1. The Patient With An Altered Mental Status October 2009 CE Advocate Condell Medical Center Objectives by Jeremy Lockwood FFPM Mundelein Fire Department Prepared by Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: Upon successful completion of this module, the EMS provider will be able to: 1. Identify components evaluated in determining a patient’s mental status and orientation. 1. Identify components evaluated in determining a patient’s mental status and orientation. 2. Define altered mental status. 2. Define altered mental status. 3. Identify the possible causes of altered mental status. 3. Identify the possible causes of altered mental status. 4. Identify signs and symptoms of altered mental status. 4. Identify signs and symptoms of altered mental status. 5. Identify elderly considerations related to altered mental status. 5. Identify elderly considerations related to altered mental status.

3. Objectives cont’d 6. Identify assessment procedures related to patients with altered mental status. 6. Identify assessment procedures related to patients with altered mental status. 7. Describe how to obtain an accurate Glasgow Coma Scale assessment. 7. Describe how to obtain an accurate Glasgow Coma Scale assessment. 8. Describe the procedure to obtain a blood glucose determinant. 8. Describe the procedure to obtain a blood glucose determinant. 9. Identify the components of the Cincinnati Stroke Scale. 9. Identify the components of the Cincinnati Stroke Scale. 10. Identify the treatment of patients with altered mental status. 10. Identify the treatment of patients with altered mental status.

4. Objectives cont’d 11. Describe methods of restraining the combative patient. 11. Describe methods of restraining the combative patient. 12. Identify the indications, contraindications, complications, and documentation when using the QuickTrach airway device. 12. Identify the indications, contraindications, complications, and documentation when using the QuickTrach airway device. 13. Given a scenario obtain the GCS. 13. Given a scenario obtain the GCS. 14. Perform assessment of the Cincinnati Stroke Scale. 14. Perform assessment of the Cincinnati Stroke Scale. 15. Given a manikin, demonstrate placement of the QuickTrach airway Device. 15. Given a manikin, demonstrate placement of the QuickTrach airway Device.

5. Normal Mentation To identify abnormal mental status, need to understand what is normal To identify abnormal mental status, need to understand what is normal We all practice a number of means and ways to identify the mental status We all practice a number of means and ways to identify the mental status General appearance General appearance Orientation to person, place, and time Orientation to person, place, and time AVPU AVPU

6. General Appearance Can gain important information looking at the “big picture” Can gain important information looking at the “big picture” Observe hygiene Observe hygiene Observe clothing Observe clothing Observe overall appearance Observe overall appearance Observe verbal and nonverbal behavior Observe verbal and nonverbal behavior Facial expressions Facial expressions Tone of voice, volume, quality, speech pattern Tone of voice, volume, quality, speech pattern Eye contact Eye contact Memory intact for recent and long-term events? Memory intact for recent and long-term events? Is the patient focused; paying attention? Is the patient focused; paying attention?

7. Orientation to Person, Place, Time Can be insulting to a patient to ask pointedly “what’s your name?” “who’s the president?” Can be insulting to a patient to ask pointedly “what’s your name?” “who’s the president?” Often helpful to state: Often helpful to state: “Since I don’t know your condition very well, I need to ask some very basic questions.” “Since I don’t know your condition very well, I need to ask some very basic questions.” Person – patient can state their name Person – patient can state their name Place – patient can recognize they are at home, in a store, in an ambulance, at a hospital Place – patient can recognize they are at home, in a store, in an ambulance, at a hospital Time – patient can tell what year it is and time of year (by month or season) Time – patient can tell what year it is and time of year (by month or season)

8. AVPU A – alert meaning the patient is awake A – alert meaning the patient is awake “A” is not meant to indicate orientation; just level of awakeness “A” is not meant to indicate orientation; just level of awakeness V – responding to verbal stimuli only V – responding to verbal stimuli only Any response including fluttering of eyelids is a positive response to calling the patient’s name or asking a command Any response including fluttering of eyelids is a positive response to calling the patient’s name or asking a command P – responding to “pain” P – responding to “pain” Could also indicate responding to tactile stimuli so do not always need to inflict a painful stimuli Could also indicate responding to tactile stimuli so do not always need to inflict a painful stimuli Any response including fluttering of eyelids or any body twitch is a positive response Any response including fluttering of eyelids or any body twitch is a positive response U – unresponsive U – unresponsive Patient is flaccid with no responses at all Patient is flaccid with no responses at all

9. Stimulating a Painful Response Acceptable methods Acceptable methods Pressing on supraorbital ridge (bone below eyebrow) Pressing on supraorbital ridge (bone below eyebrow) Trapezium squeeze – twisting muscle where neck and shoulder meet Trapezium squeeze – twisting muscle where neck and shoulder meet Rubbing sternum with knuckles Rubbing sternum with knuckles Pressing on finger nail bed Pressing on finger nail bed Unacceptable methods Unacceptable methods Any technique that would leave bruising Any technique that would leave bruising Discouraged methods Discouraged methods Any stimuli that may cause movement of the c-spine by the patient pulling away from the stimuli Any stimuli that may cause movement of the c-spine by the patient pulling away from the stimuli

10. Altered Mental Status Patient not awake, alert or oriented Patient not awake, alert or oriented Patient not aware of their environment Patient not aware of their environment Patient not oriented to person, place, time Patient not oriented to person, place, time Patient confused Patient confused Patient unable to demonstrate an understanding of what is being said Patient unable to demonstrate an understanding of what is being said Most important is noting any change over the course of time in level of consciousness Most important is noting any change over the course of time in level of consciousness

11. Level of Consciousness One of the first indicators to change when the level of perfusion is diminishing is level of consciousness One of the first indicators to change when the level of perfusion is diminishing is level of consciousness FYI – The blood pressure is one of the last indicators to change when the level of perfusion diminishes FYI – The blood pressure is one of the last indicators to change when the level of perfusion diminishes

12. Possible Cause of Altered Mental Status Many lists have been created Many lists have been created Mnemonics have been created to trigger lists Mnemonics have been created to trigger lists AEIOU-TIPS AEIOU-TIPS SMASHED SMASHED EMS should think outside the box and look for all potential causes EMS should think outside the box and look for all potential causes When you find one cause, keep looking in case there are more than one cause associated with the altered mental status When you find one cause, keep looking in case there are more than one cause associated with the altered mental status

13. Thinking Outside The Box How many squares do you see?

14. Thinking Outside The Box 30 squares: 30 squares: 1 large 4 x 4 square 1 large 4 x 4 square 16 small 1 x 1 squares 16 small 1 x 1 squares 4 – 3 x 3 squares in each corner 4 – 3 x 3 squares in each corner 9 – 2 x 2 squares 9 – 2 x 2 squares

15. Mnemonic - AEIOU-TIPS A – alcohol A – alcohol E – endocrine, electrolytes, encephalopathy E – endocrine, electrolytes, encephalopathy I – insulin I – insulin O – opiates O – opiates U – uremia U – uremia T – trauma – head injury, blood loss (shock) T – trauma – head injury, blood loss (shock) I – intracranial, infection I – intracranial, infection P – poisoning; psychiatric P – poisoning; psychiatric S – seizures; syncope S – seizures; syncope

16. Mnemonic - SMASHED S – substrates, sepsis S – substrates, sepsis Hyper/hypoglycemia, thiamine Hyper/hypoglycemia, thiamine M- meningitis, mental illness (ie: psychosis) M- meningitis, mental illness (ie: psychosis) A – alcohol (intoxication/withdrawal) A – alcohol (intoxication/withdrawal) S – seizure, stimulants S – seizure, stimulants H- hyper/hypothyroidism, hyper/hypothermia, hypotension, hypoxia, hypercarbia H- hyper/hypothyroidism, hyper/hypothermia, hypotension, hypoxia, hypercarbia E – electrolyte imbalance, encephalopathy E – electrolyte imbalance, encephalopathy D- drugs of any sort D- drugs of any sort

17. A - Alcohol Includes beer, wine, and spirits Includes beer, wine, and spirits Alcohol is a psychoactive drug with depressant effects Alcohol is a psychoactive drug with depressant effects Decreases attention and slows reaction speed Decreases attention and slows reaction speed Short term effects: intoxication, dehydration, alcohol poisoning Short term effects: intoxication, dehydration, alcohol poisoning Long term effects: changes to metabolism in the liver and brain; possible addiction Long term effects: changes to metabolism in the liver and brain; possible addiction Binge drinking Binge drinking Men- 5 or more drinks in a row Men- 5 or more drinks in a row Women – 4 or more drinks in a row Women – 4 or more drinks in a row

18. A- Alcohol Evaluate Evaluate Clarity of speech Clarity of speech Ability to comprehend the conversation Ability to comprehend the conversation Gait Gait Not all persons drinking alcohol have altered mental states Not all persons drinking alcohol have altered mental states Contact Medical Control if the patient with alcohol “on board” wants to sign a release Contact Medical Control if the patient with alcohol “on board” wants to sign a release

19. E - Endocrine Endocrine system is an informational system much like the nervous system Endocrine system is an informational system much like the nervous system Chemical messengers, hormones, travel mainly via blood vessels to trigger responses Chemical messengers, hormones, travel mainly via blood vessels to trigger responses Common conditions involving the endocrine system Common conditions involving the endocrine system Diabetes mellitus Diabetes mellitus Thyroid disease Thyroid disease Obesity Obesity

20. E - Electrolytes Electrically conductive medium Electrically conductive medium Principally: sodium, potassium, calcium, magnesium, chloride Principally: sodium, potassium, calcium, magnesium, chloride Activates muscles and neurons Activates muscles and neurons Homeostasis of electrolytes regulated by hormones Homeostasis of electrolytes regulated by hormones Generally kidneys flush out excess levels of electrolytes Generally kidneys flush out excess levels of electrolytes Electrolyte disturbance (ie: dehydration or overhydration) may lead to cardiac and neurological complications (ie: medical emergencies) Electrolyte disturbance (ie: dehydration or overhydration) may lead to cardiac and neurological complications (ie: medical emergencies) Dehydration: exercise, diaphoresis, diarrhea, vomiting, intoxication, starvation Dehydration: exercise, diaphoresis, diarrhea, vomiting, intoxication, starvation

21. E- Encephalopathy A syndrome of brain dysfunction A syndrome of brain dysfunction Brain function and/or structure is altered Brain function and/or structure is altered Causes Causes Brain infection, tumor, increased intracranial pressure, exposure to toxins, radiation, tumor, poor nutrition, hypoxia, decreased blood flow to the brain Brain infection, tumor, increased intracranial pressure, exposure to toxins, radiation, tumor, poor nutrition, hypoxia, decreased blood flow to the brain Hallmark – altered mental status Hallmark – altered mental status Common signs and symptoms include loss of cognitive function and subtle personality changes Common signs and symptoms include loss of cognitive function and subtle personality changes More signs and symptoms listed in the notes section More signs and symptoms listed in the notes section

22. I - Insulin Diabetes mellitus Diabetes mellitus The brain is very dependant on a set level of glucose to function The brain is very dependant on a set level of glucose to function If the glucose level falls, the brain cannot function normally If the glucose level falls, the brain cannot function normally Rapid change in behavior, level of consciousness when the blood sugar level drops Rapid change in behavior, level of consciousness when the blood sugar level drops All persons with altered level of consciousness need to have their blood sugar level checked All persons with altered level of consciousness need to have their blood sugar level checked

23. O - Opiates Used for pleasure and pain relief Used for pleasure and pain relief Depresses body functions and reactions Depresses body functions and reactions Taken in pill form, smoked, injected Taken in pill form, smoked, injected Single dose effect can last 3 – 6 hours Single dose effect can last 3 – 6 hours Detection time lasts usually up to 2 days Detection time lasts usually up to 2 days High physical and psychological dependence High physical and psychological dependence Develop physical symptoms, behavioral symptoms, health effects, increased pain tolerance Develop physical symptoms, behavioral symptoms, health effects, increased pain tolerance

24. Examples of Opiates Codeine Codeine Darvocet Darvocet Demerol Demerol Dilaudid Dilaudid Fentanyl Fentanyl Heroin Heroin Hydrocodone Hydrocodone Lorcet Lorcet Lortab Methadone Morphine Percocet Percodan Oxycodone Oxycontin Ultram Vicodin

25. Signs and Symptoms - Opiates Constricted pupils Constricted pupils Sweating Sweating Nausea/vomiting/diarrhea Nausea/vomiting/diarrhea Needle marks Needle marks Loss of appetite Loss of appetite Slurred speech Slurred speech Slowed reflexes Slowed reflexes Depressed breathing Depressed breathing Depressed pulse rate Depressed pulse rate Drowsiness Drowsiness Fatigue Fatigue Mood swings Mood swings Impaired coordination Impaired coordination Depression Depression Apathy Apathy Stupor Stupor Euphoria Euphoria

26. U - Uremia Urea and waste products not eliminated from the blood Urea and waste products not eliminated from the blood Accompanies kidney failure/renal failure Accompanies kidney failure/renal failure Usually diagnosed when kidney function < 50% of normal Usually diagnosed when kidney function < 50% of normal Early symptoms: anorexia and lethargy Early symptoms: anorexia and lethargy Late symptoms: decreased mental acuity and coma Late symptoms: decreased mental acuity and coma

27. Causes of Uremia (besides kidney failure) Increased production of urea in the liver Increased production of urea in the liver High protein diet; GI bleed; drugs; increased protein breakdown (surgery, infection, trauma, cancer) High protein diet; GI bleed; drugs; increased protein breakdown (surgery, infection, trauma, cancer) Decreased elimination of urea Decreased elimination of urea Decreased blood flow through the kidneys (ie: hypotension); urinary outflow obstruction Decreased blood flow through the kidneys (ie: hypotension); urinary outflow obstruction Dehydration Dehydration Chronic kidney infections (chronic pyelonephritis) Chronic kidney infections (chronic pyelonephritis)

28. T - Trauma Head injury Head injury Epidural bleed Epidural bleed Rapid bleeding with unresponsiveness often following a lucid interval Rapid bleeding with unresponsiveness often following a lucid interval Subdural bleed Subdural bleed Slow bleeding with subtle changes Slow bleeding with subtle changes Intracerebral bleed Intracerebral bleed Ruptured blood vessel releases blood into brain tissue with resulting tissue edema Ruptured blood vessel releases blood into brain tissue with resulting tissue edema Blood loss  shock Blood loss  shock

29. I - Intracranial Tumor Tumor Symptoms/neurological deficits often point to the area of brain affected Symptoms/neurological deficits often point to the area of brain affected Right sided brain insult affects left sided body function Right sided brain insult affects left sided body function Left sided brain insult affects right sided body function Left sided brain insult affects right sided body function

30. Intracranial cont’d Head injury Head injury Pupillary changes reflect same side of brain insult Pupillary changes reflect same side of brain insult Right pupillary change reflects right sided brain insult Right pupillary change reflects right sided brain insult Left pupillary change reflects left sided brain insult Left pupillary change reflects left sided brain insult Consider acute vs chronic condition Consider acute vs chronic condition Chronic conditions: Chronic conditions: Elderly with frequent falls Elderly with frequent falls Chronic alcoholism with frequent falls Chronic alcoholism with frequent falls

31. I - Infection Meningitis Meningitis Bacterial is highly contagious Bacterial is highly contagious Mask the patient and all EMS personnel Mask the patient and all EMS personnel Urinary tract infection (UTI) Urinary tract infection (UTI) Elderly often do not present with high fevers Elderly often do not present with high fevers Sepsis Sepsis Newborns/very young infants will be very ill Newborns/very young infants will be very ill Encephalitis Encephalitis Pneumonia – viral and bacterial Pneumonia – viral and bacterial Liver abscess Liver abscess

32. P - Poisoning Drug overdose Drug overdose Intentional Intentional Assume you are not getting the full story Assume you are not getting the full story Mixing any meds with alcohol increases the risk of worsening conditions Mixing any meds with alcohol increases the risk of worsening conditions Accidental Accidental Assume young children will not be truthful (fear of being punished) Assume young children will not be truthful (fear of being punished) Bring in all containers Bring in all containers

33. P - Psychiatric Schizophrenia Schizophrenia Common mental health problem Common mental health problem Hallmark – significant change in behavior and loss of contact with reality Hallmark – significant change in behavior and loss of contact with reality Hallucinations, delusions, depression Hallucinations, delusions, depression Bipolar Bipolar Not particularly common mental health problem Not particularly common mental health problem One or more manic episodes with or without subsequent or alternating periods of depression One or more manic episodes with or without subsequent or alternating periods of depression

34. S - Seizure Epilepsy Epilepsy Head injury Head injury Hypoglycemia Hypoglycemia Hypertensive crisis Hypertensive crisis Rapid increase in diastolic B/P >130mmHg Rapid increase in diastolic B/P >130mmHg Hypertensive disorder of pregnancy Hypertensive disorder of pregnancy Formerly referred to as toxemia Formerly referred to as toxemia

35. S- Syncope Brief loss of consciousness with spontaneous recovery Brief loss of consciousness with spontaneous recovery “Fainting” “Fainting” Typically a very short episode resolved when the patient lies flat (as in when they pass out) Typically a very short episode resolved when the patient lies flat (as in when they pass out) Often warning signs &/or symptoms Often warning signs &/or symptoms LightheadednessVision changes LightheadednessVision changes DizzinessSudden pallor DizzinessSudden pallor NauseaSweating NauseaSweating Weakness Weakness

36. Causes of Syncope Hypovolemia – fluid &/or blood loss Hypovolemia – fluid &/or blood loss Metabolic – alteration in brain chemistry Metabolic – alteration in brain chemistry Hypoglycemia Hypoglycemia Inner/ middle ear problem Inner/ middle ear problem Environmental Environmental Room temperature, carbon monoxide Room temperature, carbon monoxide Toxicological – excessive alcohol Toxicological – excessive alcohol Cardiovascular - dysrhythmias Cardiovascular - dysrhythmias

37. Elderly Considerations Contributing factors to confusion Contributing factors to confusion Stress Stress Fear of removal from their home Fear of removal from their home Talking with strangers (ie: EMS) Talking with strangers (ie: EMS) Answering questions they do not know the answers to Answering questions they do not know the answers to

38. Elderly Considerations Altered mental status possibly due to: Altered mental status possibly due to: Medical insult or traumatic head injury Medical insult or traumatic head injury Heart rhythm disturbance; AMI Heart rhythm disturbance; AMI Dementia Dementia Infection Infection Related to prescription medications Related to prescription medications Decreased blood volume – shock Decreased blood volume – shock Respiratory disorders and/or hypoxia Respiratory disorders and/or hypoxia Hypo/hyperthermia Hypo/hyperthermia Decreased blood sugar level Decreased blood sugar level

39. Distinguishing Dementia From Delirium Dementia Dementia Chronic, slow progression Chronic, slow progression Irreversible disorder Irreversible disorder Impaired memory Impaired memory Global cognitive deficits Global cognitive deficits Most commonly caused by Alzheimer’s Most commonly caused by Alzheimer’s Does not require immediate treatment Does not require immediate treatment Delirium Delirium Rapid in onset (hours to days), fluctuating course May be reversed esp if treated early Greatly impairs attention Focal cognitive deficits Most commonly caused by systemic disease, drug toxicity, or metabolic changes Requires immediate treatment

40. Dementia Causes of this progressive disorientation Causes of this progressive disorientation Small strokes Small strokes Atherosclerosis Atherosclerosis Age related neurological changes Age related neurological changes Neurological changes Neurological changes Certain hereditary diseases (ie: Huntington’s) Certain hereditary diseases (ie: Huntington’s) Alzheimer’s disease Alzheimer’s disease

41. Delirium Disorganized thinking with reduced ability to maintain attention and to shift attention Disorganized thinking with reduced ability to maintain attention and to shift attention Synonyms: Synonyms: Acute confusional state Acute confusional state Acute cognitive impairment Acute cognitive impairment Acute encephalopathy Acute encephalopathy Acute altered mental status Acute altered mental status

42. Patient Assessment ABC’s ABC’s Is ventilation/breathing adequate? Is ventilation/breathing adequate? Does supplemental oxygen need to be given? Does supplemental oxygen need to be given? Room air contains 21 % O 2 Room air contains 21 % O 2 Nasal cannula delivers 24% - 44% O 2 (2 – 6 L/min) Nasal cannula delivers 24% - 44% O 2 (2 – 6 L/min) Non-rebreather can deliver up to 100% O 2 (12-15 L/min) Non-rebreather can deliver up to 100% O 2 (12-15 L/min) Does the C-spine need to be controlled? Does the C-spine need to be controlled? Can the patient protect their own airway? Can the patient protect their own airway?

43. Patient Assessment Adequacy of circulation Adequacy of circulation What is the blood pressure? What is the blood pressure? Does the blood pressure equate with the patient assessment? Does the blood pressure equate with the patient assessment? Is there a peripheral pulse? Is there a peripheral pulse? What is the peripheral pulse rate and quality? What is the peripheral pulse rate and quality? Do you need to gain IV access? Do you need to gain IV access? Is IV access necessary? Is IV access necessary? Is IV access needed as a precaution? Is IV access needed as a precaution?

44. Patient Assessment Cardiac monitor Cardiac monitor Is there a dysrhythmia present? Is there a dysrhythmia present? What is the blood sugar level? What is the blood sugar level? Does the patient require isolation for potential infectious disease? Does the patient require isolation for potential infectious disease? History History From the patient, caregiver, bystander From the patient, caregiver, bystander History of present illness History of present illness Pertinent past medical history Pertinent past medical history

45. Patient Assessment Allergies Allergies Current medications Current medications Use of drugs or other substances Use of drugs or other substances Physical exam Physical exam Vital signs – B/P – P – R – SpO 2 Vital signs – B/P – P – R – SpO 2 Hands-on assessment head to toe Hands-on assessment head to toe Skin exam Skin exam Rashes? Evidence of infection? Rashes? Evidence of infection?

46. Patient Assessment - Neurological Evaluate appearance, behavior, attitude Evaluate appearance, behavior, attitude Thought disorders – logical and realistic? Thought disorders – logical and realistic? False beliefs/delusions? False beliefs/delusions? Suicidal/homicidal thoughts? Suicidal/homicidal thoughts? Perception disorders? Perception disorders? Hallucinations present? Hallucinations present? Mood and affect Mood and affect Insight and judgement – can patient understand circumstances and identify surroundings? Insight and judgement – can patient understand circumstances and identify surroundings? Sensorium and intelligence – normal level of consciousness? Impaired cognition/intellectual functioning? Sensorium and intelligence – normal level of consciousness? Impaired cognition/intellectual functioning?

47. Neurological Assessment cont’d Level of consciousness Level of consciousness AVPU AVPU Pupillary response Pupillary response Ability to identify person, place, time Ability to identify person, place, time Glasgow coma scale Glasgow coma scale Scores 3 – 15 Scores 3 – 15 More important than any one score is the trend the score is making More important than any one score is the trend the score is making

48. Glasgow Coma Scale Evaluates wakefulness and awareness Evaluates wakefulness and awareness Wakefulness Wakefulness The state of being aware of the environment The state of being aware of the environment Awareness Awareness A demonstrated understanding of what is being said A demonstrated understanding of what is being said

49. GCS Tips Always give the patient the best score possible Always give the patient the best score possible If the patient can move the right extremity and not the left, score for the movement of the right extremity If the patient can move the right extremity and not the left, score for the movement of the right extremity Deteriorations will be noted faster as the score drops by awarding the highest points possible Deteriorations will be noted faster as the score drops by awarding the highest points possible Pediatric component Pediatric component Used for the young patient who is not verbal yet due to age Used for the young patient who is not verbal yet due to age

50. Glasgow Coma Scale EYE OPENING VERBAL RESPONSE MOTOR RESPONSE 4--Spontaneous5--Oriented6--Obeys 3—Verbal stimuli 4--Confused/ disoriented 5--Localizes 2--Pain 3--Inappropriate words 4--Withdraws 1--None 2--Incomprehensible sounds 3--Abnormal flexion 1--None2--Extensor posturing 1--None

51. GCS Score GCS 13 – 15 GCS 13 – 15 Mild brain injury Mild brain injury GCS 9 – 12 GCS 9 – 12 Moderate brain injury Moderate brain injury GCS <8 GCS <8 Severe brain injury Severe brain injury Most patients with this score are in coma Most patients with this score are in coma Evaluate for the need to assist in protecting the patient’s airway Evaluate for the need to assist in protecting the patient’s airway

52. Evaluating Eye Opening Best response is obtained, if at all possible, before physical contact is made with patient Best response is obtained, if at all possible, before physical contact is made with patient This is not always possible when the C-spine needs to be controlled This is not always possible when the C-spine needs to be controlled Patient gets credit if eyelids open even for a brief moment or just flicker Patient gets credit if eyelids open even for a brief moment or just flicker Always consider need to control the C-spine over the verbal response of the GCS Always consider need to control the C-spine over the verbal response of the GCS

53. Evaluating Verbal Response 5 – uses appropriate words/conversation 5 – uses appropriate words/conversation 4 – speaks but is confused and disoriented 4 – speaks but is confused and disoriented 3 – speaking and you can understand the words spoken but the words have no bearing on the current situation 3 – speaking and you can understand the words spoken but the words have no bearing on the current situation 2 – making sounds like grunts; no intelligible words 2 – making sounds like grunts; no intelligible words 1 – no response; no speech; no noise 1 – no response; no speech; no noise

54. Modifying GCS for Pediatrics Adult GCS must be modified to match the developmental age of the young nonverbal child Adult GCS must be modified to match the developmental age of the young nonverbal child Best eye opening remains unchanged Best eye opening remains unchanged Best verbal response for non-verbal patient Best verbal response for non-verbal patient 5 – Smiles, coos, follows objects 5 – Smiles, coos, follows objects 4 – Irritable cry but is consolable 4 – Irritable cry but is consolable 3 – Inappropriate crying; cries to pain 3 – Inappropriate crying; cries to pain 2 – Inconsolable, agitated; moans or groans to pain 2 – Inconsolable, agitated; moans or groans to pain 1 – No response 1 – No response

55. Evaluating Motor Response 6 – Obeys commands 6 – Obeys commands 5 – Purposeful movement 5 – Purposeful movement Hits at you, grabs at your hands, pulling equipment off, pushing you away Hits at you, grabs at your hands, pulling equipment off, pushing you away 4 – Withdraws from pain (unable to localize) 4 – Withdraws from pain (unable to localize) 3 – Flexing with internal rotation and adduction of shoulders and flexion of elbows 3 – Flexing with internal rotation and adduction of shoulders and flexion of elbows 2 – Extension with elbows straightened and possible internal shoulder and wrist rotation 2 – Extension with elbows straightened and possible internal shoulder and wrist rotation

56. Pediatric GCS Motor Response Best motor response for non-verbal patient Best motor response for non-verbal patient 6 – obeys commands 6 – obeys commands May be difficult to determine if child understands May be difficult to determine if child understands 5 – localizes pain by withdrawing to touch stimuli 5 – localizes pain by withdrawing to touch stimuli 4 – withdraws to pain (more stimuli than touch) 4 – withdraws to pain (more stimuli than touch) 3 – same – abnormal flexion 3 – same – abnormal flexion 2 – same – abnormal extension 2 – same – abnormal extension 1 – no motor response; patient flaccid 1 – no motor response; patient flaccid

57. GCS Practice Patient #1 Patient #1 The patient is watching you approach The patient is watching you approach The patient speaks normally and answers questions The patient speaks normally and answers questions The patient raises their arm when you ask to take their B/P The patient raises their arm when you ask to take their B/P Patient #2 Patient #2 The patient is looking around the environment The patient is looking around the environment The patient speaks normally but is confused The patient speaks normally but is confused When you ask the patient to raise their arm, they are slow to do so but eventually raises their arm When you ask the patient to raise their arm, they are slow to do so but eventually raises their arm

58. GCS Practice Patient #3 Patient #3 The patient’s eyes are closed and there is no movement even after squeezing the trapezius The patient’s eyes are closed and there is no movement even after squeezing the trapezius The patient groans when the trapezius is squeezed The patient groans when the trapezius is squeezed The patient flexes their arms to the chest wall The patient flexes their arms to the chest wall Patient #4 Patient #4 Patient eyes open briefly when their name is called Patient eyes open briefly when their name is called Patient groans while being pinched Patient groans while being pinched Patient does not follow commands and pushes you away whenever you try to treat the patient Patient does not follow commands and pushes you away whenever you try to treat the patient

59. GCS Practice Patient #5 Patient #5 Eyes are closed but open when calling the patient Eyes are closed but open when calling the patient The patient yells “don’t” and “stop it” when being touched, assessed, and treated but is not speaking The patient yells “don’t” and “stop it” when being touched, assessed, and treated but is not speaking Patient pushes the EMS provider hands away and is trying to pull off the cervical collar and IV Patient pushes the EMS provider hands away and is trying to pull off the cervical collar and IV Patient #6 Patient #6 Eyes open briefly when asked to open them Eyes open briefly when asked to open them The patient moans weakly when being touched The patient moans weakly when being touched The patient tries to pull away when care is being provided (ie: IV start) The patient tries to pull away when care is being provided (ie: IV start)

60. GCS Practice Patient #7 Patient #7 Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyes Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyes The patient responds verbally saying their head hurts and the lights make it hurt worse The patient responds verbally saying their head hurts and the lights make it hurt worse Patient follows commands except for opening eyes Patient follows commands except for opening eyes Patient #8 Patient #8 Eyes are open looking straight ahead Eyes are open looking straight ahead When asked what month it is, the patient responds “he, umm, he, my jacket, don’t…” When asked what month it is, the patient responds “he, umm, he, my jacket, don’t…” Does not follow commands. Pulls one hand away and the other hand is pushing the EMS provider away Does not follow commands. Pulls one hand away and the other hand is pushing the EMS provider away

61. GCS Practice – Pediatrics < 1y/o Patient #9 (6 month old) Patient #9 (6 month old) Infant’s eyes flutter when touched Infant’s eyes flutter when touched Patient cries when gently touched; is consolable Patient cries when gently touched; is consolable Patient withdraws when first touching them Patient withdraws when first touching them Patient #10 (9 month old) Patient #10 (9 month old) Eyelids flutter when the IO needle is placed Eyelids flutter when the IO needle is placed Patient moans during the IO insertion and when deformed extremity is handled Patient moans during the IO insertion and when deformed extremity is handled The patient pulls their arms into their chest wall rolling their shoulders and wrists inward The patient pulls their arms into their chest wall rolling their shoulders and wrists inward

62. GCS Answers Patient # 1 - 4, 5, 6 = 15 Patient # 1 - 4, 5, 6 = 15 Patient # 2 – 4, 4, 6 = 14 Patient # 2 – 4, 4, 6 = 14 Patient # 3 – 1, 2, 3 = 6 Patient # 3 – 1, 2, 3 = 6 Patient # 4 – 3, 2, 5 = 10 Patient # 4 – 3, 2, 5 = 10 Patient # 5 – 3, 3, 5 = 11 Patient # 5 – 3, 3, 5 = 11 Patient # 6 – 3, 2, 4 = 9 Patient # 6 – 3, 2, 4 = 9 Patient # 7 – 3, 5, 6 = 14 Patient # 7 – 3, 5, 6 = 14 Patient # 8 – 4, 3, 5 = 12 Patient # 8 – 4, 3, 5 = 12 Patient # 9 – 2, 4, 5 = 11 Patient # 9 – 2, 4, 5 = 11 Patient # 10 – 2, 2, 3 = 7 Patient # 10 – 2, 2, 3 = 7

63. Blood Glucose Level To be obtained when: To be obtained when: Patient is known diabetic with diabetic related problem Patient is known diabetic with diabetic related problem Patient has an altered level of consciousness for unknown reasons Patient has an altered level of consciousness for unknown reasons Patient is unresponsive (includes post-ictal patients) Patient is unresponsive (includes post-ictal patients) Consider the patient to have more than one problem at a time Consider the patient to have more than one problem at a time Make sure a 2 nd or 3 rd issue is not present once you find the first issue (ie: hypoglycemia) Make sure a 2 nd or 3 rd issue is not present once you find the first issue (ie: hypoglycemia) Be aware: Peds patients can drop their blood sugar level fast Be aware: Peds patients can drop their blood sugar level fast

64. Blood Glucose Monitor Machines calibrated for capillary specimen Machines calibrated for capillary specimen Keep the site hanging dependently Keep the site hanging dependently Can use side of finger tips or the forearm Can use side of finger tips or the forearm Once the site is wiped with an alcohol prep pad, let the site air dry before obtaining a sample Once the site is wiped with an alcohol prep pad, let the site air dry before obtaining a sample Use a lancet to obtain a blood sample from the finger or forearm Use a lancet to obtain a blood sample from the finger or forearm Do not let a patient sign a release until you can document a blood sugar level >60 Do not let a patient sign a release until you can document a blood sugar level >60

65. Stroke Care Rapid detection of signs and symptoms with rapid diagnosis is essential Rapid detection of signs and symptoms with rapid diagnosis is essential Need to avoid delays Need to avoid delays 3 hour time limit to administer a fibrinolytic from time of first onset of signs and symptoms 3 hour time limit to administer a fibrinolytic from time of first onset of signs and symptoms Increase risk of cerebral bleeding beyond a 3 hour time frame Increase risk of cerebral bleeding beyond a 3 hour time frame Most important question to ask: Most important question to ask: What time did symptoms begin? What time did symptoms begin?

66. Cincinnati Stroke Scale Quick and simple evaluation tool Quick and simple evaluation tool Documentation Documentation Facial droop Facial droop Right/left facial droop or no droop Right/left facial droop or no droop Arm drift Arm drift Right/left arm drift or no drift Right/left arm drift or no drift Speech Speech Clear or not clear Clear or not clear

67. Facial Drooping Ask the patient to smile real big and show you their teeth Ask the patient to smile real big and show you their teeth Best way to see if a droop is present Best way to see if a droop is present

68. Arm Drift Demonstrate first and then have patient hold their hands out in front, palms up, for 10 seconds Demonstrate first and then have patient hold their hands out in front, palms up, for 10 seconds

69. Clarity of Speech Most likely you’ll know by now if there is a speech problem Most likely you’ll know by now if there is a speech problem Can have the patient repeat after you any words or a sentence you give them Can have the patient repeat after you any words or a sentence you give them “You can’t teach an old dog new tricks” “You can’t teach an old dog new tricks”

70. 7 D’S Of Stroke Care Detection – of signs and symptoms Detection – of signs and symptoms Dispatch – call 911 Dispatch – call 911 Delivery – to the appropriate facility Delivery – to the appropriate facility Door – emergent triage in the ED Door – emergent triage in the ED Data – appropriate tests Data – appropriate tests Decision – to administer a fibrinolytic or not Decision – to administer a fibrinolytic or not Drug – must administer the fibrinolytic within 3 hours of onset of symptoms Drug – must administer the fibrinolytic within 3 hours of onset of symptoms

71. Quick Fixes of Altered Mental Status Hypoglycemia – Dextrose Hypoglycemia – Dextrose Hypoxia – oxygen Hypoxia – oxygen Pinpoint pupils – Narcan Pinpoint pupils – Narcan Seizures – Valium Seizures – Valium Dextrose if seizure due to hypoglycemia Dextrose if seizure due to hypoglycemia Cold – warm the patient up Cold – warm the patient up

72. Combative Patient Talking down a patient is an art that requires effort and skill Talking down a patient is an art that requires effort and skill Need enhanced people skills of listening and observation Need enhanced people skills of listening and observation Make sure the scene is safe Make sure the scene is safe Provide a calm and supportive environment Provide a calm and supportive environment Treat any existing medical conditions Treat any existing medical conditions Do not confront or argue with the patient Do not confront or argue with the patient Provide realistic reassurance Provide realistic reassurance Respond to the patient in a direct, simple manner Respond to the patient in a direct, simple manner

73. 2 Extremes of Behavioral Emergencies Combative patient Combative patient Fidgeting, nervous energy Fidgeting, nervous energy Voice getting louder Voice getting louder Pacing Pacing Shouting, apparent anger Shouting, apparent anger Withdrawn patient Withdrawn patient Facing away from EMS Decreasing eye contact No eye contact or conversation Totally withdrawn

74. System Operating Guidelines – Use of Restraints EMS personnel should contact Medical Control if possible before restraining patient EMS personnel should contact Medical Control if possible before restraining patient May restrain patient first for patient and personnel safety May restrain patient first for patient and personnel safety All attempts must be made to avoid injury to patient and EMS personnel All attempts must be made to avoid injury to patient and EMS personnel Do not compromise the patient’s ability to breath or further aggravate any injury or illness Do not compromise the patient’s ability to breath or further aggravate any injury or illness Clearly document the behavior leading to use of restraints Clearly document the behavior leading to use of restraints Handcuffs applied by police only Handcuffs applied by police only Officer must accompany patient in the ambulance during transport Officer must accompany patient in the ambulance during transport

75. Methods of Restraint Verbal de-escalation Verbal de-escalation First method to employ First method to employ Avoids physical contact with the patient – safer Avoids physical contact with the patient – safer Watch “personal space” Watch “personal space” 1.5 – 4 feet in the United States 1.5 – 4 feet in the United States Keep open an “escape route” for yourself Keep open an “escape route” for yourself

76. Methods of Restraint cont’d Physical restraint Physical restraint Materials or techniques that will restrict the movement of a patient Materials or techniques that will restrict the movement of a patient Soft restraints: sheets, wristlets, chest Posy Soft restraints: sheets, wristlets, chest Posy Hard restraints: plastic ties, handcuffs, leathers Hard restraints: plastic ties, handcuffs, leathers Police must be in ambulance for transport if patient is in handcuffs Police must be in ambulance for transport if patient is in handcuffs Patients need frequent reassessment to evaluate for injury or possible neurovascular compromise or airway compromise Patients need frequent reassessment to evaluate for injury or possible neurovascular compromise or airway compromise Use a surgical mask placed loosely over the face to control spitting Use a surgical mask placed loosely over the face to control spitting

77. Physical Restraints Do not transport a restrained patient prone Do not transport a restrained patient prone Positional asphyxia may cause death Positional asphyxia may cause death Be prepared to protect the patient’s airway Be prepared to protect the patient’s airway Do not secure straps to moving side rails Do not secure straps to moving side rails Restraining thighs just above knees often prevents kicking Restraining thighs just above knees often prevents kicking Struggling against restraints may lead to severe acidosis and fatal dysrhythmias Struggling against restraints may lead to severe acidosis and fatal dysrhythmias NEVER leave restrained patient unattended NEVER leave restrained patient unattended

78. Methods of Restraints cont’d Chemical restraint Chemical restraint Administration of specific pharmacological agents Administration of specific pharmacological agents Decrease agitation Decrease agitation Increase cooperation Increase cooperation Not alter a patient’s level of consciousness Not alter a patient’s level of consciousness Common agents used are haldol (in the ED) and/or benzodiazepines Common agents used are haldol (in the ED) and/or benzodiazepines Diazepam (Valium) Diazepam (Valium) Lorazepam (Ativan) Lorazepam (Ativan) Midazolam (Versed) Midazolam (Versed)

79. SOP - Severe Anxiety or Agitation Valium 5 mg IVP slowly over 2 minutes Valium 5 mg IVP slowly over 2 minutes Repeat as needed Repeat as needed Maximum total dose is 10 mg Maximum total dose is 10 mg In the absence of an IV, Valium 10 mg IM/rectally In the absence of an IV, Valium 10 mg IM/rectally Watch for respiratory depression with administration of a benzodiazepine Watch for respiratory depression with administration of a benzodiazepine Have a BVM ready to use as a precaution Have a BVM ready to use as a precaution

80. Documentation Tips All patients require a blood glucose level for altered mental status All patients require a blood glucose level for altered mental status Documentation should reflect serial monitoring of the patient’s condition looking for changes Documentation should reflect serial monitoring of the patient’s condition looking for changes GCS GCS AVPU AVPU If restraints are used, document objectively and in detail the behavior that led to the need for restraints If restraints are used, document objectively and in detail the behavior that led to the need for restraints Document distal circulation of any restrained extremity Document distal circulation of any restrained extremity Patients with altered mental status cannot sign a release Patients with altered mental status cannot sign a release

81. Securing the Airway - QuickTrach Indications Indications Patient requires emergency assisted ventilation when all other conventional methods have failed Patient requires emergency assisted ventilation when all other conventional methods have failed Contraindications Contraindications Tracheal transection Tracheal transection Other less invasive maneuver allows ventilation Other less invasive maneuver allows ventilation >77# (35kg) – use 4.0mm ID device >77# (35kg) – use 4.0mm ID device 22# – 77# (10 -35kg) use 2.0 mm ID 22# – 77# (10 -35kg) use 2.0 mm ID <22# (10kg) – use needle cricothyrotomy <22# (10kg) – use needle cricothyrotomy

82. QuickTrach Device Connecting tube Syringe Flanges to attach ties Stopper that is removed before final insertion

83. QuickTrach Procedure Position patient supine; hyperextend neck if no trauma) Position patient supine; hyperextend neck if no trauma) Locate cricothyroid membrane and cleanse site Locate cricothyroid membrane and cleanse site Palpate the soft indentation between the thyroid and cricothyroid cartilages Palpate the soft indentation between the thyroid and cricothyroid cartilages Secure the larynx laterally between the thumb and forefinger Secure the larynx laterally between the thumb and forefinger Puncture the cricothyroid membrane at a 90 0 angle Puncture the cricothyroid membrane at a 90 0 angle

84. Cricothyroid Membrane Target area

85. QuickTrach cont’d Confirm entry into the trachea by aspirating air thru the syringe Confirm entry into the trachea by aspirating air thru the syringe If air is present, the needle is in the trachea If air is present, the needle is in the trachea Now change the angle to 60 0 with the tip pointing towards the feet and advance the device forward into the trachea to the level of the stopper Now change the angle to 60 0 with the tip pointing towards the feet and advance the device forward into the trachea to the level of the stopper Stopper to be snug against the skin Stopper to be snug against the skin Stopper reduces risk of inserting the needle too deeply Stopper reduces risk of inserting the needle too deeply Remove the stopper Remove the stopper

86. QuickTrach cont’d Holding needle and syringe firmly, slide only the plastic cannula into the trachea Holding needle and syringe firmly, slide only the plastic cannula into the trachea Stop when the flange rests snug against the neck Stop when the flange rests snug against the neck Carefully remove the needle and syringe Carefully remove the needle and syringe Apply the connecting tube to the cannula Apply the connecting tube to the cannula Attach a BVM to the connecting tube Attach a BVM to the connecting tube Begin to bag the patient Begin to bag the patient Secure the cannula with the neck tape ties provided Secure the cannula with the neck tape ties provided

87. QuickTrach Complications Puncture through of the trachea Puncture through of the trachea During bagging attempts surrounding tissue will expand due to leakage of air During bagging attempts surrounding tissue will expand due to leakage of air Inadvertent puncture of a blood vessel Inadvertent puncture of a blood vessel Formation of a hematoma under the skin and surrounding the airway Formation of a hematoma under the skin and surrounding the airway External bleeding External bleeding Inability to ventilate the patient Inability to ventilate the patient There may be an obstruction at a more distal site There may be an obstruction at a more distal site

88. QuickTrach Documentation Indicate the reason(s) an alternate airway devise was necessary Indicate the reason(s) an alternate airway devise was necessary Document size airway placed Document size airway placed 4.0 mm for persons over 77# 4.0 mm for persons over 77# 2.0 mm for persons 22# - 77# 2.0 mm for persons 22# - 77# Document confirmation of airway placement Document confirmation of airway placement Bilateral breath sounds Bilateral breath sounds Bilateral chest wall rise and fall Bilateral chest wall rise and fall

89. Case Study #1 57 year old patient found behind a garage unresponsive. 57 year old patient found behind a garage unresponsive. Breathing and has a radial pulse. Dry blood on lips. Breathing and has a radial pulse. Dry blood on lips. What are your impressions? What are your impressions? How does your assessment proceed? How does your assessment proceed?

90. Case Study #1 Impression list Impression list Post-ictal from seizure Post-ictal from seizure Hypoglycemia Hypoglycemia Alcohol intoxication Alcohol intoxication Drug overdose Drug overdose Acute MI Acute MI Stroke Stroke Head trauma Head trauma

91. Case Study #1 Assessment Assessment Control c-spine while palpating neck area Control c-spine while palpating neck area Evaluate if respiratory assistance is needed Evaluate if respiratory assistance is needed Check quality, depth, rate of respirations, SpO 2 Check quality, depth, rate of respirations, SpO 2 Calculate GCS; obtain vital signs Calculate GCS; obtain vital signs Consider IV-O 2 -monitor Consider IV-O 2 -monitor Assess for need for fluid challenge Assess for need for fluid challenge Assess cardiac rhythm; consider obtaining a 12 lead EKG Assess cardiac rhythm; consider obtaining a 12 lead EKG Obtain a blood glucose sample Obtain a blood glucose sample

92. Case Study #2 Patient’s spouse called EMS Patient’s spouse called EMS Patient dropping silverware at lunch, unable to sit up straight, unable to complete sentences Patient dropping silverware at lunch, unable to sit up straight, unable to complete sentences Vital signs: 170/110; P – 64; R – 16; GCS -14 Vital signs: 170/110; P – 64; R – 16; GCS -14 EKG monitor - EKG monitor -

93. Case Study #2 What is your impression? What is your impression? What is the cardiac rhythm? What is the cardiac rhythm? Atrial fibrillation Atrial fibrillation How does this rhythm relate to any impressions? How does this rhythm relate to any impressions? What assessments need to be done? What assessments need to be done? Blood sugar level for all patients with altered level of consciousness Blood sugar level for all patients with altered level of consciousness Cincinnati stroke scale Cincinnati stroke scale

94. Case Study #2 Cincinnati stroke scale Cincinnati stroke scale Ask the patient to smile real big showing you their teeth Ask the patient to smile real big showing you their teeth Ask the patient to put their hands out in front, palms up, and close their eyes Ask the patient to put their hands out in front, palms up, and close their eyes Hold the position for 10 seconds Hold the position for 10 seconds Ask the patient to repeat a saying Ask the patient to repeat a saying “You can’t teach an old dog new tricks” “You can’t teach an old dog new tricks”

95. Case Study #2 What’s the most important question to ask the patient? What’s the most important question to ask the patient? When did the symptoms begin? When did the symptoms begin?

96. Case Study #3 Your 18 year-old patient is found under the bleachers at school unresponsive with shallow respirations. Your 18 year-old patient is found under the bleachers at school unresponsive with shallow respirations. AVPU - responds to painful stimuli AVPU - responds to painful stimuli Vital signs: 110/70; P – 110; R – 4; pupils constricted Vital signs: 110/70; P – 110; R – 4; pupils constricted GCS – 8 GCS – 8 What are your impressions? What are your impressions?

97. Case Study #3 Impression list Impression list Drug overdose Drug overdose Opiates – constricted pupils, depressed respirations Opiates – constricted pupils, depressed respirations Head injury Head injury Hypoglycemia Hypoglycemia Post-ictal Post-ictal

98. Case Study #3 Treatment Treatment Control c-spine Control c-spine Consider c-spine injury until proven otherwise Consider c-spine injury until proven otherwise Secure airway Secure airway Frequency to ventilate? Frequency to ventilate? Once every 5 – 6 seconds Once every 5 – 6 seconds Gain IV access Gain IV access Peripheral site? Peripheral site? IO if peripheral unobtainable IO if peripheral unobtainable Evaluate cardiac rhythm Evaluate cardiac rhythm

99. Case Study #3 Medications to administer Medications to administer If blood sugar < 60 give 50 ml of 50% Dextrose If blood sugar < 60 give 50 ml of 50% Dextrose As a diagnostic tool give Narcan As a diagnostic tool give Narcan 2 mg IVP every 5 minutes as needed for desired effect 2 mg IVP every 5 minutes as needed for desired effect Maximum total of 10 mg Maximum total of 10 mg Consider need to protect the airway with intubation following conscious sedation Consider need to protect the airway with intubation following conscious sedation No indication for lidocaine No indication for lidocaine Versed to relax the patient Versed to relax the patient Morphine alternated with Versed to potentiate the effects of both medications Morphine alternated with Versed to potentiate the effects of both medications Benzocaine if a blink reflex is present Benzocaine if a blink reflex is present

100. Case Study #4 You are called to the scene for an unknown medical emergency You are called to the scene for an unknown medical emergency Police have secured the scene Police have secured the scene Your patient is a 54 year-old male who is combative Your patient is a 54 year-old male who is combative What are your impressions? What are your impressions? What actions are indicated? What actions are indicated?

101. Case Study #4 Impressions Impressions Psychiatric problem Psychiatric problem Altered blood sugar Altered blood sugar Head injury Head injury Electrolyte imbalance Electrolyte imbalance

102. Case Study #4 Action to take Action to take Make sure the scene is safe and remains safe for the rescuers 1 st and then the patient Make sure the scene is safe and remains safe for the rescuers 1 st and then the patient Will need a blood sugar at some point Will need a blood sugar at some point A cardiac monitor to evaluate rhythm could be important assessment information A cardiac monitor to evaluate rhythm could be important assessment information May need to restrain the patient for crew safety and patient safety May need to restrain the patient for crew safety and patient safety

103. Case Study #4 Methods to restrain patients Methods to restrain patients Verbal de-escalation Verbal de-escalation Soft restraints Soft restraints Wrist and ankle restraints Wrist and ankle restraints Chest posey or sheet Chest posey or sheet Hard restraints Hard restraints If police handcuff the patient, police must ride with the patient in the ambulance If police handcuff the patient, police must ride with the patient in the ambulance Police are not allowed to hand off cuff keys to EMS Police are not allowed to hand off cuff keys to EMS

104. Case Study #4 Documentation Documentation Patient’s behavior in descriptive, objective terms that indicated the need for restraint Patient’s behavior in descriptive, objective terms that indicated the need for restraint If no time to contact Medical Control before restraining patient, contact them after the patient is restrained If no time to contact Medical Control before restraining patient, contact them after the patient is restrained Document distal circulation, motion, and sensation periodically after restraining the patient Document distal circulation, motion, and sensation periodically after restraining the patient

105. Case Study #5 32 year-old patient who was found combative at work. This is very unusual behavior for this patient 32 year-old patient who was found combative at work. This is very unusual behavior for this patient Vital signs: 110/70; P – 80; R – 18; skin damp Vital signs: 110/70; P – 80; R – 18; skin damp Impression? Impression? Further assessment? Further assessment? Treatment? Treatment?

106. Case Study #5 Impression Impression Hypoglycemia Hypoglycemia Head injury Head injury Drug / alcohol influence Drug / alcohol influence Assessment Assessment Blood sugar level Blood sugar level Cardiac monitor Cardiac monitor Neurological evaluation Neurological evaluation

107. Case Study #5 Blood sugar was 25 Blood sugar was 25 Treatment indicated Treatment indicated 50 ml 50% Dextrose IVP 50 ml 50% Dextrose IVP Patient now alert and oriented Patient now alert and oriented Repeat blood sugar 56 Repeat blood sugar 56 Patient wants to sign a release. Can they? Patient wants to sign a release. Can they? No release until the blood sugar is >60 No release until the blood sugar is >60 Stay on the scene and continue to reassess as the patient takes in food or liquids Stay on the scene and continue to reassess as the patient takes in food or liquids

108. Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices 3 rd Edition. Prentice Hall. 2009 Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices 3 rd Edition. Prentice Hall. 2009 Limmer, D. O’Keefe, M. Emergency Care. 10 th Edition. Prentice Hall. 2005. Limmer, D. O’Keefe, M. Emergency Care. 10 th Edition. Prentice Hall. 2005. Region X SOP’s March 2007. Amended January 1, 2008. Region X SOP’s March 2007. Amended January 1, 2008. En.wikipedia.org/wiki/Endocrine_system En.wikipedia.org/wiki/Endocrine_system En.wikipedia.org/wiki/Electrolyte_system En.wikipedia.org/wiki/Electrolyte_system En.wikipedia.org/wiki/Encephalopathy_system En.wikipedia.org/wiki/Encephalopathy_system En.wikipedia.org/wiki/Opiate_system En.wikipedia.org/wiki/Opiate_system En.wikipedia.org/wiki/Uremia_system En.wikipedia.org/wiki/Uremia_system

109. Bibliography cont’d www.chems.alaska.gov/EMS/documents/GCS_Activity_ 2003.pdf www.chems.alaska.gov/EMS/documents/GCS_Activity_ 2003.pdf www.chems.alaska.gov/EMS/documents/GCS_Activity_ www.doi.gov/nbc/eps/signsymptoms.html www.doi.gov/nbc/eps/signsymptoms.html www.en.wikibooks.org.wiki/Emergency_Medicine/altered _mental_status www.en.wikibooks.org.wiki/Emergency_Medicine/altered _mental_status www.en.wikibooks.org.wiki/Emergency_Medicine/altered _mental_status www.en.wikibooks.org.wiki/Emergency_Medicine/altered _mental_status www.nursingtimes.net www.nursingtimes.net www.nursingtimes.net www.opiates.com/opiates www.opiates.com/opiates www.opiates.com/opiates staff.washington.edu/momus/PB/comachan.htm staff.washington.edu/momus/PB/comachan.htm staff.washington.edu/momus/PB/comachan.htm www.ucsfcme.com/2008/slides/MDM08Q05/01- sporer.pdf www.ucsfcme.com/2008/slides/MDM08Q05/01- sporer.pdf www.ucsfcme.com/2008/slides/MDM08Q05/01- sporer.pdf www.ucsfcme.com/2008/slides/MDM08Q05/01- sporer.pdf www.uic.edu/com/ferne/slides/Delerium.pps www.uic.edu/com/ferne/slides/Delerium.pps