1. 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

2. 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).

3. 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.

4. 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.

5. 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

6. 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

7. 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.

8. Regions of the Brain

9. 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

10. 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

11. 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

12. 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

13. 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?

14. “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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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)

35. 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.

36. 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

37. 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

38. 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

39. 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.

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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.

47. FYI - Differentiating Delirium vs Dementia

48. 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

49. 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

50. 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

51. 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)

52. 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”

53. 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

54. Ventricular Tachycardia
Monomorphic VT
Polymorphic VT

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. 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

68. Preceptor Role Demonstrated Competencies
Teacher / coach
Leader / influencer
Facilitator
Evaluator
Protector
Role model
How do you fill this role???

69. 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

70. 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

71. 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

72. 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

73. Case Review Read the following cases
Discuss important aspects of assessment related to the presentation
Determine your working diagnosis
Discuss treatment/interventions required

74. 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

75. 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

76. 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

77. 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

78. 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

79. 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

80. 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

81. 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???

82. 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

83. 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

84. 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

85. 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

86. 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

87. 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”.

88. 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

89. 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)

90. 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

91. 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)

92. 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

93. 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

94. 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

95. Video Clips for Behavioral Emergencies
Patient on bath salts
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Patient out of control
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96. 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.

97. Bibliography cont’d
h_to_the_neurologic_patient/evaluation_of_the_neurologic_patient.html ge