Altered Mental Status

Altered Mental Status

• What is AMS?• Any change from the normal of a pt’s mental status

• Example• Mild confusion/abnormal behavior • Coma

• Indications• Problem in the brain -(CVA/Stroke)• Problem affecting the brain -(Hypoxia)

Prehospital Goals of Treatment

• Ensure adequate ventilation/circulation• Administer supplemental O2/glucose• Assess and treat underlying cause(s)• Assess and treat other problems• Consider possibility of trauma• PT may start at one LOC and degrade to

another less stable one…

The Nervous System

• Function• Controls voluntary/involuntary activity

• Components • Central Nervous System (Computer)

• Brain• Brainstem • Spinal Cord

• Peripheral Nervous System (Communicator)• Associated nerves• Sensory- Carry info from body to brain• Motor – Carry info from the brain to the body• Divided into

• Somatic NS = voluntary• Autonomic NS= Involuntary

Divisions of the Autonomic Nervous System

• Sympathetic• “Fight or flight”

• Parasympathetic• “Feed or breed”

OR

The Nervous System The Brain

• Cerebrum• Largest most superior portion of the brain• Divided into R & L hemispheres• Hemispheres divided into specialized lobes

• Frontal = Intellect and motor function• Occipital = Eyesight• Temporal = Smell/Hearing• Parietal = Sensory information

• Brainstem• Lower part of the brain• Circulation, Respiration, BP

• Cerebellum• Outpocketing of brain, posterior to brainstem• Coordination and movement

The Nervous System The Brain: Blood Supply

• Cerebral Blood Supply• 15% of Cardiac output• 80% of blood is supplied by

the carotid arteries• Vertebral arteries supply the

rest• Circle of Willis

• Each area of the brain has its own blood supply

• Sensitivity to Deprivation of glucose and O2

• Cannot store glucose itself• Deprivation = AMS

• Interruption in O2 supply• Unconsciousness 5-10

seconds • Blockage of O2 supply

• Neural death 4-6 minutes

Structural Causes of AMS

• Structural• Stroke/CVA

• Blockage/disruption of blood flow in an artery feeding the brain

• Only part of the brain is damaged

• Asymmetry is noted in S/S

• CVA pt may also have AMS

• Asymmetric motor and sensory findings in the medical pt with AMS = Structural Condition

Metabolic Causes of AMS

• Usually originates outside of the CNS• Tend to effect both sides of the body

• Diffuse S/S• External & Internal Sources

• External• -Poisoning - OD – Infection – Hypo/Hyperthermia

• Internal• - Hypoxia – Hypotension – Diabetes/Endocine

Emergencies – Organ failure

Endocrine Emergencies

Endocrine Glands– Secrete hormones directly into blood without aid of ducts– Pineal gland, Pituitary gland, Hypothalamus, Thyroid gland,

Parathyroid glands, Adrenals, Pancreas, Ovaries, Testes

Hormones– Chemical produced by an organ/tissue– Controls/regulates activities of other organs– Rarely cause emergency disorders

Pancreas

The Pancreas

Pancreas– Retroperitoneal space, in folds

of small intestine Islets of Langerhans

– 3 Different Cell types & Hormones

– α cells – Glucagon Causes stored

carbohydrates/glycogen to break down to glucose

– β cells – Insulin Mediates passage of glucose

into cells– Δ cells – Somatostatin

Inhibits release of Glucagon/Insulin

Diabetic Emergencies

• What is it?• A disease of the pancreas in which

insufficient amounts of insulin is produced or receptors become refractory to insulin

• Glucose • C6H12O6• Carbohydrate energy source for

cells. • Insulin

• Hormone secreted by the pancreas that is essential for glucose metabolism.

• Glucagon• Hormone secreted by the pancreas

that causes stored forms of glucose to be released and glucose to be made from other molecules.

Glucose Metabolism

• Glucose Metabolism • After a meal what glucose is

needed is used• Excess glucose is stored as

glycogen in:• Liver• Skeletal Muscles • Fat cells

• Insulin• Binds to cells and through a

cascade of events glucose it allowed into the cell through its receptor.

• Glucagon• Secreted when blood sugar is low• Causes glycogen to convert to

glucose• Epinephrine

• Glucagon like effect• Further release from the liver• Pale, cool, diaphoretic skin• Rapid pulse, elevated bp

• Effects of insulin/glucagon maintain constant level of glucose in blood

Diabetes MellitusHyperglycemia Type 1 Diabetes

Type I –Insulin Dependent DM (IDDM)

– Destruction of Insulin producing β cells

Inadequate production of insulin by pancreas

– Unsure as to cause Viral infection?

Autoimmune response? Heredity?

– Frequent in children– Medicate with daily insulin

injections LIFELONG

DEPENDENCEY– Diabetic Ketoacidosis

(DKA)

Diabetes MellitusHyperglycemia Type II Diabetes

Type II – Non-Insulin Dependent DM (NIDDM)

– Insulin resistance and relative insulin deficiency

Decreased insulin production, resistance by receptors, relative reduction in receptors

– Associated with obesity– Weight loss, Oral diabetic

medications– Does not usually cause

DKA– Hyperosmolar

Hyperglycemic Nonketonic Syndrome

Diabetic Ketoacidosis

• What• Relatively prolonged insulin deficiency in which the blood glucose level rises and fatty acids are used

as a fuel source• Slow onset, lasts 12-24 hrs

• Why• Insulin levels are low and the liver reacts as if the body is starving• In spite of potentially high levels of plasma glucose

• How • The liver produces glucose from fatty acids • Ketones are made as intermediate stages and used as fuel• Ketones are acidic• The pH of the body changes to an acid state• The brain switches from glucose to ketones for energy• Massive amounts of unusable glucose build up in the blood

• S/S• Fruity acetone smell on pt breath• Kussmaul Respirations = (Deep rapid breath (compensation for acidic metabolic state)• Excessive urination/Osmotic Diuresis = (Glucose spills into urine, takes H2O with it)

• Dehydration • Thirst

• Unresponsiveness • Death

Hyperosmolar Hyperglycemic Nonketonic Syndrome

High serum glucose without ketoacidosis– Blood glucose > 600 mg/dL (33.3 mmol/L)

Body still produces enough Insulin to avoid entering starvation

– No ketones produced– pH of blood not affected

Effects– Cellular dehydration

Fluid shift from intracellular to intravascular space– Hypotonic to hypertonic

– Osmotic diuresis Glucose dumps into urine, water follows = polyuria Decreases blood volume

Hypoglycemia

• Hypoglycemia • What

• Excessively high insulin level• Abnormally low blood glucose

level• TRUE MEDICAL

EMERGENCY • Why

• Too much insulin or not enough food intake

• S/S• AMS

• Combative, hostile, anxious, excited, agitated, uneasiness

• Intoxicated appearance • S/S of epi release

• Pale, cool, clammy, diaphoretic skin, increased pulse/bp, dilated pupils

• Seizure/coma• Hunger, nausea, weakness,

increased salivation

Blood glucose testing

• Use BSI • Obtain:

• Glucometer• Lancets • Alcohol prep pad• Bandaid/gauze

• Take one of the pt fingers• Clean the tip and side of the finger

with the alcohol prep pad• Allow alcohol to evaporate• Insert test strip into glucometer • Blanch side of pt finger • Uncap lancet and puncture pt finger• Squeeze a sample of blood from the

finger and wipe it clean with gauze• Squeeze a second sample of blood

from the finger and apply it to test strip

• Wipe finger clean and apply bandage• Treat accordingly per findings of blood

glucose level

Oral Glucose Pharmacology

• Indication• AMS with suspected low blood

glucose level• Contraindication

• Unresponsive – Unable to swallow – No gag

• Form• Gel

• Dose• 1 tube = 1 unit = 15 g

• Route• Oral• Placed between the cheek and gum

• Action• Raises blood glucose level

• Generic Name• Oral Glucose

• Trade Name• Glucose, Insta-glucose

Administration

• Obtain SAMPLE Hx and vitals• Ensure pt is AO and has a gag reflex• Allow pt to squeeze some of the glucose between

cheek and gum OR

• Place glucose on a tongue blade and administer accordingly

• Allow glucose to dissolve and continue with administration until tube is empty

• Reassess glucose level shortly after giving glucose • DOCUMENT time given

Seizures

• What• Temporary alteration in behavior caused by abnormal electrical activity in

the brain• Causes

• AMS• Trauma• Drug/alcohol withdrawal• Eclamspia• Infection• Fever• Poisoning• Hypoglycemia • Hypoxia

• S/S• Depend on which section of the brain is affected

Gran Mal Seizures

• Grand Mal• The type most people think of

when they think of seizures• Three phases

• Tonic• Sustained contraction of all

voluntary muscles• Lasts approximately 30 seconds

• Clonic• Intermittent

contraction/relaxation of muscles

• Rapid Jerking• Few seconds to several minutes

• Postictal• Depressed LOC/confusion

Other Seizures Types

• Focal Seizures• Do not generalize/involve entire brain• Seizure movement with 1 side of the body

• Status Epilepticus• Rapid succession of seizures without an intervening period of

consciousness• Threat to life b/c of sustained respiratory compromise

• Febrile Seizures• In children 6 months-6 years that is precipitated by a rapid raise in

temperature in the setting of an infection• Petit mal Seizures

• Brief lapses of attention and awareness • 10-20 seconds• May suddenly stare with eyes turned upward or to the side with fluttering• Always brief and pt can resume normal activities as if nothing happened

Seizure Management

• Airway• Pt may need assistance maintaining an airway• NPA/OPA• High flow O2• Suction• ALS?

• Do not restrain pt or put anything in pt mouth• Remove objects in immediate area of pt• Be ready to take control of airway/breathing

Cerebrovascular Attacks (CVA) Strokes

• Statistics• 3rd leading cause of death in U.S.• 1 CVA every 40 seconds in U.S. • Approx. 795,000 CVA/yr (¼ die)• Aprrox 143,579 deaths/yr• Approx. ¼ of these die• Almost ¾ occur in people > 65 yo• Window for fibrinolytic drugs

• 3 hours

• Causes • Arteriosclerosis

• Thrombus & Embolisms • Hemorrhages/Aneurysm

CVA TypesTransient Ischemic Attacks (TIA)

• Transient Ischemic Attacks• What

• Temporary loss of brain function

• Precursor to a CVA 50% of the time

• AKA: “Mini Stroke” • Pathophysiology

• Temporary diminished blood flow to the brain

• S/S• Presents like typical CVA• Resolves completely in 24

hours

CVA TypesAcute CVA

• Acute CVA• What

• Permanent neurological impairment

• Why• Disruption of blood flow to the

brain• Hemorrhage (10%), Ischemic

(87%) • How

• Clots form in cerebral arteries• Clots elsewhere in the body

break off and travel to brain• Cerebral vessels rupture and

bleed into the brain

CVA S/S

• Alteration in consciousness • Decreased LOC • Facial Weakness, Asymmetry • Incoherent/slurred Speech• Headache• Uncoordination, weakness,

paralysis• Sensory loss in limbs• Poor balance• Visual loss• Vertigo• Double vision• Hearing loss• Nausea/vomiting

CVA Assessment

• Initial Assessment• ABC’s

• Possible airway obstructions??• Supplemental O2• AVPU

• Focused Hx and Px• Suspect CVA in pt with sudden loss of neurologic function/ALOC • TIME CRITICAL!!!!!!!• Focuses Hx

• Focus on S/S• Interview conscious pt• Interview pt family, bystanders if pt ALOC• Time “0” = Symptom onset • Baseline Vitals

Cincinnati Prehospital Stroke Scale

• Focused Hx and Px• Px Exam

• Cincinnati Prehospital Stroke Scale• Facial Droop

• Have pt show teeth/smile• Normal= Both sides are symmetric• Abnormal = Facial drooping/asymmetry noted on one side

• Arm Drift• Have pt close their eyes and extend their arms and hold them out 8 -10 sec.• Normal= Both arms remain stable and equal• Abnormal= One arm either doesn’t move or slowly falls back to body

• Abnormal Speech • Have pt repeat “You cant teach an old dog new tricks”• Normal= Correct words without slurring• Abnormal= Slurred words, wrong words, unable to speak

• Interpretation • If ANY 1 of the above is + there is 75% chance the pt has a CVA

Glasgow Coma Scale

• Px Exam• Glasgow coma scale- GCS scale

• Numerical values assigned to responses of:• Eye• Verbal• Motor

• Values range 1-4, 1-5, 1-6 respectively • 15 = Normal• 3 = Dead

CVA Assessment

• Prehospital Management• Maintain patent airway

• Airway• Breathing• Oxygenation• Suction• Adjuncts

• Supportive therapy• Rapid transport• ALS intercept? • Cincinnati Stroke Scale and GCS score • Vitals

Altered Mental Status:Overall Management

• Initial Assessment• Life threats• Ensure patent airway• Ventilation support if needed• Consider trauma• Hypo/hyperglycemia

• Focuses Hx & Px• Provides rationale for transport • Focused Hx

• Hx important as pt S/S may be minimal• Assoc complaints/chronology/hx of similar past episodes

• i.e. Deterioration of LOC with hx of head trauma/Diabetes/Epilepsy • Px exam

• Baseline vitals • Skin color, moisture, temperature• Fruity odor? (DKA)• PMS for motor deficit• Medic alert tags?• Cincinnati Stoke Scale & GSS score

Altered Mental Status:Overall Management

• Management • Airway Compromise

• Tongue & Inability to clear secretions

• Manual airway techniques • Mechanical airways• Suction

• Ventilation Support• ALL AMS pt should be

assumed to have inadequate oxygenation

• Supplemental O2 indicated• If in doubt err for BVM

• Tx decision• Load and Go• Stay and play

• On going assessment• Note any changes in pt

condition• Repeat Vitals, AVPU, GCS

score, Stroke Scale, etc.

TWINS???