altered mental status

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Altered Mental StatusAltered Mental StatusChapter 19Chapter 19


Case HistoryCase History

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


Central and Peripheral Central and Peripheral Nervous SystemNervous System


BrainBrain


Blood Supply to the BrainBlood Supply to the Brain


Altered Mental StatusAltered Mental Status

Structural problems Structural problems Injury or damage to an area of the brainInjury or damage to an area of the brain

OROR

Metabolic problems Metabolic problems Affect the entire brainAffect the entire brain


StructuralStructural

StrokeStroke Head injuryHead injury Characterized by “one-sided” signsCharacterized by “one-sided” signs

ParalysisParalysis Facial droopFacial droop Weakness on one side of the bodyWeakness on one side of the body Unequal pupilsUnequal pupils


MetabolicMetabolic

ExternalExternal PoisoningPoisoning OverdoseOverdose Hypo- or hyperthermiaHypo- or hyperthermia InfectionsInfections

Internal Internal DiabetesDiabetes HypoxiaHypoxia HypotensionHypotension Organ failureOrgan failure

Affects both sides of the brain equallyAffects both sides of the brain equally

Primarily recognized on the basis of altered mental status and historyPrimarily recognized on the basis of altered mental status and history


Causes of Causes of Altered Mental StatusAltered Mental Status

Hypoglycemia, diabetic ketoacidosisHypoglycemia, diabetic ketoacidosis PoisoningPoisoning After seizureAfter seizure InfectionInfection Head traumaHead trauma Decreased oxygen levels (hypoxia)Decreased oxygen levels (hypoxia)


DiabetesDiabetes

Disease of the pancreas Disease of the pancreas Caused by a partial or total lack of insulin Caused by a partial or total lack of insulin

productionproduction Symptoms of diabetesSymptoms of diabetes

Increased urinationIncreased urination Increased thirstIncreased thirst Increased hungerIncreased hunger


Diabetes – InsulinDiabetes – Insulin

Insulin “escorts” glucose into cells.Insulin “escorts” glucose into cells.

Glucose provides fuel for basic energy needs.Glucose provides fuel for basic energy needs. Excess glucose is stored as fat.Excess glucose is stored as fat. Brain depends almost exclusively on glucose.Brain depends almost exclusively on glucose.

• When glucose level is low, brain function is altered.When glucose level is low, brain function is altered. Unconsciousness, seizures, brain cell deathUnconsciousness, seizures, brain cell death


DiabetesDiabetes

Two major diabetic emergenciesTwo major diabetic emergencies HypoglycemiaHypoglycemia

• Abnormally low blood glucose levelAbnormally low blood glucose level

Diabetic ketoacidosisDiabetic ketoacidosis• Blood glucose level too high and insulin level too lowBlood glucose level too high and insulin level too low


Hypoglycemia – Hypoglycemia – Signs and SymptomsSigns and Symptoms

Alteration of mental status (rapid onset)Alteration of mental status (rapid onset)• Anxiety, confusion, intoxicated behavior, combativeness, Anxiety, confusion, intoxicated behavior, combativeness,

bizarre behavior, or comabizarre behavior, or coma

HungerHunger Rapid pulseRapid pulse Pale, cool, and clammy skinPale, cool, and clammy skin Dilated pupilsDilated pupils SeizuresSeizures


Hypoglycemia – Hypoglycemia – Signs and SymptomsSigns and Symptoms

Took prescribed insulinTook prescribed insulin After missing a mealAfter missing a meal Vomiting after a mealVomiting after a meal After unusual exercise or physical workAfter unusual exercise or physical work

Insulin in refrigeratorInsulin in refrigerator

Medications found at sceneMedications found at scene Diabinese™Diabinese™ Orinase™Orinase™ Micronase™Micronase™


Hypoglycemia - Hypoglycemia - Signs and SymptomsSigns and Symptoms

Can also occur in patients who do not have Can also occur in patients who do not have diabetesdiabetes Infants with poor glycogen suppliesInfants with poor glycogen supplies Malnourished individualsMalnourished individuals

• AlcoholicsAlcoholics


Diabetic KetoacidosisDiabetic Ketoacidosis

Blood glucose level is too high and insulin Blood glucose level is too high and insulin level is too low.level is too low. When insulin level is low, body burns fat for fuel.When insulin level is low, body burns fat for fuel.

• Acetone breath from fatty acidsAcetone breath from fatty acids

Excess glucose spills into urine, pulling water with Excess glucose spills into urine, pulling water with it.it.• Increased urination, dehydration, hunger, thirstIncreased urination, dehydration, hunger, thirst


Diabetic KetoacidosisDiabetic Ketoacidosis

Increased acidity in bloodIncreased acidity in blood Body tries to compensate by breathing deeply and Body tries to compensate by breathing deeply and

rapidly.rapidly.

Slow onsetSlow onset


Emergency Medical Care - Emergency Medical Care - History of Diabetes History of Diabetes

Initial assessmentInitial assessment

Focused history and physical examFocused history and physical exam

Vital signsVital signs

SAMPLE historySAMPLE history


Focused History and Focused History and Physical ExaminationPhysical Examination

Description of episodeDescription of episode OnsetOnset DurationDuration Associated symptomsAssociated symptoms Evidence of traumaEvidence of trauma InterruptionsInterruptions SeizuresSeizures FeverFever


Vital Signs and SAMPLE HistoryVital Signs and SAMPLE History

History of diabetes History of diabetes Medical identification tags, etc.Medical identification tags, etc.

Last mealLast meal Last medication doseLast medication dose Related illnessRelated illness Determine if patient can swallow.Determine if patient can swallow.


Management – Management – Diabetic EmergenciesDiabetic Emergencies

Ensure patent airway.Ensure patent airway.

Supplemental oxygen; consider positive-pressure Supplemental oxygen; consider positive-pressure ventilationventilation

Consider oral glucose administration.Consider oral glucose administration. Per local protocolPer local protocol

Reassess patient en route to hospital.Reassess patient en route to hospital.


Glucose AdministrationGlucose Administration

Administer if patient has altered mental status when Administer if patient has altered mental status when hypoglycemia is suspected.hypoglycemia is suspected. Will save hypoglycemic patient from brain cell deathWill save hypoglycemic patient from brain cell death Will not harm patient in diabetic ketoacidosisWill not harm patient in diabetic ketoacidosis

NeverNever administer oral glucose to patients who are administer oral glucose to patients who are unconsciousness or have no gag reflex.unconsciousness or have no gag reflex.


Side Effects and Side Effects and ReassessmentReassessment

Side effectsSide effects No side effects when given properlyNo side effects when given properly Glucose gel may be aspirated by the patient Glucose gel may be aspirated by the patient

without a gag reflex.without a gag reflex.

Reassessment strategiesReassessment strategies If patient loses consciousness or has a seizureIf patient loses consciousness or has a seizure


SeizuresSeizures

May be brief or prolongedMay be brief or prolonged CausesCauses

FeverFever InfectionsInfections PoisoningPoisoning HypoglycemiaHypoglycemia Trauma Trauma Drug or alcohol withdrawalDrug or alcohol withdrawal HypoxiaHypoxia IdiopathicIdiopathic


Seizures – Seizures – Infants and ChildrenInfants and Children

Chronic seizures in children are rarely life Chronic seizures in children are rarely life threatening.threatening.

Febrile seizures should be considered Febrile seizures should be considered life-threatening.life-threatening.


Types of SeizuresTypes of Seizures

Grand malGrand mal

FocalFocal

Status epilepticusStatus epilepticus

FebrileFebrile

Petit malPetit mal


Grand Mal SeizuresGrand Mal Seizures

Three phasesThree phases

TonicTonic

ClonicClonic

PostictalPostictal


Grand Mal Seizures – Grand Mal Seizures – Tonic PhaseTonic Phase

All voluntary muscles in sustained contractionAll voluntary muscles in sustained contraction Body and extremities are usually extended.Body and extremities are usually extended.

Lasts for up to 30 secondsLasts for up to 30 seconds

All respiratory muscles in contractionAll respiratory muscles in contraction Ventilation can be compromised.Ventilation can be compromised.


Grand Mal Seizures –Grand Mal Seizures –Clonic PhaseClonic Phase

Skeletal muscles intermittently contract and relax.Skeletal muscles intermittently contract and relax. Rapid, jerking movementsRapid, jerking movements

Patient may be injured by striking surrounding objects.Patient may be injured by striking surrounding objects. Clonic phase lasts a few seconds to a few minutes.Clonic phase lasts a few seconds to a few minutes. Spasms may interfere with respirations.Spasms may interfere with respirations.

Patient may become cyanotic.Patient may become cyanotic. Spasms may be followed by short periods of flaccid paralysis.Spasms may be followed by short periods of flaccid paralysis. Patient may urinate or bite tongue.Patient may urinate or bite tongue.


Grand Mal Seizures – Grand Mal Seizures – Postictal PhasePostictal Phase

Decreased LOC and confusionDecreased LOC and confusion

Slow awakeningSlow awakening Patient may fall asleep for short period.Patient may fall asleep for short period.

Afterward, may complain of headacheAfterward, may complain of headache


Focal SeizuresFocal Seizures

May affect only a portion of the bodyMay affect only a portion of the body

OROR

May present as altered mental status with May present as altered mental status with bizarre behavior bizarre behavior


Status EpilepticusStatus Epilepticus

Rapid succession of seizures without an Rapid succession of seizures without an intervening period of consciousnessintervening period of consciousness

Prolonged seizureProlonged seizure

Life-threatening because of sustained Life-threatening because of sustained respiratory compromiserespiratory compromise


Febrile SeizuresFebrile Seizures

Caused by feverCaused by fever

Children – 6 months to 6 years of ageChildren – 6 months to 6 years of age

Occur in up to 5% of childrenOccur in up to 5% of children


Petit Mal SeizuresPetit Mal Seizures

Brief lapse of attention and awarenessBrief lapse of attention and awareness StaringStaring Fluttering eyelidsFluttering eyelids Eyes turned upwardEyes turned upward

Last from 10 to 20 secondsLast from 10 to 20 seconds

More common in childrenMore common in children


Seizures – Seizures – Emergency Medical Care Emergency Medical Care

Protect patient from harm.Protect patient from harm. Position patient on side, if no possibility of cervical Position patient on side, if no possibility of cervical

spine trauma.spine trauma. Ensure patent airway; suction as needed; administer Ensure patent airway; suction as needed; administer

high-concentration oxygen.high-concentration oxygen. Transport immediately.Transport immediately. Obtain vital signs en route.Obtain vital signs en route. Rule out trauma.Rule out trauma.


StrokeStroke

Permanent neurologic impairment caused by a Permanent neurologic impairment caused by a disruption in blood supply to a region of the braindisruption in blood supply to a region of the brain

Two causesTwo causes Related to arteriosclerosis Related to arteriosclerosis

• IschemicIschemic Weakened artery in brain ruptures Weakened artery in brain ruptures

• HemorrhagicHemorrhagic


StrokeStroke

Third leading cause of death in the U.S.Third leading cause of death in the U.S. 500,000 Americans are affected annually.500,000 Americans are affected annually.

• Nearly 25% die.Nearly 25% die.


Transient Ischemic Attack Transient Ischemic Attack (TIA)(TIA)

Symptoms are the same as for stroke.Symptoms are the same as for stroke. Lasts few minutes to a few hoursLasts few minutes to a few hours

• Resolves within 24 hoursResolves within 24 hours

Approximately 25% of patients presenting with stroke Approximately 25% of patients presenting with stroke had a TIA.had a TIA.

Approximately 5% of patients with TIA will have Approximately 5% of patients with TIA will have stroke within 1 month, if untreated.stroke within 1 month, if untreated.


Acute StrokeAcute Stroke

IschemicIschemic Approximately 75% of strokesApproximately 75% of strokes May be eligible for treatment if in ED within 3 May be eligible for treatment if in ED within 3

hours of onsethours of onset

HemorrhagicHemorrhagic Can be fatal at onsetCan be fatal at onset


Stroke – Initial AssessmentStroke – Initial Assessment

Ensure patent airway.Ensure patent airway.

Support ventilations, as necessary.Support ventilations, as necessary.


Stroke – Stroke – Signs and Symptoms Signs and Symptoms

Altered level of consciousnessAltered level of consciousness• Confusion, stupor, delirium, coma, seizuresConfusion, stupor, delirium, coma, seizures

Severe headacheSevere headache• ““Worst headache of my life”Worst headache of my life”

AphasiaAphasia Facial weakness or asymmetryFacial weakness or asymmetry Incoordination, weakness, paralysis, sensory loss of one or Incoordination, weakness, paralysis, sensory loss of one or

more limbsmore limbs AtaxiaAtaxia Visual lossVisual loss DysarthriaDysarthria Intense vertigo, diplopiaIntense vertigo, diplopia


Stroke –Stroke –Focused History and Physical ExamFocused History and Physical Exam

Focused historyFocused history Chief complaintChief complaint Time of onset, if knownTime of onset, if known

• Accurate time of onset is crucialAccurate time of onset is crucial

• If onset unknown, ask what time patient was last seen or If onset unknown, ask what time patient was last seen or went to bed.went to bed.

Gather SAMPLE history.Gather SAMPLE history.


Stroke –Stroke –Focused History and Physical ExamFocused History and Physical Exam

Physical examinationPhysical examination If stroke is suspected, examine rapidly.If stroke is suspected, examine rapidly.

• Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale

• Los Angeles Prehospital Stroke ScreenLos Angeles Prehospital Stroke Screen

• Glasgow Coma ScaleGlasgow Coma Scale

Consider transport to appropriate facility without delay.Consider transport to appropriate facility without delay.• Notify receiving facility.Notify receiving facility.

• Monitor vital signs en route.Monitor vital signs en route.


Stroke – Stroke – Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale


Stroke – Stroke – Los Angeles Prehospital Stroke ScreenLos Angeles Prehospital Stroke Screen


Glasgow Coma ScaleGlasgow Coma Scale


Altered Mental Status – Altered Mental Status – Emergency Medical CareEmergency Medical Care

Initial assessmentInitial assessment Ensure patent airway.Ensure patent airway.

• Consider potential for head trauma; provide spinal Consider potential for head trauma; provide spinal immobilization.immobilization.

Consider hypoxiaConsider hypoxia• Provide appropriate ventilatory support.Provide appropriate ventilatory support.

Consider hypoglycemia.Consider hypoglycemia.• Administer oral glucose, if appropriate.Administer oral glucose, if appropriate.



Focused historyFocused history Patient’s last normal level of functionPatient’s last normal level of function Associated complaintsAssociated complaints Chronology of eventsChronology of events History of similar past experiencesHistory of similar past experiences SAMPLE historySAMPLE history



Physical examinationPhysical examination Vital signsVital signs Abnormal smellsAbnormal smells Pupillary statusPupillary status Motor and sensory functionMotor and sensory function

• AsymmetryAsymmetry

Check for medical alert tag.Check for medical alert tag.

altered mental status

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