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Patient with Altered Mental Status
May 2014 CE Condell Medical Center EMS System Site Code: E-1214 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev
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Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Describe common causes of altered mental status. 2. Describe components of a field neurological examination. 3. Describe required field assessment of the patient with a possible stroke including documentation of time of onset, blood sugar level, and Cincinnati Stroke Scale. 4. Define the characteristics of excited delirium syndrome (ExDS).
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Objectives cont’d 5. Describe field interventions for the patient experiencing an episode of excited delirium syndrome (ExDS). 6. Given a variety of patient presentations, assign a Glasgow Coma Scale score (GCS). 7. Actively participate in review of revised Region X SOP’s. 8. Actively participate in review of a variety of EKG rhythms and 12 lead EKG’s. 9. Actively participate in case scenario discussion.
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Objectives cont’d 10. Review responsibilities of the preceptor role.
11. Describe use of the CAT device as a means to control bleeding. 12. Describe the benefits and procedure to use QuikClot gauze as a means to control bleeding. 13. Actively participate in return demonstration of preparing the Flow Safe II CPAP device for patient application. 14. Successfully complete the post quiz with a score of 80% or better.
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The Brain A complex organ that weighs approximately 3 pounds
Makes up 2% of our body weight The cerebrum makes up the majority of the brain We are all born with the same number of brain cells Personal experiences, education, and social environment shape the person we are
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The Brain Divided into 2 hemispheres – right and left brains
Strongly symmetrical Left brain controls all muscles on right side of body Right brain controls all muscles on left side of body
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The Brain Left brain Has region of speech and language
Broca’s area (expressive aphasia) & Wernicke’s areas (receptive aphasia) Associated with mathematical calculations and fact retrieval Right brain Role in visual and auditory processing, spatial skills, and artistic ability Spatial skills – to understand problems with physical spaces, shapes, forms Expressive aphasia – loss of ability to express oneself through language although can understand Receptive aphasia – person can read or hear but does not understand the communication Spatial skills – a reasoning skill with the capacity to think about objects in 3 dimensions and draw conclusions about those objects. A mental function.
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Regions of the Brain
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Consciousness Arousal requires an intact and functioning brainstem
Normal consciousness requires arousal and cognition Ability to think, understand, learn, and remember Display of orientation, judgment, and memory Think of the questions we ask patients testing these areas Person, place, time, and event Arousal requires an intact and functioning brainstem
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What is Altered Mental Status?
Altered behavior Confusion Change in higher cerebral function Change in memory Change in attention Change in awareness Change in judgment
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Obtaining a Baseline Determine when patient last seen normal
Evaluate for allergies and current medications Inquire regarding recent hospitalizations, infection, trauma, psychiatric illness Check environment for bottles (medications, alcohol, poisonings) Family extremely helpful to indicate subtle changes noted
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Evidence of Changes in Brain Function
Confusion Amnesia Loss of alertness Loss of orientation Person, place, time, event Defects in judgment/thought Poor regulation of emotions Disruption in perception, psychomotor skills, behavior
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Content of Thought and Speech Evaluation
Can patient stay focused? Is their speech tangential (abruptly moving off topic)? Is patient oriented? Is patient concerned and focused on the issue? Are they asking repetitive questions?
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“Alert & Oriented” What is this reference to? A & O x3 or A & O x4???
Depending on what you test: x1 - Alert & oriented to person – their name x2 - Alert & oriented to place – do they recognize where they are x3 - Alert & oriented to time – time / day / date / season (any is reasonable) x4 - Alert & oriented to event – what just happened or what is happening
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Components of Field Neurological Assessment
Level of alertness – AVPU and GCS scales Ability to keep person awake 12 cranial nerves (CN) CN 3 (oculomotor nerve) checked in the field – pupillary response Bilateral motor and sensory responses Gait – not consistently able to observe in the field 12 cranial nerves: “On old Olympic towering tops a Finn and German viewed some hops” CN I – olfactory – smell CN II – optic – vision CN III – oculomotor – eyelid/eyeball movement CN IV – trochlear – turns eyes downward and laterally CN V – trigeminal – chewing CN VI – abducens – eyes turn laterally CN VII – facial – controls most facial movement; taste anterior 2/3 of tongue CN VIII – auditory – hearing, equilibrium (balance) CN IX – glossopharyngeal – sense carotid B/P; taste posterior 1/3 tongue; some muscles in swallowing CN X – vagus – senses aortic B/P, slows heart rate, stimulates digestive organs, taste CN XI – spinal accessory – controls trapezius and sternocleidomastoid muscles (shoulder and head movement); controls swallowing movement CN XII – hypoglossal – controls tongue movement Gag reflex – sensory limb innervated predominately by CN IX glossopharyngeal; motor limb innervated by CN X vagus nerve Blink reflex – corneal reflex – opthalmic branch of CN V (trigeminal); temporal and zygomatic branches of CN VII (facial)
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Neurological Assessment - AVPU
An assessment scale not as detailed as GCS Can be performed very quickly Provides global picture of level of responsiveness Most important is monitoring for changes in a response
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AVPU A – alert V – responds to verbal commands
Not necessarily oriented; just awake V – responds to verbal commands Difficult to distinguish if patient responded to voice or touch as they are often done simultaneously in the field P – responds to pain or tactile stimulation U – unresponsive, flaccid, no response at all
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Glasgow Coma Scale (GCS)
Assesses overall level of arousal Originated in Glasgow, Scotland A tool originally designed to predict prognosis in traumatic brain injured patients Used to diagnose, provide outcome, and evaluate progression of disease Change in 2 or more points represents significant change in patients level of consciousness
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GCS Evaluate BEST RESPONSE to 3 components: best eye opening, verbal response, and motor response Assign a score of 3 to 15 The higher the score the more favorable the outcome Not just useful in traumatic head injury usually indicate minor head trauma 9 – 12 usually indicate moderate head trauma
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GCS – Eye Opening Need to approach patient and attempt to illicit eye opening response to verbal stimuli prior to making physical contact with the patient Not always easy or in the best interest of the patient May need to apply manual c-spine control as soon as patient contact made 4 – eyes open spontaneously 3 – eyes open to command spoken or shouted 2 – eyes open after painful/noxious/tactile stimuli applied 1 – no eye response at all
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GCS – Verbal Response 5 – oriented to person, place, time, event
4 – confused; not oriented to person, place, time, and/or event 3 – Inappropriate words – not able to speak in sentences; uses random words; swearing is common 2 – Incomprehensible sounds – moaning and groaning; no distinguishable words heard 1 – not making any verbal sounds
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GCS – Motor Response 6 – obeys commands
5 – Purposeful movement – generally able to cross center of body; reaches for noxious stimuli to remove it (i.e.: IV, B/P cuff, c-collar, your hands) 4 – Withdraws to pain – pulls arm/shoulder into body (adduction) 3 – Abnormal flexion – arm/shoulder abducted, extremity bends/flexes 2 – Abnormal extension – extremities straighten and rotate, back generally arches 1- no response to all; flaccid
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Potential Causes Altered Mental Status AEIOU - TIPS
A – Alcohol E – Endocrine, encephalopathy, electrolytes I – Insulin (hypoglycemia) O – O2 (hypoxia), opiates U – uremia (kidney disease) T – Toxins, temperature, trauma I – Infection P – Psychiatric, porphyria S – stroke, shock, subarachnoid hemorrhage, space-occupying lesion (i.e.: tumor) Porphyria – usually an inherited disorder of build up of a body chemical (heme) normally associated with hemoglobin.
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Potential Causes Altered Mental Status SMASHED
S – substrates (glucose, thiamine deficiency), sepsis M – meningitis A – Alcohol, accident S – Seizure, stimulants, hallucinogens, anticholinergics H – Hyper/hypo (B/P, thyroid, temp, hypercarbia, hypoxia) E – electrolytes, encephalopathy D – drugs (intoxication/withdrawal), illicit drugs, CO poisoning, steroids, salicylates Substrates – a base upon which an organism lives
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Stroke Injury or death to brain tissue
Usually from an interruption in cerebral blood flow Tissue deprived of oxygen and glucose 2 components brain cells rely on to function 3rd leading cause of death and disability Can strike any age Increased risk with history of atherosclerosis, heart disease, or hypertension
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Occlusive Strokes 85% Incidence
Cerebral artery blocked by clot or other foreign matter Ischemia infarction Embolic stroke – usually occur suddenly A mass, generally a clot Often a thromboemboli traveling from diseased vessels or from chambers in heart Thrombotic stroke – usually develop gradually Clot developed in and obstructs cerebral artery usually related to atherosclerosis
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Hemorrhagic Strokes 15% Incidence
Usually bleeding within brain (intracerebral) or space around outer surface of brain (subarachnoid) Onset marked with sudden, severe headache Often related to history hypertension or congenital abnormalities in blood vessels
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Risk Factors for Stroke
Hypertension Diabetes Abnormal blood lipid levels (elevated cholesterol) Oral contraceptive use Sickle cell disease Some cardiac dysrhythmias (i.e.: atrial fibrillation)
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Assessment of the Patient With A Possible Acute Stroke
Onset of signs or symptoms or last known normal with exact time Blood glucose level Cincinnati Stroke Scale An abnormal finding in any one parameter associated with 72% probability of stroke Facial droop Arm drift Change in speech
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Acute Stroke Assessment cont’d
Medication history of anticoagulant use Coumadin - Warfarin Xarelto - Rivaroxaban Pradaxa - Dabigatran Eliquis – Apixaban Lovenox – Enoxaparin History of antiplatelet use less of concern but still helpful to recognize Aspirin and Plavix - Clopidogrel
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Motor and Sensory Assessment
Noting that responses generated from different areas of the brain, evaluator can predict area of infarct by noting the deficit Important to document specific results of assessments performed
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Region X SOP – Stroke/Brain Attack
RMC Determine time of onset / last known normal Obtain and record blood sugar level Intervene if <60 Perform Cincinnati Stroke Scale Watch for rapid neurological deterioration Consider drug assisted intubation to protect airway if necessary
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Rapid Neurological Deterioration
Assess patient for changes indicating a worsening of condition Unequal pupils Extensor posturing Lateralizing signs A function attributed to one side of the brain Evaluate for deficits from patient’s normal or baseline
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Treatment Rapid Neurological Deterioration
Brain reliant on adequate supply of oxygen and glucose to function Need to provide oxygenated blood Need to avoid blowing off too much carbon dioxide to prevent potential vasoconstriction that would limit brain blood flow Ventilate adults 1 breath every 3 seconds via BVM (20 bpm) Ventilate children 1 breath every 2 seconds via BVM (30 bpm) Ventilate infants 1 breath every 1.7 seconds via BVM (35 bpm)
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Excited Delirium (ExDS)
Sudden, unexplained onset with rapid progression Delirium – fundamental manifestation Agitation Aggression Acute distress Unusual physical strength Acidosis – prominent role in cardiovascular collapse; usually leads to brady-asystole or PEA Ventricular dysrhythmias are rare.
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Excited Delirium (ExDS)
Exact cause uncertain but felt to have multiple etiologies No “test” exists for diagnosis Need to differentiate from bad behavior, drunken behavior, and excited delirium (ExDS) Hallmark Profuse sweating High body temperature (105.20F (40.70C) common on autopsy Delusional behavior
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Excited Delirium - ExDS
Increased risk of death with physiologic stress Immediate sedation decreases risk of death Stressful encounter increases chemical imbalance in brain Process progresses rapidly Most patients that die exhibit severe aggression and are non-compliant to requests to halt their behavior Most patients that die found with evidence of trying to cool down Disrobed, empty ice trays in the environment
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Excited Delirium – ExDS and Chronic Cocaine Abuse
Suspected to be co-existing risk factor causing death Contributes to development of coronary artery disease Acts as potent adrenergic agonist leading to chronic catecholamine toxicity Hypertrophy Microangiopathy Myocardial fibrosis
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Excited Delirium – ExDS CNS Dysfunction
Central nervous system (CNS) dysfunction of dopamine signaling with aberrant dopamine processing blamed for clinical presentation Mimics of ExDS Hypoglycemia – rule out by obtaining blood sugar Heat stroke Serotonin syndrome and neuroleptic malignant syndrome – but no aggressive violent behavior Psychiatric issues Serotonin is a chemical in the body that allows brain and other nervous system cells to communicate with each other. Serotonin syndrome – event where medications are taken that cause high levels of serotonin to accumulate in the body causing excessive nerve cell activity. Neuroleptic malignant syndrome – life threatening neurological disorder often caused by adverse reaction to neuroleptic or antipsychotic medications.
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Excited Delirium (ExDS) Typical Presentation
Male, mean age 36 Hyperaggressive, bizarre behavior Impervious to pain Combative Hyperthermic Tachycardic, tachypnea No rational thoughts for safety Tolerance to pain Sweating Non-compliant, no remorse or fear Does not tire Unusual strength Inappropriately clothed Occ attraction to glass & mirrors
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Excited Delirium (ExDS)Treatment
Aggressive chemical sedation required Treatment is concurrent with evaluation for other precipitating causes or additional pathology Physical struggle increases the catecholamine surge leading to metabolic acidosis and increasing risk of death Most patients that die are non-compliant and exhibit severe aggression Need to minimize time spent struggling while safely achieving physical control
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Region X SOP Field Interventions Behavioral Emergencies
Personal, personnel, and scene safety Utilize law enforcement support Must have prior dialogue to determine how these 2 agencies will best work together in this potentially violent situation Restrain as necessary Document reasons, type, time, patient response
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Region X SOP Behavioral Emergencies cont’d
Consider medical etiologies Hypoxia Substance abuse/overdose Excited delirium/hyperthermia Neurologic disease – CVA, intracerebral bleed Metabolic problem – hypoglycemia Routine Medical Care as warranted
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Region X SOP Behavioral Emergencies cont’d
For severe anxiety or agitation Versed 2 mg IN Avoids exposure to potential needle stick If needed, may repeat Versed 2 mg IN every 2 minute titrated to desired effect Maximum dose of 10 mg If additional sedation required Valium 5 mg IVP over 2 minutes Can repeat up to maximum of 10 mg OR: Valium 10 mg IM
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Benzodiazepines Versed® and Valium®
Sedative agents Relatively short acting - Versed® shorter than Valium® but more potent Caution Relatively slow onset (Versed® IN 3 – 5 minutes) Unpredictable action if not IVP Need for repeated dosing Potential for respiratory depression – support ventilations via BVM if necessary
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Medication Via Intranasal (IN) Route
IN route medications do not pass through the gut; dosing is not diminished Med absorbed directly into cerebral spinal fluid via a nose brain pathway May cause a burning sensation for seconds after delivery Ideal volume 0.5 ml per nares; max 1 ml per nares More volume would run out nose Insert wedge into nostril Aim to same side ear and depress plunger to create mist Aim MAD syringe up and outward.
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FYI - Differentiating Delirium vs Dementia
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Updates to Region X SOP Increase to adult dose of Fentanyl to 1 mcg/kg IVP/IO/IN For managing adult pain appropriately – use of TCP General adult pain management Adult weight based medication reference chart reflects changes Oral glucose gel (Glutose) 15 G can be used for the adult diabetic If patient is able to tolerate oral preparation Patient has an intact gag reflex Patient able to protect their own airway
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New Oral Glucose Gel – Glutose 15
A monosaccharide (simple sugar) medication primarily of dextrose and water Absorbs directly through oral tissue Once squirted into mouth, generally swallowed for absorption via small intestine Can remain in mouth momentarily for absorption via oral cavity first Provides 15 grams of glucose No common side effects reported Store room temperature away from heat, light, and moisture
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Duoneb Update Ipratropium (Atrovent) added to 1st and 2nd Duoneb treatments Adult asthma/COPD with wheezing Stable adult allergic reaction with airway involvement if wheezing Pediatric asthma in mild to moderate distress Pediatric croup Stable pediatric allergic reaction with airway involvement if wheezing
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Zofran Update Zofran ODT oral route Remains same dose at 4 mg
ODT = orally disintegrating tablet Dissolves quickly as soon as placed in the mouth on the tongue Some patients initially complain of brief nauseous sensation For adult nausea management For pediatric nausea management if > 40 kg (88 pounds)
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Zofran ODT - Ondansetron®
Prevents nausea and vomiting by blocking a chemical that causes the reactions Avoid use in congenital long QT syndrome Rhythm could degenerate into polymorphic VT – Torsades Take tablet orally with or without food or water DO NOT PUSH TABLET THRU FOIL – peel foil back Tablet dissolves instantly and can be swallowed with saliva Document: Time given; “Zofran ODT”; “4 mg”; route – “po”
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Long QT Syndrome Can cause aberrant ventricular electrical activity
Increases risk for ventricular dysrhythmias, esp torsades de pointes Can lead to syncope and death Normal QT interval 0.42 seconds
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Ventricular Tachycardia
Monomorphic VT Polymorphic VT
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Region X SOP Review Stable Monomorphic Wide Complex
Adenosine 6 mg rapid IVP followed immediately with rapid 20 ml saline flush Rhythm may be SVT with aberrancy Conduction took detour which widens out QRS width If no effect in 2 minutes Amiodarone 150 mg diluted in 100 ml D5W IVPB over 10 minutes
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Region X SOP Stable Polymorphic Wide Complex
Need an antidysrhythmic to be administered Amiodarone 150 mg diluted in 100 ml D5W IVPB over 10 minutes Place primary IV line Piggyback medication into port as close to patient as possible Both bags can hang at equivalent height Both bags will drip independent of each other
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Additional SOP Revisions
Pediatric near drowning If patient is to be intubated, ventilations provided at a rate of 1 breath every 6 – 8 seconds via advanced airway Document this as 8 – 10 breaths per minute assisted Tourniquet use Guidelines providing directions for use of a tourniquet placed in skill section CAT device distributed to departments in Region X
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CAT® Device Life threatening extremity hemorrhage
May be black or orange in color CAT® Device Life threatening extremity hemorrhage Amputation or failure of direct pressure Place as far distally as possible and proximal to wound Tighten windlass until bleeding stops and distal pulse no longer palpable Record time tourniquet placed Consider pain management Note: Part of the EMT –Basic curriculum so is a Basic skill
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GCS Practice Remember Always assign the highest score possible
Deterioration in patient’s condition becomes more evident More important than any one score is the score over the course of time
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GCS Practice #1 25 year old found sitting on bench
Eyes are spontaneously open Patient keeps saying “I”, “I”, “I” Slaps at your hands; pulling off equipment Eye opening – 4 Verbal response – 3 Motor response – 5 Total - 12
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GCS Practice #2 50 year old male found on ground
No eye movement Occasionally groaning Withdrawing to pain Eye opening – 1 Verbal response – 2 Motor response 4 Total 7
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GCS Practice #3 27 year old male found in garage
Eyes pop open when patient touched and then they close Randomly cries out “mom”, “don’t”, “no”, “ok” Pulling off collar, IV, other equipment, slapping at your hands Eye opening – 2 Verbal response – 3 Motor response – 5 Total 10
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GCS Practice #4 12 year old found prone at grocery store
Eyes are open but with vacant stare; not focusing Talking about being at skateboard park; not responding to commands Trying to pull off B/P cuff Eye opening – 4 Verbal response – 4 Motor response – 5 Total - 13
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GCS Practice #5 8 year old found laying in bed
Eyes close tighter when touched Crying and whimpering Pulling away when touched or equipment applied Eye opening – 2 Verbal response – 2 Motor response – 4 Total - 8
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GCS Practice #6 62 year old male found at home on couch
Eyes open to command and then close Mumbling and yells out random words Right arm flaccid; left pulls back and withdraws to pain Eye opening – 3 Verbal response – 3 Motor response – 4 Total - 10
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GCS Practice #7 30 year old at home suddenly slumped over
Eyes are open and following you around room Yelling out spontaneous words and swearing Moves all extremities but not to command; swatting at your hands Eye opening – 4 Verbal response – 3 Motor response – 5 Total - 12
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Preceptor Role Useful role to have in place for:
New students Person new to the role In presence of new skill to learn When a person is new to the environment Preceptor to develop & validate competencies of another
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Preceptor Role Demonstrated Competencies
Teacher / coach Leader / influencer Facilitator Evaluator Protector Role model How do you fill this role???
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FlowSafe II CPAP Continuous Positive Airway Pressure
Goal: to maintain open airways CPAP works by keeping airways from collapsing closed during exhalation Takes lots of energy to reopen closed airways Outcome Improved pulmonary air exchange Increase in intrathoracic pressure that reduces preload and afterload preload – less blood returning to the heart afterload – less vascular resistance heart has to pump against
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CPAP Continuous airway pressures delivered throughout respiratory cycle CPAP is to be delivered simultaneously with medications CPAP begins to work and bridges gap waiting for medications to work Nitroglycerin is to be administered after patient assessment and as CPAP is being set up Continue to deliver Nitroglycerin during CPAP treatment An effective, predictable, rapid acting method to reduce preload
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FlowSafe II CPAP Connect oxygen tubing nipple to gas source
Secure mask snugly to patient’s face Adjust flowmeter to CPAP of 10 (13 – 14 liters per minute) Note ranges provided on yellow tag on O2 tubing
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FlowSafe II CPAP Patient should respond to treatment within minutes
Patient needs encouragement and support especially first few minutes of mask use If needed for wheezing, can add in-line nebulizer treatment
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Case Review Read the following cases
Discuss important aspects of assessment related to the presentation Determine your working diagnosis Discuss treatment/interventions required
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Case Review #1 EMS is called for a patient who is acting bizarre and running through the streets While responding, you verify police have been dispatched Upon arrival, you note approximately 5 police officers wrestling with a male subject What is your impression? Consider behavioral emergencies, especially excited delirium Consider other causes of altered mental status
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Case Review #1 After scene safety, what is the most important intervention to consider for this patient? Sedation What are you considering administering? Versed 2 mg May repeat every 2 minutes to max of 10 mg What route would be safest and why? IN – avoids risk of needle exposure
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Case Review #1 Important note:
Delay in administering sedation increases risk of death for patient Tough call: need to get patient held down/manually restrained, for EMS to get close enough to perform quick essential assessment and deliver sedation Then EMS moves out and lets police take over to continue to restrain patient Remember: this patient will not obey command, cannot be reasoned with
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Case Review #2 35 year old male presented with weakness to left arm and slurred speech Co-workers felt initially that he was “drunk” Upon your arrival patient is sitting in chair leaning to the side Eyes open, following your movement in the room Attempts to follow commands Speech is garbled; becoming agitated that you cannot understand him
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Case Review #2 What is included in your assessment?
Time last known normal Typical vital signs, pulse oximetry, AVPU/GCS Blood glucose level Cincinnati Stroke Scale
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Case Review #2 Why is the speech unintelligible?
Different functions arise from different areas of the brain Deficits can point to area of brain most likely affected Left brain – responsible for normal speech and language; control right sided motor function Right brain – responsible for visual and auditory, spatial skill (reasoning skills when viewing 2 -3 dimension objects), and artistic ability; controls left sided motor function
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Case Review #2 Why is blood sugar level necessary if patient is alert and oriented presenting with a stroke? Required by AHA/ASA American Heart Association/American Stroke Association Best practice related to assessing the potential stroke patient
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Case Review #3 EMS responds to a “fight” in progress between police and a subject Patient reportedly naked running through the streets yelling/screaming Upon your arrival police are attempting to mechanically restrain patient As you walk up to the scene, you no longer hear the patient screaming or yelling You notice the patient’s head rolling to the side with eyes closed Patient appears unconscious What are you going to do???
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Case Review #3 What do you do as soon as you see a rhythm?
As quickly as possible, evaluate the patient Patient is apneic and pulseless Now what do you do? Begin CPR with compressions Get the monitor on and interpret the rhythm as soon as possible What do you do as soon as you see a rhythm? Check for a pulse; if no pulse, begin CPR
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Case Review #3 What is the rhythm and what do you do? PEA
CPR 30:2 ratio (1 and 2 man CPR) Search for treatable causes – the H’s and T’s Fluid challenge 200 ml increments Assess lung sounds first Epinephrine 1:10,000 1 mg IVP/IO – repeat every 3 – 5 minutes as needed
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Case Review #3 What are the most likely treatable causes to search for and treat for this patient? H – hypovolemia – provide fluid challenges if lungs are clear H – hypoxia – ventilate with supplemental oxygen H+ ion - Acidosis – ventilate to get rid of the acid CO2 Toxins – if ExDS suspected, then cocaine abuse is most likely
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Case Review #3 Would treatment be any different if the initial presenting rhythm is asystole? No Treatment is the same for PEA and asystole PEA is treated the same regardless of the rate of the presenting rhythm But, check for pulses every 2 minute pause in setting of PEA
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Case Review #4 EMS responds to a work environment for a 64 year old with complaints of left upper extremity numbness Are you already thinking possible stroke? What information is important to obtain if thinking stroke? Last known normal Blood glucose level Cincinnati Stroke Scale results Baseline vital signs
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Case Review #4 AVPU – alert and oriented x3 (or x4)
VS: B/P 150/90; P – 76; R – 16; SpO2 98%; Blood sugar 130 GCS 4/5/6 (total 15) History of hypertension and diabetes Meds: enalapril, metformin Denies: headache, weakness, vision or gait problems Cincinnati stroke scale – no facial droop, no arm drift, speech clear ACE inhibitors usually have meds that end with “pril”.
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Case Review #4 Need to think “out of the box”
Be suspicious of person having a stroke for unusual presentations Legs don’t work Numbness, tingling, weakness not explained “Something is just not right” Better to err on side of worst case scenario
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Case Review #5 76 year old calls 911 for sudden onset dyspnea
Upon arrival patient is in chair, tripod position Extremely anxious, diaphoretic, labored & rapid breathing Quick assessment: Patient responds verbally (level of consciousness intact) Patient has a rapid, regular radial pulse (if distal pulse felt, B/P must be reasonable)
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Case Review #5 Further Assessment
Lung sounds – bilateral crackles half way up VS: B/P 170/98; P – 104; R – 28; SpO2 93% What is your working diagnosis? Acute pulmonary edema What else do you need to consider happening simultaneously to this patient? Acute MI Not sure if AMI causes acute pulmonary edema or if pulmonary edema led to AMI
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Case Review #5 What action do you need to take for this patient?
Determine that patient is relatively stable Administer nitroglycerin 0.4 mg sl – may repeat every 5 minutes x3 total Begin CPAP Lasix 40 mg IVP (80 mg IVP if on Lasix at home) If B/P >90 Morphine 2 mg IVP slowly over 2 minutes; may repeat every 2 minutes (max 10 mg)
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Case Review #5 What is benefit of nitroglycerin?
Venodilator to open vessels decreases preload and afterload to reduce workload on heart What is benefit of CPAP? Keeps airways open Improves gas exchange
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Case Review #5 What is benefit of Lasix?
More immediately causes venodilation to decrease preload and afterload Acts as a diuretic (can take up to 20 minutes to kick in) What is benefit of morphine sulfate? Anxiolytic – to reduce anxiety level of patient Does cause venodilation to a degree
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QuikClot A new tool currently being piloted in Region X by volunteer departments Department members must be in-serviced before tool put into use To be used in uncontrollable bleeding If an extremity, special 4x4 placed after tourniquet use has failed Requires direct pressure be maintained Avoid urge to peek at site
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Video Clips for Behavioral Emergencies
Patient on bath salts v=mhlaHwnErBI&sns=em Patient out of control GeiB57iMhQA
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Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady Region X SOP’s; IDPH Approved January 6, 2012.
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Bibliography cont’d h_to_the_neurologic_patient/evaluation_of_the_neurologic_patient.html ge
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