1. Copyright © 2004, Mosby Inc. All rights reserved.

2. Altered Mental Status Slide 1 Copyright © 2004, Mosby Inc. All rights reserved. Chapter 19

3. Case History The police are requesting your response for a semiconscious patient in the subway. On arrival, the police tell you that they found this 40-year-old male stumbling around the platform about 15 minutes ago. The patient is now lying down on the ground. While doing your initial assessment, you find a medical alert tag that says “Diabetic.” The police are requesting your response for a semiconscious patient in the subway. On arrival, the police tell you that they found this 40-year-old male stumbling around the platform about 15 minutes ago. The patient is now lying down on the ground. While doing your initial assessment, you find a medical alert tag that says “Diabetic.” Slide 2 Copyright © 2004, Mosby Inc. All rights reserved.

4. Central and Peripheral Nervous System Slide 3 Copyright © 2004, Mosby Inc. All rights reserved.

5. Brain Slide 4 Copyright © 2004, Mosby Inc. All rights reserved.

6. Blood Supply to the Brain Slide 5 Copyright © 2004, Mosby Inc. All rights reserved.

7. Altered Mental Status Structural problems Structural problems  Injury or damage to an area of the brain OR OR Metabolic problems Metabolic problems  Affect the entire brain Slide 6 Copyright © 2004, Mosby Inc. All rights reserved.

8. Structural Stroke Stroke Head injury Head injury Characterized by “one-sided” signs Characterized by “one-sided” signs  Paralysis  Facial droop  Weakness on one side of the body  Unequal pupils Slide 7 Copyright © 2004, Mosby Inc. All rights reserved.

9. Metabolic External External  Poisoning  Overdose  Hypo- or hyperthermia  Infections Internal Internal  Diabetes  Hypoxia  Hypotension  Organ failure Affects both sides of the brain equally Affects both sides of the brain equally Primarily recognized on the basis of altered mental status and history Primarily recognized on the basis of altered mental status and history Slide 8 Copyright © 2004, Mosby Inc. All rights reserved.

10. Causes of Altered Mental Status Hypoglycemia, diabetic ketoacidosis Hypoglycemia, diabetic ketoacidosis Poisoning Poisoning After seizure After seizure Infection Infection Head trauma Head trauma Decreased oxygen levels (hypoxia) Decreased oxygen levels (hypoxia) Slide 9 Copyright © 2004, Mosby Inc. All rights reserved.

11. Diabetes Disease of the pancreas Disease of the pancreas Caused by a partial or total lack of insulin production Caused by a partial or total lack of insulin production Symptoms of diabetes Symptoms of diabetes  Increased urination  Increased thirst  Increased hunger Slide 10 Copyright © 2004, Mosby Inc. All rights reserved.

12. Diabetes – Insulin Insulin “escorts” glucose into cells. Insulin “escorts” glucose into cells. Glucose provides fuel for basic energy needs. Glucose provides fuel for basic energy needs.  Excess glucose is stored as fat.  Brain depends almost exclusively on glucose. »When glucose level is low, brain function is altered. o Unconsciousness, seizures, brain cell death Slide 11 Copyright © 2004, Mosby Inc. All rights reserved.

13. Diabetes Two major diabetic emergencies Two major diabetic emergencies  Hypoglycemia »Abnormally low blood glucose level  Diabetic ketoacidosis »Blood glucose level too high and insulin level too low Slide 12 Copyright © 2004, Mosby Inc. All rights reserved.

14. Hypoglycemia – Signs and Symptoms Alteration of mental status (rapid onset) Alteration of mental status (rapid onset) »Anxiety, confusion, intoxicated behavior, combativeness, bizarre behavior, or coma Hunger Hunger Rapid pulse Rapid pulse Pale, cool, and clammy skin Pale, cool, and clammy skin Dilated pupils Dilated pupils Seizures Seizures Slide 13 Copyright © 2004, Mosby Inc. All rights reserved.

15. Hypoglycemia – Signs and Symptoms Took prescribed insulin Took prescribed insulin  After missing a meal  Vomiting after a meal  After unusual exercise or physical work Insulin in refrigerator Insulin in refrigerator Medications found at scene Medications found at scene  Diabinese™  Orinase™  Micronase™ Slide 14 Copyright © 2004, Mosby Inc. All rights reserved.

16. Hypoglycemia - Signs and Symptoms Can also occur in patients who do not have diabetes Can also occur in patients who do not have diabetes  Infants with poor glycogen supplies  Malnourished individuals »Alcoholics Slide 15 Copyright © 2004, Mosby Inc. All rights reserved.

17. Diabetic Ketoacidosis Blood glucose level is too high and insulin level is too low. Blood glucose level is too high and insulin level is too low.  When insulin level is low, body burns fat for fuel. »Acetone breath from fatty acids  Excess glucose spills into urine, pulling water with it. »Increased urination, dehydration, hunger, thirst Slide 16 Copyright © 2004, Mosby Inc. All rights reserved.

18. Diabetic Ketoacidosis Increased acidity in blood Increased acidity in blood  Body tries to compensate by breathing deeply and rapidly. Slow onset Slow onset Slide 17 Copyright © 2004, Mosby Inc. All rights reserved.

19. Emergency Medical Care - History of Diabetes Initial assessment Initial assessment Focused history and physical exam Focused history and physical exam Vital signs Vital signs SAMPLE history SAMPLE history Slide 18 Copyright © 2004, Mosby Inc. All rights reserved.

20. Focused History and Physical Examination Description of episode Description of episode Onset Onset Duration Duration Associated symptoms Associated symptoms Evidence of trauma Evidence of trauma Interruptions Interruptions Seizures Seizures Fever Fever Slide 19 Copyright © 2004, Mosby Inc. All rights reserved.

21. Vital Signs and SAMPLE History History of diabetes History of diabetes  Medical identification tags, etc. Last meal Last meal Last medication dose Last medication dose Related illness Related illness Determine if patient can swallow. Determine if patient can swallow. Slide 20 Copyright © 2004, Mosby Inc. All rights reserved.

22. Management – Diabetic Emergencies Ensure patent airway. Ensure patent airway. Supplemental oxygen; consider positive- pressure ventilation Supplemental oxygen; consider positive- pressure ventilation Consider oral glucose administration. Consider oral glucose administration.  Per local protocol Reassess patient en route to hospital. Reassess patient en route to hospital. Slide 21 Copyright © 2004, Mosby Inc. All rights reserved.

23. Glucose Administration Administer if patient has altered mental status when hypoglycemia is suspected. Administer if patient has altered mental status when hypoglycemia is suspected.  Will save hypoglycemic patient from brain cell death  Will not harm patient in diabetic ketoacidosis Never administer oral glucose to patients who are unconsciousness or have no gag reflex. Never administer oral glucose to patients who are unconsciousness or have no gag reflex. Slide 22 Copyright © 2004, Mosby Inc. All rights reserved.

24. Side Effects and Reassessment Side effects Side effects  No side effects when given properly  Glucose gel may be aspirated by the patient without a gag reflex. Reassessment strategies Reassessment strategies  If patient loses consciousness or has a seizure Slide 23 Copyright © 2004, Mosby Inc. All rights reserved.

25. Seizures May be brief or prolonged May be brief or prolonged Causes Causes  Fever  Infections  Poisoning  Hypoglycemia  Trauma  Drug or alcohol withdrawal  Hypoxia  Idiopathic Slide 24 Copyright © 2004, Mosby Inc. All rights reserved.

26. Seizures – Infants and Children Chronic seizures in children are rarely life threatening. Chronic seizures in children are rarely life threatening. Febrile seizures should be considered life-threatening. Febrile seizures should be considered life-threatening. Slide 25 Copyright © 2004, Mosby Inc. All rights reserved.

27. Types of Seizures Grand mal Grand mal Focal Focal Status epilepticus Status epilepticus Febrile Febrile Petit mal Petit mal Slide 26 Copyright © 2004, Mosby Inc. All rights reserved.

28. Grand Mal Seizures Three phases Three phases  Tonic  Clonic  Postictal Slide 27 Copyright © 2004, Mosby Inc. All rights reserved.

29. Grand Mal Seizures – Tonic Phase All voluntary muscles in sustained contraction All voluntary muscles in sustained contraction  Body and extremities are usually extended. Lasts for up to 30 seconds Lasts for up to 30 seconds All respiratory muscles in contraction All respiratory muscles in contraction  Ventilation can be compromised. Slide 28 Copyright © 2004, Mosby Inc. All rights reserved.

30. Grand Mal Seizures – Clonic Phase Skeletal muscles intermittently contract and relax. Skeletal muscles intermittently contract and relax.  Rapid, jerking movements Patient may be injured by striking surrounding objects. Patient may be injured by striking surrounding objects. Clonic phase lasts a few seconds to a few minutes. Clonic phase lasts a few seconds to a few minutes. Spasms may interfere with respirations. Spasms may interfere with respirations.  Patient may become cyanotic. Spasms may be followed by short periods of flaccid paralysis. Spasms may be followed by short periods of flaccid paralysis. Patient may urinate or bite tongue. Patient may urinate or bite tongue. Slide 29 Copyright © 2004, Mosby Inc. All rights reserved.

31. Grand Mal Seizures – Postictal Phase Decreased LOC and confusion Decreased LOC and confusion Slow awakening Slow awakening  Patient may fall asleep for short period. Afterward, may complain of headache Afterward, may complain of headache Slide 30 Copyright © 2004, Mosby Inc. All rights reserved.

32. Focal Seizures May affect only a portion of the body May affect only a portion of the body OR OR May present as altered mental status with bizarre behavior May present as altered mental status with bizarre behavior Slide 31 Copyright © 2004, Mosby Inc. All rights reserved.

33. Status Epilepticus Rapid succession of seizures without an intervening period of consciousness Rapid succession of seizures without an intervening period of consciousness Prolonged seizure Prolonged seizure Life-threatening because of sustained respiratory compromise Life-threatening because of sustained respiratory compromise Slide 32 Copyright © 2004, Mosby Inc. All rights reserved.

34. Febrile Seizures Caused by fever Caused by fever Children – 6 months to 6 years of age Children – 6 months to 6 years of age Occur in up to 5% of children Occur in up to 5% of children Slide 33 Copyright © 2004, Mosby Inc. All rights reserved.

35. Petit Mal Seizures Brief lapse of attention and awareness Brief lapse of attention and awareness  Staring  Fluttering eyelids  Eyes turned upward Last from 10 to 20 seconds Last from 10 to 20 seconds More common in children More common in children Slide 34 Copyright © 2004, Mosby Inc. All rights reserved.

36. Seizures – Emergency Medical Care Protect patient from harm. Protect patient from harm. Position patient on side, if no possibility of cervical spine trauma. Position patient on side, if no possibility of cervical spine trauma. Ensure patent airway; suction as needed; administer high-concentration oxygen. Ensure patent airway; suction as needed; administer high-concentration oxygen. Transport immediately. Transport immediately. Obtain vital signs en route. Obtain vital signs en route. Rule out trauma. Rule out trauma. Slide 35 Copyright © 2004, Mosby Inc. All rights reserved.

37. Stroke Permanent neurologic impairment caused by a disruption in blood supply to a region of the brain Permanent neurologic impairment caused by a disruption in blood supply to a region of the brain Two causes Two causes  Related to arteriosclerosis »Ischemic  Weakened artery in brain ruptures »Hemorrhagic Slide 36 Copyright © 2004, Mosby Inc. All rights reserved.

38. Stroke Third leading cause of death in the U.S. Third leading cause of death in the U.S.  500,000 Americans are affected annually. »Nearly 25% die. Slide 37 Copyright © 2004, Mosby Inc. All rights reserved.

39. Transient Ischemic Attack (TIA) Symptoms are the same as for stroke. Symptoms are the same as for stroke.  Lasts few minutes to a few hours »Resolves within 24 hours Approximately 25% of patients presenting with stroke had a TIA. Approximately 25% of patients presenting with stroke had a TIA. Approximately 5% of patients with TIA will have stroke within 1 month, if untreated. Approximately 5% of patients with TIA will have stroke within 1 month, if untreated. Slide 38 Copyright © 2004, Mosby Inc. All rights reserved.

40. Acute Stroke Ischemic Ischemic  Approximately 75% of strokes  May be eligible for treatment if in ED within 3 hours of onset Hemorrhagic Hemorrhagic  Can be fatal at onset Slide 39 Copyright © 2004, Mosby Inc. All rights reserved.

41. Stroke – Initial Assessment Ensure patent airway. Ensure patent airway. Support ventilations, as necessary. Support ventilations, as necessary. Slide 40 Copyright © 2004, Mosby Inc. All rights reserved.

42. Stroke – Signs and Symptoms Altered level of consciousness Altered level of consciousness »Confusion, stupor, delirium, coma, seizures Severe headache Severe headache »“Worst headache of my life” Aphasia Aphasia Facial weakness or asymmetry Facial weakness or asymmetry Incoordination, weakness, paralysis, sensory loss of one or more limbs Incoordination, weakness, paralysis, sensory loss of one or more limbs Ataxia Ataxia Visual loss Visual loss Dysarthria Dysarthria Intense vertigo, diplopia Intense vertigo, diplopia Slide 41 Copyright © 2004, Mosby Inc. All rights reserved.

43. Stroke – Focused History and Physical Exam Focused history Focused history  Chief complaint  Time of onset, if known »Accurate time of onset is crucial »If onset unknown, ask what time patient was last seen or went to bed.  Gather SAMPLE history. Slide 42 Copyright © 2004, Mosby Inc. All rights reserved.

44. Stroke – Focused History and Physical Exam Physical examination Physical examination  If stroke is suspected, examine rapidly. »Cincinnati Prehospital Stroke Scale »Los Angeles Prehospital Stroke Screen »Glasgow Coma Scale  Consider transport to appropriate facility without delay. »Notify receiving facility. »Monitor vital signs en route. Slide 43 Copyright © 2004, Mosby Inc. All rights reserved.

45. Stroke – Cincinnati Prehospital Stroke Scale Slide 44 Copyright © 2004, Mosby Inc. All rights reserved.

46. Stroke – Los Angeles Prehospital Stroke Screen Slide 45 Copyright © 2004, Mosby Inc. All rights reserved.

47. Glasgow Coma Scale Slide 46 Copyright © 2004, Mosby Inc. All rights reserved.

48. Altered Mental Status – Emergency Medical Care Initial assessment Initial assessment  Ensure patent airway. »Consider potential for head trauma; provide spinal immobilization.  Consider hypoxia »Provide appropriate ventilatory support.  Consider hypoglycemia. »Administer oral glucose, if appropriate. Slide 47 Copyright © 2004, Mosby Inc. All rights reserved.

49. Altered Mental Status – Emergency Medical Care Focused history Focused history  Patient’s last normal level of function  Associated complaints  Chronology of events  History of similar past experiences  SAMPLE history Slide 48 Copyright © 2004, Mosby Inc. All rights reserved.

50. Altered Mental Status – Emergency Medical Care Physical examination Physical examination  Vital signs  Abnormal smells  Pupillary status  Motor and sensory function »Asymmetry  Check for medical alert tag. Slide 49 Copyright © 2004, Mosby Inc. All rights reserved. Slide 49 Copyright © 2004, Mosby Inc. All rights reserved.