1. Altered Mental States …or everything you need to know about coma, stroke, seizures, syncope, diabetic emergencies, etc...

2. Altered Mental States Defined as when a patient is not thinking clearly or is incapable of being aroused. Defined as when a patient is not thinking clearly or is incapable of being aroused. Consciousness/unconsciousness Consciousness/unconsciousness Responsiveness/unresponsiveness Responsiveness/unresponsiveness Coma Coma

3. Nervous System Anatomy

4. Brain Anatomy & Function Major Functions: Major Functions: Brain Stem Brain Stem Cerebellum Cerebellum Cerebrum Cerebrum

5. Brain Function

6. Altered Mental States Hypoglycemia Hypoglycemia Hypoxemia Hypoxemia Intoxication Intoxication Drug overdose Drug overdose Head injury Head injury Brain tumors Glandular abnormalities Poisoning Hypo/hyperthermia Brain infection

7. Differential Diagnosis A – Alcohol A – Alcohol E – Electrolyte imbalance E – Electrolyte imbalance I – Insulin (diabetic emergencies) I – Insulin (diabetic emergencies) O – Opiates O – Opiates U – Uremia U – Uremia T – Trauma T – Trauma I – Infection (sepsis) I – Infection (sepsis) P – Psychogenic causes P – Psychogenic causes S – Stroke, seizure, syncope S – Stroke, seizure, syncope

8. Stroke Third leading cause of death in industrialized countries after heart disease and cancer. Third leading cause of death in industrialized countries after heart disease and cancer. Risk factors include hypertension, age, smoking, lack of exercise, obesity, stress, with prevalence in certain racial/ethnic groups. Risk factors include hypertension, age, smoking, lack of exercise, obesity, stress, with prevalence in certain racial/ethnic groups. High rate of successful recovery if recognized and treated quickly! High rate of successful recovery if recognized and treated quickly!

9. Stroke (CVA) Cerebral vascular accident (CVA) is the interruption of blood flow to the brain. Cerebral vascular accident (CVA) is the interruption of blood flow to the brain. Stroke is the loss of brain function that results from CVA when blood flow is interrupted. Stroke is the loss of brain function that results from CVA when blood flow is interrupted. Hemorrhagic Hemorrhagic Ischemic Ischemic TIA TIA

10. Hemorrhagic Stroke Results from vessel rupture on the surface or within the brain. Results from vessel rupture on the surface or within the brain. Subarachnoid Subarachnoid Intracerebral Intracerebral 10% of all strokes with a 50 % mortality rate. 10% of all strokes with a 50 % mortality rate. Typically sudden onset of signs/symptoms. Typically sudden onset of signs/symptoms.

11. Ischemic Stroke Ischemic stroke results from arterial blockage, either: Ischemic stroke results from arterial blockage, either: Thrombus Thrombus Embolis Embolis Greater chances of survivability if treatment initiated within 3 hours. Greater chances of survivability if treatment initiated within 3 hours.

12. Transient Ischemic Attack Temporary disruption of brain function due to insufficient oxygenation. (“Mini-stroke”) Temporary disruption of brain function due to insufficient oxygenation. (“Mini-stroke”) Stroke-like symptoms usually rapid in onset with complete resolution within 24 hours. Stroke-like symptoms usually rapid in onset with complete resolution within 24 hours. Often proceeds a stroke. Often proceeds a stroke. Hard to distinguish from a stroke at onset. Hard to distinguish from a stroke at onset.

13. Stroke: Signs & Symptoms One-sided weakness or paralysis (hemiparesis) One-sided weakness or paralysis (hemiparesis) Facial droop on one side. Facial droop on one side. Altered level of consciousness (confusion to coma). Altered level of consciousness (confusion to coma). Change in personality or mood Change in personality or mood Headache or dizziness Headache or dizziness Impaired speech, blurred vision, poor coordination. Impaired speech, blurred vision, poor coordination.

14. Stroke: Signs & Symptoms Left Hemisphere Problems: Left Hemisphere Problems: Aphasia Aphasia Receptive aphasia Receptive aphasia Expressive aphasia Expressive aphasia Right Hemisphere Problems: Right Hemisphere Problems: Dysarthria Dysarthria Neglect Neglect

15. Stroke Mimics Hypoglycemia (Insulin reaction) Hypoglycemia (Insulin reaction) Postictal state after a seizure Postictal state after a seizure Head injury: Head injury: Epidural bleed (rapid onset) Epidural bleed (rapid onset) Subdural bleed (slower onset) Subdural bleed (slower onset)

16. Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan

17. Stroke ALS Indicators Unconsciousness Unconsciousness Decreased level of consciousness Decreased level of consciousness Severe hypertension (systolic > 200 mmHg or diastolic > 110 mmHg with neurologic signs) Severe hypertension (systolic > 200 mmHg or diastolic > 110 mmHg with neurologic signs) Hypotension and severe bradycardia Hypotension and severe bradycardia Seizures Seizures Severe headache/vomiting Severe headache/vomiting Airway problems Airway problems Progression of stroke symptoms Progression of stroke symptoms

18. Physical Exam Baseline vitals signs Baseline vitals signs Blood glucometry Blood glucometry Neurological function (Cincinnati Prehospital Stroke Scale: Neurological function (Cincinnati Prehospital Stroke Scale: Facial droop Facial droop Arm drift Arm drift Speech Speech Check for stroke mimics! Check for stroke mimics!

19. Cincinnati Stroke Scale

20. Patient History Chief complaint and time of onset are key in the assessment of stroke. Chief complaint and time of onset are key in the assessment of stroke. Signs/symptoms (hypertension, HA, numbness or weakness, difficulty with speech/movement) Signs/symptoms (hypertension, HA, numbness or weakness, difficulty with speech/movement) Allergies Allergies Medications (blood thinners or anticoagulants) Medications (blood thinners or anticoagulants) Past medical history ( previous stroke or TIA, AVM, cerebral aneurysm) Past medical history ( previous stroke or TIA, AVM, cerebral aneurysm) Last oral intake Last oral intake Events leading to call Events leading to call

21. Treatment and Plan Revascularization by clot dissolving medication must be initiated within 3 hours of a stroke. Revascularization by clot dissolving medication must be initiated within 3 hours of a stroke. If a stroke is of recent onset, very short scene and transport times are CRITICAL! If a stroke is of recent onset, very short scene and transport times are CRITICAL! Determine time of onset of symptoms and notify hospital as soon as possible. Determine time of onset of symptoms and notify hospital as soon as possible. Arrival at hospital is critical within first two hours of onset of symptoms. Arrival at hospital is critical within first two hours of onset of symptoms.

22. Patient Care ABCS!Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Rapid transport

23. Seizure Defined as generalized, uncoordinated muscular activity associated with a loss of consciousness; a convulsion. Defined as generalized, uncoordinated muscular activity associated with a loss of consciousness; a convulsion. Catergorized as: Catergorized as: Generalized (grand mal) Generalized (grand mal) Absence (petite mal) Absence (petite mal) Simple partial (focal motor) Simple partial (focal motor) Complex partial (psychomotor) Complex partial (psychomotor)

24. Generalized Seizure Usually presents with an aura. Usually presents with an aura. May be unifocal with progression to convulsion May be unifocal with progression to convulsion Loss of consciousness Loss of consciousness Tonic phase Tonic phase Clonic phase Clonic phase Postictal phase Postictal phase Be concern with status epilecticus Be concern with status epilecticus

25. Absence Seizure Also known as petit mal seizures Also known as petit mal seizures Most common in children Most common in children No loss of consciousness No loss of consciousness No loss of postural tone No loss of postural tone “Spacing out” “Spacing out”

26. Simple Partial Seizure Focal motor seizure or “Jacksonian” seizure. Focal motor seizure or “Jacksonian” seizure. Characterized by a rhythmic jerking of limb or one side of the body. Characterized by a rhythmic jerking of limb or one side of the body. No loss of consciousness No loss of consciousness

27. Complex Partial Seizure Also known as pyschomotor seizures Also known as pyschomotor seizures Involve loss of consciousness Involve loss of consciousness Characterized by stereotyped movements (automatisms) Characterized by stereotyped movements (automatisms) Movements may look purposeful but they are not Movements may look purposeful but they are not Lip smacking, movement of hands Lip smacking, movement of hands Typically present as intoxication, drug OD, or “psych patient” Typically present as intoxication, drug OD, or “psych patient”

28. Febrile Seizures Common in children under age of 2 years Common in children under age of 2 years Caused by spike in fever, usually patient has had cold or flu-like signs/symptoms. Caused by spike in fever, usually patient has had cold or flu-like signs/symptoms. Presents similar to grand mal seizure with accompanying postictal phase. Presents similar to grand mal seizure with accompanying postictal phase.

29. Causes Congenital defects (epilepsy) Febrile or high fever Brain structural problems (trauma) Metabolic disorders Chemical disorders (poisons/overdoses)

30. Seizure: Signs & Symptoms Cyanosis Cyanosis Abnormal breathing Abnormal breathing Obvious head injury Obvious head injury Loss of bowel control/incontinence Loss of bowel control/incontinence Severe muscle twitching/motion Severe muscle twitching/motion Bite marks on tongue Bite marks on tongue Postictal state with unresponsiveness/labored breathing Postictal state with unresponsiveness/labored breathing

31. Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan

32. Seizure ALS Indicators Status seizures Status seizures Seizure lasting longer than 5 minutes or postictal stage > 15 minutes without change in LOC Seizure lasting longer than 5 minutes or postictal stage > 15 minutes without change in LOC Seizures in pregnant female Seizures in pregnant female Seizures due to: Seizures due to: Hypogylcemia (Insulin reaction) Hypogylcemia (Insulin reaction) Hypoxia Hypoxia Head trauma Head trauma Drugs or alcohol Drugs or alcohol

33. Physical Exam Look for signs of trauma, overdose Baseline vital signs Blood glucometry

34. Patient History Chief complaint, description and length of seizure are key to seizure assessment Chief complaint, description and length of seizure are key to seizure assessment Signs/symptoms (witnessed event?) Signs/symptoms (witnessed event?) Allergies Allergies Medications (anticonvulsants) Medications (anticonvulsants) Past medical history (previous seizure history?) Past medical history (previous seizure history?) Last oral intake Last oral intake Events leading to call (historians?) Events leading to call (historians?)

35. Treatment & Plan If patient is in active seizure, allow seizure to run it’s course. Protect patient from further harm. If patient is in active seizure, allow seizure to run it’s course. Protect patient from further harm. Airway management (most common cause of seizure deaths are postictal airway loss!) Airway management (most common cause of seizure deaths are postictal airway loss!) Treat trauma. Treat trauma. Know when to call for medics! Know when to call for medics! Do not assume that all seizures are epilepsy. Do not assume that all seizures are epilepsy.

36. Patient Care ABCS!Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Transport

37. Diabetes Diabetes affects over 20 million people in the US alone, 7% of the total population! Diabetes affects over 20 million people in the US alone, 7% of the total population! Condition in which the body does not produce or use insulin properly. Condition in which the body does not produce or use insulin properly. Complications can include kidney failure, blindness, heart disease, stroke, and lower extremity amputations. Complications can include kidney failure, blindness, heart disease, stroke, and lower extremity amputations. Risk factors include: genetics, obesity, lack of exercise, and certain racial/ethnic groups. Risk factors include: genetics, obesity, lack of exercise, and certain racial/ethnic groups.

38. Diabetes Type I: Type I: Juvenile diabetes Juvenile diabetes No insulin production No insulin production Controlled with insulin injections Controlled with insulin injections Type II: Type II: Adult onset diabetes Adult onset diabetes Inadequate insulin production with increased tissue resistance to insulin effects Inadequate insulin production with increased tissue resistance to insulin effects Controlled with diet, exercise, oral medications Controlled with diet, exercise, oral medications

39. Diabetic Emergencies Hypergylcemia (high blood glucose level) Hypergylcemia (high blood glucose level) Diabetic Ketoacidosis (DKA) Diabetic Ketoacidosis (DKA) Hyperosmolar coma (HHNC) Hyperosmolar coma (HHNC) Hypogylcemia (low blood glucose level) Hypogylcemia (low blood glucose level) Insulin shock Insulin shock

40. Diabetic Ketoacidosis (DKA) Pancreas not producing enough or effectively insulin. Pancreas not producing enough or effectively insulin. Slow onset over several days Slow onset over several days Cells metabolizing fat for energy Cells metabolizing fat for energy Result of: Result of: Too little insulin Too little insulin Not enough exercise Not enough exercise Too much food Too much food Stress, fever, infection Stress, fever, infection

41. DKA: Signs & Symptoms Kussmaul respirations Kussmaul respirations Weak, rapid pulse (possibly irregular) Weak, rapid pulse (possibly irregular) Warm, dry skin Warm, dry skin Normal to profoundly decreased blood pressure Normal to profoundly decreased blood pressure Fruity odor on breath (ketones) Fruity odor on breath (ketones) Nausea, vomiting, abdominal pain Nausea, vomiting, abdominal pain Altered level of consciousness Altered level of consciousness Polyuria, polydipsia, polyphagia Polyuria, polydipsia, polyphagia

42. Hyperosmolar Coma  State of unconsciousness resulting from:  Hypergylcemia  Ketoacidosis (no fruity breath)  Profound dehydration  Signs & symptoms:  3 – P’s  Dry skin, mucous membranes  Tachycardia, hypotension

43. Insulin Shock Insufficient glucose stores necessary for blood oxygenation Insufficient glucose stores necessary for blood oxygenation Sudden onset, life threatening Sudden onset, life threatening Occurs as a result of: Occurs as a result of: Too much insulin – accidental or intentional Too much insulin – accidental or intentional Low food intake Low food intake Too much exercise Too much exercise

44. Insulin Shock: Signs & Symptoms Cold, clammy, pale skin Cold, clammy, pale skin Abnormal, bizarre, or hostile behavior Abnormal, bizarre, or hostile behavior Shaking, trembling, weakness Shaking, trembling, weakness Full, rapid pulse Full, rapid pulse Normal or elevated blood pressure Normal or elevated blood pressure Normal or elevated respirations Normal or elevated respirations Dizziness, headache, blurred vision Dizziness, headache, blurred vision Extreme hunger Extreme hunger Slurred speech Slurred speech Seizures, loss of consciousness Seizures, loss of consciousness

45. Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan

46. Diabetic ALS Indicators Altered level of consciousness Altered level of consciousness Patient unable to protect airway (absent gag) Patient unable to protect airway (absent gag) Unstable vital signs Unstable vital signs Rapid respirations Rapid respirations Shock signs and symptoms Shock signs and symptoms Failure to respond to oral glucose Failure to respond to oral glucose Suspected DKA Suspected DKA Seizures Seizures

47. Physical Exam Mental status/level of consciousness Airway management (ability to swallow?) Baseline vital signs Blood glucometry

48. Patient History Chief complaint, think about other possibilities. Chief complaint, think about other possibilities. Signs/symptoms: DKA vs. Insulin shock Signs/symptoms: DKA vs. Insulin shock Allergies Allergies Medications (Using insulin/meds? Last used?) Medications (Using insulin/meds? Last used?) Past medical history (Diabetic?) Past medical history (Diabetic?) Last oral intake (Last meal or food) Last oral intake (Last meal or food) Events leading to call (Changes in health, stress level, exercise routine) Events leading to call (Changes in health, stress level, exercise routine)

49. Treatment & Plan Perform glucose check Position patient upright and give oral glucose if able to swallow (intact gag) Document times and blood glucose levels, patient responses to oral glucose

50. Patient Care ABCS!Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Transport

51. King County Guidelines Patients on insulin may be safely left at home: Patients on insulin may be safely left at home: Blood glucose level is > 60 Blood glucose level is > 60 Able to eat and drink normally Able to eat and drink normally Someone is able to stay with them Someone is able to stay with them After care instructions left with repeat blood glucose level check and proper documentation After care instructions left with repeat blood glucose level check and proper documentation

52. Overdose Overdose is an excessive exposure, either accidental or intentional, to a chemical substance. Overdose is an excessive exposure, either accidental or intentional, to a chemical substance. Majority of calls will involve habitual drug users and attempted suicide with prescription medications. Majority of calls will involve habitual drug users and attempted suicide with prescription medications. Observations at the scene and accurate history are critical in assessment of these patients. Observations at the scene and accurate history are critical in assessment of these patients.

53. Overdose: Signs & Symptoms Altered Mental Status: Altered Mental Status: Paranoia Paranoia Agitation Agitation Nonsensical conversation Nonsensical conversation Aggression Aggression Lethargy Lethargy Coma Coma Hallucinations Hallucinations Rapid speech Rapid speech Skin Signs: Diaphoretic Pale Flushed Cyanotic Look for needle track marks and/or abcesses

54. Overdose: Signs & Symptoms Pupil Reaction: Pupil Reaction: Normal Normal Dilated Dilated Constricted Constricted Respiratory: Respiratory: Tachypnea Tachypnea Bradypnea Bradypnea Apnea Apnea Cardiovascular: Hyper/hypotension Tachycardia Bradycardia Arrhythmias Cardiac Arrest Temperature: Hyperthermia Hypothermia

55. Overdose: Signs & Symptoms CNS depressants, sedatives, tranquilizers CNS depressants, sedatives, tranquilizers SSRI’s SSRI’s Stimulants Stimulants Antidepressants Antidepressants Acetaminophen Acetaminophen Pyschedlic drugs (LSD) Alcohol Intoxication Opiates/narcotics Cannabis Inhalants GHB ASA

56. Poisoning 2.2 million poison exposures reported in the U.S. in 2000, that’s 1 every 15 seconds. 2.2 million poison exposures reported in the U.S. in 2000, that’s 1 every 15 seconds. 90% occur at home with > 50% under the age of 6 years. 90% occur at home with > 50% under the age of 6 years. Poisoning occurs through the following routes: Poisoning occurs through the following routes: Ingestion Ingestion Inhalation Inhalation Injection Injection Absorption Absorption

57. Common Toxidromes: Carbon Monoxide Poisoning: Carbon Monoxide Poisoning: Headache Headache Tachypnea Tachypnea Nausea and vomiting Nausea and vomiting Altered level of consciousness Altered level of consciousness Pink, flushed membranes Pink, flushed membranes Coma Coma Inaccurate SpO2 readings Inaccurate SpO2 readings

58. Common Toxidromes Organophosphate Poisoning: Organophosphate Poisoning: Decreased level of consciousness Decreased level of consciousness Bradycardia/hypotension Bradycardia/hypotension Vomiting/excessive salivation Vomiting/excessive salivation Miosis Miosis Diaphoresis Diaphoresis Bronchospasm Bronchospasm

59. Common Toxidromes Cyanide Poisoning: Cyanide Poisoning: Headache Headache Burning sensation in mouth or throat Burning sensation in mouth or throat Confusion Confusion Decreased level of consciousness Decreased level of consciousness Agitation or combative behavior Agitation or combative behavior Shortness of breath Shortness of breath Bitter smell of almonds Bitter smell of almonds

60. Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan

61. Altered LOC ALS Indicators Decreased LOC Decreased LOC Respiratory distress or compromise Respiratory distress or compromise Signs/symptoms of shock Signs/symptoms of shock Signs of inadequate perfussion Signs of inadequate perfussion Sustained tachycardia Sustained tachycardia Hypotension Hypotension Unstable vital signs Unstable vital signs Cyanosis Cyanosis

62. Scene Safety Protection of yourself and crew are your first priority! Do not become part of the problem! Protection of yourself and crew are your first priority! Do not become part of the problem! Scene secure? Police back-up needed? Scene secure? Police back-up needed? Contamination/exposure issues? Contamination/exposure issues? Watch for needles! Watch for needles! Stay alert! Stay alert! Restrain a patient whenever there are safety concerns! Restrain a patient whenever there are safety concerns!

63. Focused Exam Airway! (check gag reflex) Airway! (check gag reflex) Chief complaint Chief complaint Baseline vital signs (pupil check, lung sounds) Baseline vital signs (pupil check, lung sounds) Blood glucometry Blood glucometry Neurological exam (GCS) Neurological exam (GCS) Ask pertinent SAMPLE/OPQRST questions Ask pertinent SAMPLE/OPQRST questions Look for ALL possible clues…do a thorough exam! Look for ALL possible clues…do a thorough exam!

64. Pupillary Reaction Dilated = Reactive: Dilated = Reactive: Hypoxia, alcohol, stimulants (cocaine, meth) Hypoxia, alcohol, stimulants (cocaine, meth) Dilated = Non-reactive: Dilated = Non-reactive: Anoxia, profound ETOH, SZ, drugs (LSD) Anoxia, profound ETOH, SZ, drugs (LSD) Dilated/Unequal/Non-reactive: Dilated/Unequal/Non-reactive: CVA (hemorrhagic), head injury CVA (hemorrhagic), head injury Constricted = Non-reactive: Constricted = Non-reactive: Opiate/barbituate OD, brainstem injury Opiate/barbituate OD, brainstem injury

65. Patient Care ABCS!Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Transport

66. Syncope Fainting Fainting Sudden loss of consciousness Sudden loss of consciousness Usually caused by lack of blood flow to the brain Usually caused by lack of blood flow to the brain

67. Syncope Causes Stress, fright, pain (vasovagal syncope) Stress, fright, pain (vasovagal syncope) Orthostatic hypotension (standing BP drop) Orthostatic hypotension (standing BP drop) Decreased blood volume Decreased blood volume Increased size of vascular space Increased size of vascular space Decreased cardiac output Decreased cardiac output Prolonged, forceful coughing Prolonged, forceful coughing

68. Syncope Fainting or passing out is a sign that something is not working right. Look for the underlying cause, be a good detective. Fainting or passing out is a sign that something is not working right. Look for the underlying cause, be a good detective. All syncope should be evaluated in the ER, although 60% of all syncope is undiagnosed. All syncope should be evaluated in the ER, although 60% of all syncope is undiagnosed. ALS indicators? ALS indicators?

69. Remember… … it’s okay if you do not diagnose the patient’s problem. It’s not okay if you fail to take care of what you are trained to take care of.