conversationTotally withdrawn
74System Operating Guidelines – Use of Restraints EMS personnel should contact Medical Control if possible before restraining patientMay restrain patient first for patient and personnel safetyAll attempts must be made to avoid injury to patient and EMS personnelDo not compromise the patient’s ability to breath or further aggravate any injury or illnessEMS to clearly document the behavior leading to use of restraintsHandcuffs applied by police onlyOfficer must accompany patient in the ambulance during transport if handcuffs are in place
75Methods of Restraint Verbal de-escalation First method to employ Avoids physical contact with the patient – saferWatch “personal space”1.5 – 4 feet in the United StatesKeep open an “escape route” for yourselfPersonal 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.
76Methods of Restraint cont’d Physical restraintMaterials or techniques that will restrict the movement of a patientSoft restraints: sheets, wristlets, chest PosyHard restraints: plastic ties, handcuffs, leathersPolice must be in ambulance for transport if patient is in handcuffsPatients need frequent reassessment to evaluate for injury or possible neurovascular compromise or airway compromiseUse a surgical mask placed loosely over the face to control spittingAvoid 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.
77Physical Restraints EMS to not transport a restrained patient prone Positional asphyxia may cause deathBe prepared to protect the patient’s airwayDo not secure straps to moving side railsRestraining thighs just above knees often prevents kickingStruggling against restraints may lead to severe acidosis and fatal dysrhythmiasNEVER leave restrained patient unattended
78Methods of Restraints cont’d Chemical restraintAdministration of specific pharmacological agentsDecrease agitationIncrease cooperationNot alter a patient’s level of consciousnessCommon agents used are haldol (in the ED) and/or benzodiazepinesDiazepam (Valium)Lorazepam (Ativan)Midazolam (Versed)
79Region X SOP - Severe Anxiety or Agitation Valium 5 mg IVP slowly over 2 minutesRepeat as neededMaximum total dose is 10 mgIn the absence of an IV, Valium 10 mg IM/rectallyWatch for respiratory depression with administration of a benzodiazepineHave a BVM ready to use as a precaution
80Documentation TipsAll patients require a blood glucose level for altered mental statusDocumentation should reflect serial monitoring of the patient’s condition looking for changesGCSAVPUIf restraints are used, document objectively and in detail the behavior that led to the need for restraintsDocument distal circulation of any restrained extremityPatients with altered mental status cannot sign a release in the field
81Airway Control Measures Region X EMS use the QuickTrach deviceED tools available:ACMC – Quicktrach- Melker (especially being used for largenecks- Surgical tray for surgical cricNLFH – QuickTrach- Melker- Arndt
82Securing the Airway - QuickTrach IndicationsPatient requires emergency assisted ventilation when all other conventional methods have failedContraindicationsTracheal transectionOther less invasive maneuver allows ventilation>77# (35kg) – use 4.0mm ID device22# – 77# (10 -35kg) use 2.0 mm ID<22# (10kg) – use needle cricothyrotomy
83QuickTrach Device Connecting tube Syringe Flanges to attach ties Stopper that is removed before final insertion
84QuickTrach ProcedurePatient positioned supine; neck hyperextended if no trauma)Cricothyroid membrane located and site cleansed Palpate the soft indentation between the thyroid and cricothyroid cartilagesLarynx secured laterally between the thumb and forefingerCricothyroid membrane punctured at a 900 angleThe 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.
86QuickTrach cont’dEntry into the trachea confirmed by aspirating air thru the syringeIf air is present, the needle is in the tracheaNow angle changed to 600 with the tip pointing towards the feet and device advanced forward into the trachea to the level of the stopperStopper to be snug against the skinStopper reduces risk of inserting the needle too deeplyStopper removed
87QuickTrach cont’dNeedle and syringe held firmly, only the plastic cannula is slid into the tracheaAdvancement stopped when the flange rests snug against the neckNeedle and syringe carefully removedConnecting tube attached to the cannulaCan be preattached to BVM and then attached to cannula when needle and syringe are removedBVM attached to the connecting tubePatient can be baggedCannula secured with the neck tape ties providedSuggest 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.
88QuickTrach Complications Puncture through of the tracheaDuring bagging attempts surrounding tissue will expand due to leakage of airInadvertent puncture of a blood vesselFormation of a hematoma under the skin and surrounding the airwayExternal bleedingInability to ventilate the patientThere may be an obstruction at a more distal site
89QuickTrach Documentation Reason(s) an alternate airway devise was necessarySize of airway placed4.0 mm for persons over 77#2.0 mm for persons 22# - 77#Confirmation of airway placementBilateral breath soundsBilateral chest wall rise and fall
92Case Studies Read the following case studies How would you respond? Can be a patient found by EMSCan be a walk-in Ed patientHow would you respond?More information may be provided in the notes section
93Case 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?
94Case Study #1 Impression list Post-ictal from seizure Hypoglycemia Alcohol intoxicationDrug overdoseAcute MIStrokeHead trauma
95Case Study #1 Assessment Control c-spine while palpating neck area Evaluate if respiratory assistance is neededCheck quality, depth, rate of respirations, SpO2Calculate GCS; obtain vital signsConsider IV-O2-monitorAssess for need for fluid challengeAssess cardiac rhythm; consider obtaining a 12 lead EKGObtain a blood glucose sample
96Case Study #2 Patient brought to ED by spouse Patient dropping silverware at lunch, unable to sit up straight, unable to complete sentencesVital signs: 170/110; P – 64; R – 16; GCS -14EKG monitor -
97Case Study #2 What is your impression? What is the cardiac rhythm? Atrial fibrillationHow does this rhythm relate to any impressions?What assessments need to be done?Blood sugar level for all patients with altered level of consciousnessCincinnati stroke scalePatients 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.
98Case Study #2 Cincinnati stroke scale Ask the patient to smile real big showing you their teethAsk the patient to put their hands out in front, palms up, and close their eyesHold the position for 10 secondsAsk the patient to repeat a saying“You can’t teach an old dog new tricks”
99When did the symptoms begin? Case Study #2What’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.
100Case Study #3An 18 year-old patient is found under the bleachers at school unresponsive with shallow respirations.AVPU - responds to painful stimuliVital signs: 110/70; P – 110; R – 4; pupils constrictedGCS – 8What are your impressions?
101Case Study #3 Impression list Drug overdose Head injury Hypoglycemia Opiates – constricted pupils, depressed respirationsHead injuryHypoglycemiaPost-ictal
102Case Study #3 Treatment Control c-spine Consider c-spine injury until proven otherwiseSecure airwayFrequency to ventilate via BVM to support respirations?Once every 5 – 6 secondsGain IV accessPeripheral site?IO if peripheral unobtainableEvaluate cardiac rhythmAnyone 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).
103Case Study #3 Medications to administer in the field (Region X EMS) If blood sugar < 60 give 50 ml of 50% DextroseAs a diagnostic tool give Narcan2 mg IVP every 5 minutes as needed for desired effectMaximum total of 10 mgConsider need to protect the airway with intubation following conscious sedationNo indication for lidocaineVersed to relax the patientMorphine alternated with Versed to potentiate the effects of both medicationsBenzocaine if a blink reflex is presentIf 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.
104Case Study #4EMS is called to the scene for an unknown medical emergencyPolice have secured the sceneThe patient is a 54 year-old male who is combativeWhat are your impressions?What actions are indicated?
105Case Study #4 Impressions Psychiatric problem Altered blood sugar Head injuryElectrolyte imbalance
106Case Study #4 Action to take Make sure the scene is safe and remains safe for the rescuers and the patientWill need a blood sugar at some pointA cardiac monitor to evaluate rhythm could be important assessment informationMay need to restrain the patient for staff safety and patient safety
107Case Study #4 Verbal de-escalation Soft restraints Methods to restrain patientsVerbal de-escalationSoft restraintsWrist and ankle restraintsChest posey or sheetHard restraints with EMS in the fieldIf police handcuff the patient, police must ride with the patient in the ambulancePolice are not allowed to hand off cuff keys to EMS
108Case Study #4 Documentation Patient’s behavior in descriptive, objective terms that indicated the need for restraintIf no time to contact Medical Control before restraining patient, EMS to contact Medical Control after the patient is restrainedDocument distal circulation, motion, and sensation periodically after restraining the patient
109Case Study #532 year-old patient was found combative at work. This is very unusual behavior for this patientVital signs: 110/70; P – 80; R – 18; skin dampImpression?Further assessment?Treatment?
110Case Study #5 Impression Assessment Hypoglycemia Head injury Drug / alcohol influenceAssessmentBlood sugar levelCardiac monitorNeurological evaluation
111Case Study #5 Blood sugar was 25 Patient now alert and oriented Treatment indicated50 ml 50% Dextrose IVPPatient now alert and orientedRepeat blood sugar 56Patient wants to sign a release. Can EMS allow a release to be obtained?No release until the blood sugar is >60EMS to stay on the scene and continue to reassess as the patient takes in food or liquids
112BibliographyBledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices 3rd Edition. Prentice Hall. 2009Limmer, D. O’Keefe, M. Emergency Care. 10th Edition. Prentice HallRegion X SOP’s March Amended January 1, 2008.En.wikipedia.org/wiki/Endocrine_systemEn.wikipedia.org/wiki/Electrolyte_systemEn.wikipedia.org/wiki/Encephalopathy_systemEn.wikipedia.org/wiki/Opiate_systemEn.wikipedia.org/wiki/Uremia_system