the patient with an altered mental status october 2009 ce advocate condell medical center objectives...
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The Patient With An Altered The Patient With An Altered Mental StatusMental Status
October 2009 CEOctober 2009 CE
Advocate Condell Medical CenterAdvocate Condell Medical Center
Objectives by Jeremy Lockwood FFPM Mundelein Fire DepartmentPrepared by Sharon Hopkins, RN, BSN, EMT-P
ObjectivesObjectives Upon successful completion of this module, the EMS Upon successful completion of this module, the EMS
provider will be able to:provider will be able to:
1. Identify components evaluated in determining a 1. Identify components evaluated in determining a patient’s mental status and orientation.patient’s mental status and orientation.
2. Define altered mental status.2. Define altered mental status. 3. Identify the possible causes of altered mental 3. Identify the possible causes of altered mental
status. status. 4. Identify signs and symptoms of altered mental 4. Identify signs and symptoms of altered mental
status.status. 5. Identify elderly considerations related to altered 5. Identify elderly considerations related to altered
mental status.mental status.
Objectives cont’dObjectives cont’d 6. Identify assessment procedures related to 6. Identify assessment procedures related to
patients with altered mental status.patients with altered mental status. 7. Describe how to obtain an accurate Glasgow 7. Describe how to obtain an accurate Glasgow
Coma Scale assessment.Coma Scale assessment. 8. Describe the procedure to obtain a blood 8. Describe the procedure to obtain a blood
glucose determinant.glucose determinant. 9. Identify the components of the Cincinnati 9. Identify the components of the Cincinnati
Stroke Scale.Stroke Scale. 10. Identify the treatment of patients with altered 10. Identify the treatment of patients with altered
mental status.mental status.
Objectives cont’dObjectives cont’d
11. Describe methods of restraining the 11. Describe methods of restraining the combative patient.combative patient.
12. Identify the indications, contraindications, 12. Identify the indications, contraindications, complications, and documentation when using complications, and documentation when using the QuickTrach airway device.the QuickTrach airway device.
13. 13. Given a scenario obtain the GCS.Given a scenario obtain the GCS. 14. 14. Perform assessment of the Cincinnati Perform assessment of the Cincinnati
Stroke Scale.Stroke Scale. 15. 15. Given a manikin, demonstrate placement Given a manikin, demonstrate placement
of the QuickTrach airway Device.of the QuickTrach airway Device.
Normal MentationNormal Mentation
To identify abnormal mental status, need to To identify abnormal mental status, need to understand what is normalunderstand what is normal
We all practice a number of means and ways We all practice a number of means and ways to identify the mental statusto identify the mental status General appearance General appearance Orientation to person, place, and timeOrientation to person, place, and time AVPUAVPU
General AppearanceGeneral Appearance Can gain important information looking at the Can gain important information looking at the
“big picture”“big picture” Observe hygieneObserve hygiene Observe clothingObserve clothing Observe overall appearanceObserve overall appearance Observe verbal and nonverbal behaviorObserve verbal and nonverbal behavior
Facial expressionsFacial expressions Tone of voice, volume, quality, speech patternTone of voice, volume, quality, speech pattern Eye contactEye 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?
Orientation to Person, Place, TimeOrientation to Person, Place, Time
Can be insulting to a patient to ask pointedly Can be insulting to a patient to ask pointedly “what’s your name?” “who’s the president?”“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 Since I don’t know your condition very well, I
need to ask some very basic questions.”need to ask some very basic questions.” Person – patient can state their namePerson – patient can state their name Place – patient can recognize they are at home, Place – patient can recognize they are at home,
in a store, in an ambulance, at a hospitalin a store, in an ambulance, at a hospital Time – patient can tell what year it is and time Time – patient can tell what year it is and time
of year (by month or season)of year (by month or season)
AVPUAVPU A – alert meaning the patient is awakeA – alert meaning the patient is awake
““A” is not meant to indicate orientation; just level of A” is not meant to indicate orientation; just level of awakenessawakeness
V – responding to verbal stimuli onlyV – responding to verbal stimuli only Any response including fluttering of eyelids is a positive Any response including fluttering of eyelids is a positive
response to calling the patient’s name or asking a commandresponse 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 Could also indicate responding to tactile stimuli so do not always need to inflict a painful stimulialways need to inflict a painful stimuli
Any response including fluttering of eyelids or any body Any response including fluttering of eyelids or any body twitch is a positive response twitch is a positive response
U – unresponsiveU – unresponsive Patient is flaccid with no responses at allPatient is flaccid with no responses at all
Stimulating a Painful ResponseStimulating 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 Trapezium squeeze – twisting muscle where neck and
shoulder meetshoulder meet Rubbing sternum with knucklesRubbing sternum with knuckles Pressing on finger nail bedPressing on finger nail bed
Unacceptable methodsUnacceptable methods Any technique that would leave bruisingAny technique that would leave bruising
Discouraged methodsDiscouraged methods Any stimuli that may cause movement of the c-spine by Any stimuli that may cause movement of the c-spine by
the patient pulling away from the stimulithe patient pulling away from the stimuli
Altered Mental StatusAltered Mental Status
Patient not awake, alert or orientedPatient not awake, alert or oriented Patient not aware of their environmentPatient not aware of their environment Patient not oriented to person, place, timePatient not oriented to person, place, time Patient confusedPatient confused Patient unable to demonstrate an understanding of Patient unable to demonstrate an understanding of
what is being saidwhat is being said
Most important is noting any change over the Most important is noting any change over the course of time in level of consciousnesscourse of time in level of consciousness
Level of ConsciousnessLevel of Consciousness
One of the One of the firstfirst indicators to change when the indicators to change when the level of perfusion is diminishing is level of level of perfusion is diminishing is level of consciousnessconsciousness
FYI – The blood pressure is one of the FYI – The blood pressure is one of the lastlast indicators to change when the level of indicators to change when the level of perfusion diminishes perfusion diminishes
Possible Cause of Altered Mental Possible Cause of Altered Mental StatusStatus
Many lists have been createdMany lists have been created Mnemonics have been created to trigger listsMnemonics have been created to trigger lists
AEIOU-TIPSAEIOU-TIPS SMASHEDSMASHED
EMS should think outside the box and look for EMS should think outside the box and look for all potential causesall potential causes When you find one cause, keep looking in case When you find one cause, keep looking in case
there are more than one cause associated with the there are more than one cause associated with the altered mental statusaltered mental status
Thinking Outside The BoxThinking Outside The Box
How many squares do you see?How many squares do you see?
Thinking Outside The BoxThinking Outside The Box
30 squares:30 squares:
1 large 4 x 4 square1 large 4 x 4 square 16 small 1 x 1 squares16 small 1 x 1 squares 4 – 3 x 3 squares in each corner4 – 3 x 3 squares in each corner 9 – 2 x 2 squares9 – 2 x 2 squares
Mnemonic - AEIOU-TIPSMnemonic - AEIOU-TIPS
A – alcoholA – alcohol E – endocrine, electrolytes, encephalopathyE – endocrine, electrolytes, encephalopathy I – insulinI – insulin O – opiatesO – opiates U – uremiaU – uremia T – trauma – head injury, blood loss (shock)T – trauma – head injury, blood loss (shock) I – intracranial, infectionI – intracranial, infection P – poisoning; psychiatricP – poisoning; psychiatric S – seizures; syncopeS – seizures; syncope
Mnemonic - SMASHEDMnemonic - SMASHED
S – substrates, sepsisS – substrates, sepsis Hyper/hypoglycemia, thiamineHyper/hypoglycemia, thiamine
M- meningitis, mental illness (ie: psychosis)M- meningitis, mental illness (ie: psychosis) A – alcohol (intoxication/withdrawal)A – alcohol (intoxication/withdrawal) S – seizure, stimulantsS – seizure, stimulants H- hyper/hypothyroidism, hyper/hypothermia, H- hyper/hypothyroidism, hyper/hypothermia,
hypotension, hypoxia, hypercarbiahypotension, hypoxia, hypercarbia E – electrolyte imbalance, encephalopathyE – electrolyte imbalance, encephalopathy D- drugs of any sortD- drugs of any sort
A - AlcoholA - Alcohol
Includes beer, wine, and spiritsIncludes beer, wine, and spirits Alcohol is a psychoactive drug with depressant Alcohol is a psychoactive drug with depressant
effectseffects Decreases attention and slows reaction speedDecreases attention and slows reaction speed Short term effects: intoxication, dehydration, alcohol Short term effects: intoxication, dehydration, alcohol
poisoningpoisoning Long term effects: changes to metabolism in the liver Long term effects: changes to metabolism in the liver
and brain; possible addictionand brain; possible addiction Binge drinkingBinge drinking
Men- 5 or more drinks in a rowMen- 5 or more drinks in a row Women – 4 or more drinks in a rowWomen – 4 or more drinks in a row
A- AlcoholA- Alcohol
Evaluate Evaluate Clarity of speechClarity of speech Ability to comprehend the conversationAbility to comprehend the conversation GaitGait
Not all persons drinking alcohol have altered Not all persons drinking alcohol have altered mental states mental states
Contact Medical Control if the patient with Contact Medical Control if the patient with alcohol “on board” wants to sign a releasealcohol “on board” wants to sign a release
E - EndocrineE - Endocrine
Endocrine system is an informational system Endocrine system is an informational system much like the nervous systemmuch like the nervous system
Chemical messengers, hormones, travel Chemical messengers, hormones, travel mainly via blood vessels to trigger responsesmainly via blood vessels to trigger responses
Common conditions involving the endocrine Common conditions involving the endocrine systemsystem Diabetes mellitusDiabetes mellitus Thyroid diseaseThyroid disease ObesityObesity
E - ElectrolytesE - Electrolytes Electrically conductive mediumElectrically conductive medium
Principally: sodium, potassium, calcium, Principally: sodium, potassium, calcium, magnesium, chloridemagnesium, chloride
Activates muscles and neuronsActivates muscles and neurons Homeostasis of electrolytes regulated by hormonesHomeostasis of electrolytes regulated by hormones Generally kidneys flush out excess levels of Generally kidneys flush out excess levels of
electrolyteselectrolytes Electrolyte disturbance (ie: dehydration or Electrolyte disturbance (ie: dehydration or
overhydration) may lead to cardiac and neurological overhydration) may lead to cardiac and neurological complications (ie: medical emergencies)complications (ie: medical emergencies) Dehydration: exercise, diaphoresis, diarrhea, Dehydration: exercise, diaphoresis, diarrhea,
vomiting, intoxication, starvationvomiting, intoxication, starvation
E- EncephalopathyE- Encephalopathy A syndrome of brain dysfunctionA syndrome of brain dysfunction Brain function and/or structure is alteredBrain function and/or structure is altered CausesCauses
Brain infection, tumor, increased intracranial Brain infection, tumor, increased intracranial pressure, exposure to toxins, radiation, tumor, poor pressure, exposure to toxins, radiation, tumor, poor nutrition, hypoxia, decreased blood flow to the brainnutrition, hypoxia, decreased blood flow to the brain
Hallmark – altered mental statusHallmark – altered mental status Common signs and symptoms include loss of Common signs and symptoms include loss of
cognitive function and subtle personality cognitive function and subtle personality changeschanges More signs and symptoms listed in the notes sectionMore signs and symptoms listed in the notes section
I - InsulinI - Insulin Diabetes mellitusDiabetes mellitus
The brain is very dependant on a set level of The brain is very dependant on a set level of glucose to functionglucose to function
If the glucose level falls, the brain cannot If the glucose level falls, the brain cannot function normallyfunction normally
Rapid change in behavior, level of Rapid change in behavior, level of consciousness when the blood sugar level consciousness when the blood sugar level dropsdrops
All persons with altered level of consciousness All persons with altered level of consciousness need to have their blood sugar level checkedneed to have their blood sugar level checked
O - OpiatesO - Opiates
Used for pleasure and pain reliefUsed for pleasure and pain relief Depresses body functions and reactionsDepresses body functions and reactions Taken in pill form, smoked, injectedTaken in pill form, smoked, injected Single dose effect can last 3 – 6 hoursSingle dose effect can last 3 – 6 hours Detection time lasts usually up to 2 daysDetection time lasts usually up to 2 days High physical and psychological dependenceHigh physical and psychological dependence Develop physical symptoms, behavioral Develop physical symptoms, behavioral
symptoms, health effects, increased pain symptoms, health effects, increased pain tolerancetolerance
Examples of OpiatesExamples of Opiates
CodeineCodeine DarvocetDarvocet Demerol Demerol Dilaudid Dilaudid Fentanyl Fentanyl Heroin Heroin Hydrocodone Hydrocodone Lorcet Lorcet
Lortab Lortab MethadoneMethadone Morphine Morphine Percocet Percocet Percodan Percodan OxycodoneOxycodone Oxycontin Oxycontin Ultram Ultram VicodinVicodin
Signs and Symptoms - OpiatesSigns and Symptoms - Opiates
Constricted pupilsConstricted pupils SweatingSweating Nausea/vomiting/diarrheaNausea/vomiting/diarrhea Needle marksNeedle marks Loss of appetiteLoss of appetite Slurred speechSlurred speech Slowed reflexesSlowed reflexes Depressed breathingDepressed breathing
Depressed pulse rateDepressed pulse rate DrowsinessDrowsiness FatigueFatigue Mood swingsMood swings Impaired coordinationImpaired coordination DepressionDepression ApathyApathy StuporStupor EuphoriaEuphoria
U - UremiaU - Uremia
Urea and waste products not eliminated from Urea and waste products not eliminated from the bloodthe blood
Accompanies kidney failure/renal failureAccompanies kidney failure/renal failure Usually diagnosed when kidney function Usually diagnosed when kidney function
< 50% of normal< 50% of normal Early symptoms: anorexia and lethargyEarly symptoms: anorexia and lethargy Late symptoms: decreased mental acuity and Late symptoms: decreased mental acuity and
comacoma
Causes of Uremia (besides kidney Causes of Uremia (besides kidney failure)failure)
Increased production of urea in the liverIncreased production of urea in the liver High protein diet; GI bleed; drugs; increased High protein diet; GI bleed; drugs; increased
protein breakdown (surgery, infection, trauma, protein breakdown (surgery, infection, trauma, cancer)cancer)
Decreased elimination of ureaDecreased elimination of urea Decreased blood flow through the kidneys (ie: Decreased blood flow through the kidneys (ie:
hypotension); urinary outflow obstructionhypotension); urinary outflow obstruction DehydrationDehydration Chronic kidney infections (chronic Chronic kidney infections (chronic
pyelonephritis)pyelonephritis)
T - TraumaT - Trauma Head injuryHead injury
Epidural bleedEpidural bleed Rapid bleeding with unresponsiveness often Rapid bleeding with unresponsiveness often
following a lucid interval following a lucid interval Subdural bleed Subdural bleed
Slow bleeding with subtle changesSlow bleeding with subtle changes Intracerebral bleedIntracerebral bleed
Ruptured blood vessel releases blood into brain Ruptured blood vessel releases blood into brain tissue with resulting tissue edematissue with resulting tissue edema
Blood loss Blood loss shock shock
I - IntracranialI - Intracranial
TumorTumor Symptoms/neurological deficits often point to the area of Symptoms/neurological deficits often point to the area of
brain affectedbrain affected Right sided brain insult affects left sided body functionRight sided brain insult affects left sided body function Left sided brain insult affects right sided body functionLeft sided brain insult affects right sided body function
Intracranial cont’dIntracranial cont’d
Head injuryHead injury Pupillary changes reflect same side of brain insultPupillary changes reflect same side of brain insult
Right pupillary change reflects right sided brain Right pupillary change reflects right sided brain insultinsult
Left pupillary change reflects left sided brain Left pupillary change reflects left sided brain insultinsult
Consider acute vs chronic conditionConsider acute vs chronic condition Chronic conditions:Chronic conditions:
Elderly with frequent fallsElderly with frequent falls Chronic alcoholism with frequent fallsChronic alcoholism with frequent falls
I - InfectionI - Infection MeningitisMeningitis
Bacterial is highly contagiousBacterial is highly contagious Mask the patient and all EMS personnelMask the patient and all EMS personnel
Urinary tract infection (UTI)Urinary tract infection (UTI) Elderly often do not present with high feversElderly often do not present with high fevers
SepsisSepsis Newborns/very young infants will be very illNewborns/very young infants will be very ill
EncephalitisEncephalitis Pneumonia – viral and bacterialPneumonia – viral and bacterial Liver abscessLiver abscess
P - PoisoningP - Poisoning
Drug overdoseDrug overdose IntentionalIntentional
Assume you are not getting the full storyAssume you are not getting the full story Mixing any meds with alcohol increases the risk Mixing any meds with alcohol increases the risk
of worsening conditionsof worsening conditions AccidentalAccidental
Assume young children will not be truthful (fear Assume young children will not be truthful (fear of being punished)of being punished)
Bring in all containersBring in all containers
P - PsychiatricP - Psychiatric
SchizophreniaSchizophrenia Common mental health problemCommon mental health problem Hallmark – significant change in behavior and loss Hallmark – significant change in behavior and loss
of contact with realityof contact with reality Hallucinations, delusions, depressionHallucinations, delusions, depression
BipolarBipolar Not particularly common mental health problemNot particularly common mental health problem One or more manic episodes with or without One or more manic episodes with or without
subsequent or alternating periods of depressionsubsequent or alternating periods of depression
S - SeizureS - Seizure
EpilepsyEpilepsy Head injuryHead injury HypoglycemiaHypoglycemia Hypertensive crisisHypertensive crisis
Rapid increase in diastolic B/P >130mmHgRapid increase in diastolic B/P >130mmHg Hypertensive disorder of pregnancyHypertensive disorder of pregnancy
Formerly referred to as toxemiaFormerly referred to as toxemia
S- SyncopeS- Syncope
Brief loss of consciousness with spontaneous Brief loss of consciousness with spontaneous recoveryrecovery
““Fainting”Fainting” Typically a very short episode resolved when the Typically a very short episode resolved when the
patient lies flat (as in when they pass out)patient lies flat (as in when they pass out) Often warning signs &/or symptomsOften warning signs &/or symptoms
LightheadednessLightheadedness Vision changesVision changes DizzinessDizziness Sudden pallorSudden pallor NauseaNausea SweatingSweating WeaknessWeakness
Causes of SyncopeCauses of Syncope
Hypovolemia – fluid &/or blood lossHypovolemia – fluid &/or blood loss Metabolic – alteration in brain chemistryMetabolic – alteration in brain chemistry
HypoglycemiaHypoglycemia Inner/ middle ear problemInner/ middle ear problem
EnvironmentalEnvironmental Room temperature, carbon monoxideRoom temperature, carbon monoxide
Toxicological – excessive alcoholToxicological – excessive alcohol Cardiovascular - dysrhythmiasCardiovascular - dysrhythmias
Elderly ConsiderationsElderly Considerations
Contributing factors to confusionContributing factors to confusion StressStress Fear of removal from their homeFear of removal from their home Talking with strangers (ie: EMS)Talking with strangers (ie: EMS) Answering questions they do not know the Answering questions they do not know the
answers toanswers to
Elderly ConsiderationsElderly Considerations
Altered mental status possibly due to:Altered mental status possibly due to: Medical insult or traumatic head injuryMedical insult or traumatic head injury Heart rhythm disturbance; AMIHeart rhythm disturbance; AMI DementiaDementia InfectionInfection Related to prescription medicationsRelated to prescription medications Decreased blood volume – shockDecreased blood volume – shock Respiratory disorders and/or hypoxiaRespiratory disorders and/or hypoxia Hypo/hyperthermiaHypo/hyperthermia Decreased blood sugar levelDecreased blood sugar level
Distinguishing Dementia From Distinguishing Dementia From DeliriumDelirium
DementiaDementia Chronic, slow Chronic, slow
progressionprogression Irreversible disorderIrreversible disorder
Impaired memoryImpaired memory Global cognitive deficitsGlobal cognitive deficits Most commonly caused Most commonly caused
by Alzheimer’sby Alzheimer’s
Does not require Does not require immediate treatmentimmediate treatment
DeliriumDelirium Rapid in onset (hours to days), Rapid in onset (hours to days),
fluctuating coursefluctuating course May be reversed esp if treated May be reversed esp if treated
earlyearly Greatly impairs attentionGreatly impairs attention Focal cognitive deficitsFocal cognitive deficits Most commonly caused by Most commonly caused by
systemic disease, drug systemic disease, drug toxicity, or metabolic changestoxicity, or metabolic changes
Requires immediate treatmentRequires immediate treatment
DementiaDementia
Causes of this progressive disorientationCauses of this progressive disorientation Small strokesSmall strokes AtherosclerosisAtherosclerosis Age related neurological changesAge related neurological changes Neurological changesNeurological changes Certain hereditary diseases (ie: Huntington’s)Certain hereditary diseases (ie: Huntington’s) Alzheimer’s diseaseAlzheimer’s disease
DeliriumDelirium
Disorganized thinking with reduced ability to Disorganized thinking with reduced ability to maintain attention and to shift attentionmaintain attention and to shift attention
Synonyms:Synonyms: Acute confusional stateAcute confusional state Acute cognitive impairmentAcute cognitive impairment Acute encephalopathyAcute encephalopathy Acute altered mental statusAcute altered mental status
Patient AssessmentPatient Assessment
ABC’sABC’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 % ORoom air contains 21 % O22
Nasal cannula delivers 24% - 44% ONasal cannula delivers 24% - 44% O2 2 (2 – 6 (2 – 6 L/min)L/min)
Non-rebreather can deliver up to 100% ONon-rebreather can deliver up to 100% O2 2 (12-15 (12-15 L/min)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?
Patient AssessmentPatient Assessment
Adequacy of circulationAdequacy of circulation What is the blood pressure?What is the blood pressure? Does the blood pressure equate with the patient Does the blood pressure equate with the patient
assessment?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?
Patient AssessmentPatient Assessment
Cardiac monitorCardiac 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 Does the patient require isolation for potential
infectious disease?infectious disease? HistoryHistory
From the patient, caregiver, bystanderFrom the patient, caregiver, bystander History of present illnessHistory of present illness Pertinent past medical historyPertinent past medical history
Patient AssessmentPatient Assessment
AllergiesAllergies Current medicationsCurrent medications Use of drugs or other substancesUse of drugs or other substances Physical examPhysical exam
Vital signs – B/P – P – R – SpOVital signs – B/P – P – R – SpO2 2
Hands-on assessment head to toeHands-on assessment head to toe Skin examSkin exam
Rashes? Evidence of infection?Rashes? Evidence of infection?
Patient Assessment - NeurologicalPatient Assessment - Neurological
Evaluate appearance, behavior, attitudeEvaluate 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 affectMood and affect Insight and judgement – can patient understand Insight and judgement – can patient understand
circumstances and identify surroundings?circumstances and identify surroundings? Sensorium and intelligence – normal level of Sensorium and intelligence – normal level of
consciousness? Impaired cognition/intellectual consciousness? Impaired cognition/intellectual functioning?functioning?
Neurological Assessment cont’dNeurological Assessment cont’d
Level of consciousnessLevel of consciousness AVPUAVPU
Pupillary responsePupillary response Ability to identify person, place, timeAbility to identify person, place, time Glasgow coma scaleGlasgow coma scale
Scores 3 – 15Scores 3 – 15 More important than any one score is the trend the More important than any one score is the trend the
score is makingscore is making
Glasgow Coma ScaleGlasgow Coma Scale
Evaluates wakefulness and awarenessEvaluates wakefulness and awareness Wakefulness Wakefulness
The state of being aware of the environmentThe state of being aware of the environment AwarenessAwareness
A demonstrated understanding of what is being A demonstrated understanding of what is being saidsaid
GCS TipsGCS Tips
Always give the patient the best score possibleAlways give the patient the best score possible If the patient can move the right extremity and not If the patient can move the right extremity and not
the left, score for the movement of the right the left, score for the movement of the right extremityextremity
Deteriorations will be noted faster as the score Deteriorations will be noted faster as the score drops by awarding the highest points possibledrops by awarding the highest points possible
Pediatric componentPediatric component Used for the young patient who is not verbal yet Used for the young patient who is not verbal yet
due to agedue to age
Glasgow Coma ScaleGlasgow Coma Scale
EYE OPENING
VERBAL RESPONSE
MOTOR RESPONSE
4--Spontaneous 5--Oriented 6--Obeys
3—Verbal stimuli
4--Confused/ disoriented
5--Localizes
2--Pain3--Inappropriate
words4--Withdraws
1--None2--Incomprehensible
sounds3--Abnormal flexion
1--None 2--Extensor posturing
1--None
GCS ScoreGCS Score
GCS 13 – 15GCS 13 – 15 Mild brain injuryMild brain injury
GCS 9 – 12GCS 9 – 12 Moderate brain injuryModerate brain injury
GCS GCS <<88 Severe brain injurySevere brain injury Most patients with this score are in comaMost patients with this score are in coma Evaluate for the need to assist in protecting the Evaluate for the need to assist in protecting the
patient’s airwaypatient’s airway
Evaluating Eye OpeningEvaluating Eye Opening
Best response is obtained, if at all possible, Best response is obtained, if at all possible, before physical contact is made with patientbefore physical contact is made with patient This is not always possible when the C-spine needs This is not always possible when the C-spine needs
to be controlledto be controlled Patient gets credit if eyelids open even for a Patient gets credit if eyelids open even for a
brief moment or just flickerbrief moment or just flicker Always consider need to control the C-spine Always consider need to control the C-spine
over the verbal response of the GCSover the verbal response of the GCS
Evaluating Verbal ResponseEvaluating Verbal Response
5 – uses appropriate words/conversation5 – uses appropriate words/conversation 4 – speaks but is confused and disoriented4 – speaks but is confused and disoriented 3 – speaking and you can understand the 3 – speaking and you can understand the
wordswords spoken but the words have no bearing spoken but the words have no bearing on the current situationon the current situation
2 – making 2 – making soundssounds like grunts; no intelligible like grunts; no intelligible wordswords
1 – no response; no speech; no noise1 – no response; no speech; no noise
Modifying GCS for PediatricsModifying GCS for Pediatrics
Adult GCS must be modified to match the Adult GCS must be modified to match the developmental age of the young nonverbal childdevelopmental age of the young nonverbal child
Best eye opening remains unchangedBest eye opening remains unchanged Best verbal response for non-verbal patientBest verbal response for non-verbal patient
5 – Smiles, coos, follows objects5 – Smiles, coos, follows objects 4 – Irritable cry but is consolable4 – Irritable cry but is consolable 3 – Inappropriate crying; cries to pain3 – Inappropriate crying; cries to pain 2 – Inconsolable, agitated; moans or groans to pain2 – Inconsolable, agitated; moans or groans to pain 1 – No response1 – No response
Evaluating Motor ResponseEvaluating Motor Response
6 – Obeys commands6 – Obeys commands 5 – Purposeful movement5 – Purposeful movement
Hits at you, grabs at your hands, pulling equipment Hits at you, grabs at your hands, pulling equipment off, pushing you awayoff, pushing you away
4 – Withdraws from pain (unable to localize)4 – Withdraws from pain (unable to localize) 3 – Flexing with internal rotation and 3 – Flexing with internal rotation and
adduction of shoulders and flexion of elbowsadduction of shoulders and flexion of elbows 2 – Extension with elbows straightened and 2 – Extension with elbows straightened and
possible internal shoulder and wrist rotationpossible internal shoulder and wrist rotation
Pediatric GCS Motor ResponsePediatric GCS Motor Response
Best motor response for non-verbal patientBest motor response for non-verbal patient 6 – obeys commands6 – obeys commands
May be difficult to determine if child understandsMay be difficult to determine if child understands 5 – localizes pain by withdrawing to 5 – localizes pain by withdrawing to touchtouch stimuli stimuli 4 – withdraws to 4 – withdraws to painpain (more stimuli than touch) (more stimuli than touch) 3 – same – abnormal flexion3 – same – abnormal flexion 2 – same – abnormal extension2 – same – abnormal extension 1 – no motor response; patient flaccid1 – no motor response; patient flaccid
GCS PracticeGCS Practice
Patient #1Patient #1 The patient is watching you approachThe patient is watching you approach The patient speaks normally and answers questionsThe patient speaks normally and answers questions The patient raises their arm when you ask to take The patient raises their arm when you ask to take
their B/Ptheir B/P Patient #2Patient #2
The patient is looking around the environmentThe patient is looking around the environment The patient speaks normally but is confusedThe patient speaks normally but is confused When you ask the patient to raise their arm, they When you ask the patient to raise their arm, they
are slow to do so but eventually raises their armare slow to do so but eventually raises their arm
GCS PracticeGCS Practice
Patient #3Patient #3 The patient’s eyes are closed and there is no The patient’s eyes are closed and there is no
movement even after squeezing the trapeziusmovement even after squeezing the trapezius The patient groans when the trapezius is squeezedThe patient groans when the trapezius is squeezed The patient flexes their arms to the chest wallThe patient flexes their arms to the chest wall
Patient #4Patient #4 Patient eyes open briefly when their name is calledPatient eyes open briefly when their name is called Patient groans while being pinchedPatient groans while being pinched Patient does not follow commands and pushes you Patient does not follow commands and pushes you
away whenever you try to treat the patientaway whenever you try to treat the patient
GCS PracticeGCS Practice
Patient #5Patient #5 Eyes are closed but open when calling the patientEyes are closed but open when calling the patient The patient yells “don’t” and “stop it” when being The patient yells “don’t” and “stop it” when being
touched, assessed, and treated but is not speakingtouched, assessed, and treated but is not speaking Patient pushes the EMS provider hands away and is Patient pushes the EMS provider hands away and is
trying to pull off the cervical collar and IVtrying to pull off the cervical collar and IV Patient #6Patient #6
Eyes open briefly when asked to open themEyes open briefly when asked to open them The patient moans weakly when being touchedThe patient moans weakly when being touched The patient tries to pull away when care is being The patient tries to pull away when care is being
provided (ie: IV start)provided (ie: IV start)
GCS PracticeGCS Practice Patient #7Patient #7
Patient refused to open eyes due to pain and squeezes them Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyestighter when asked to open eyes
The patient responds verbally saying their head hurts and The patient responds verbally saying their head hurts and the lights make it hurt worsethe lights make it hurt worse
Patient follows commands except for opening eyesPatient follows commands except for opening eyes Patient #8Patient #8
Eyes are open looking straight aheadEyes are open looking straight ahead When asked what month it is, the patient responds “he, When asked what month it is, the patient responds “he,
umm, he, my jacket, don’t…”umm, he, my jacket, don’t…” Does not follow commands. Pulls one hand away and the Does not follow commands. Pulls one hand away and the
other hand is pushing the EMS provider awayother hand is pushing the EMS provider away
GCS Practice – Pediatrics < 1y/oGCS Practice – Pediatrics < 1y/o
Patient #9 (6 month old)Patient #9 (6 month old) Infant’s eyes flutter when touchedInfant’s eyes flutter when touched Patient cries when gently touched; is consolablePatient cries when gently touched; is consolable Patient withdraws when first touching themPatient withdraws when first touching them
Patient #10 (9 month old)Patient #10 (9 month old) Eyelids flutter when the IO needle is placedEyelids flutter when the IO needle is placed Patient moans during the IO insertion and when Patient moans during the IO insertion and when
deformed extremity is handleddeformed extremity is handled The patient pulls their arms into their chest wall The patient pulls their arms into their chest wall
rolling their shoulders and wrists inwardrolling their shoulders and wrists inward
GCS AnswersGCS Answers
Patient # 1 - 4, 5, 6 = 15Patient # 1 - 4, 5, 6 = 15 Patient # 2 – 4, 4, 6 = 14Patient # 2 – 4, 4, 6 = 14 Patient # 3 – 1, 2, 3 = 6Patient # 3 – 1, 2, 3 = 6 Patient # 4 – 3, 2, 5 = 10Patient # 4 – 3, 2, 5 = 10 Patient # 5 – 3, 3, 5 = 11Patient # 5 – 3, 3, 5 = 11 Patient # 6 – 3, 2, 4 = 9Patient # 6 – 3, 2, 4 = 9 Patient # 7 – 3, 5, 6 = 14Patient # 7 – 3, 5, 6 = 14 Patient # 8 – 4, 3, 5 = 12Patient # 8 – 4, 3, 5 = 12 Patient # 9 – 2, 4, 5 = 11Patient # 9 – 2, 4, 5 = 11 Patient # 10 – 2, 2, 3 = 7Patient # 10 – 2, 2, 3 = 7
Blood Glucose LevelBlood Glucose Level To be obtained when:To be obtained when:
Patient is known diabetic with diabetic related Patient is known diabetic with diabetic related problemproblem
Patient has an altered level of consciousness for Patient has an altered level of consciousness for unknown reasonsunknown 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 Consider the patient to have more than one problem at a
timetime Make sure a 2Make sure a 2ndnd or 3 or 3rdrd issue is not present once you issue is not present once you
find the first issue (ie: hypoglycemia)find the first issue (ie: hypoglycemia) Be aware: Peds patients can drop their blood sugar level Be aware: Peds patients can drop their blood sugar level
fastfast
Blood Glucose MonitorBlood Glucose Monitor
Machines calibrated for capillary specimenMachines calibrated for capillary specimen Keep the site hanging dependentlyKeep the site hanging dependently
Can use side of finger tips or the forearmCan use side of finger tips or the forearm Once the site is wiped with an alcohol prep pad, let Once the site is wiped with an alcohol prep pad, let
the site air dry before obtaining a samplethe site air dry before obtaining a sample Use a lancet to obtain a blood sample from the finger Use a lancet to obtain a blood sample from the finger
or forearmor forearm Do not let a patient sign a release until you can Do not let a patient sign a release until you can
document a blood sugar level >60document a blood sugar level >60
Stroke CareStroke Care Rapid detection of signs and symptoms with Rapid detection of signs and symptoms with
rapid diagnosis is essentialrapid diagnosis is essential Need to avoid delays Need to avoid delays
3 hour time limit to administer a fibrinolytic 3 hour time limit to administer a fibrinolytic from time of first onset of signs and from time of first onset of signs and symptomssymptoms Increase risk of cerebral bleeding beyond Increase risk of cerebral bleeding beyond
a 3 hour time framea 3 hour time frame Most important question to ask:Most important question to ask:
What time did symptoms begin?What time did symptoms begin?
Cincinnati Stroke ScaleCincinnati Stroke Scale
Quick and simple evaluation toolQuick and simple evaluation tool DocumentationDocumentation
Facial droopFacial droop Right/left facial droop or no droopRight/left facial droop or no droop
Arm driftArm drift Right/left arm drift or no driftRight/left arm drift or no drift
Speech Speech Clear or not clearClear or not clear
Facial DroopingFacial Drooping
Ask the patient to smile real big and show you Ask the patient to smile real big and show you their teeththeir teeth Best way to see if a droop is presentBest way to see if a droop is present
Arm DriftArm Drift
Demonstrate first and then have patient hold Demonstrate first and then have patient hold their hands out in front, palms up, for 10 their hands out in front, palms up, for 10 secondsseconds
Clarity of SpeechClarity of Speech
Most likely you’ll know by now if there is a Most likely you’ll know by now if there is a speech problemspeech problem
Can have the patient repeat after you any Can have the patient repeat after you any words or a sentence you give themwords or a sentence you give them ““You can’t teach an old dog new tricks”You can’t teach an old dog new tricks”
7 D’S Of Stroke Care7 D’S Of Stroke Care
Detection – of signs and symptomsDetection – of signs and symptoms Dispatch – call 911Dispatch – call 911 Delivery – to the appropriate facilityDelivery – to the appropriate facility Door – emergent triage in the EDDoor – emergent triage in the ED Data – appropriate testsData – appropriate tests Decision – to administer a fibrinolytic or notDecision – to administer a fibrinolytic or not Drug – must administer the fibrinolytic within Drug – must administer the fibrinolytic within
3 hours of onset of symptoms3 hours of onset of symptoms
Quick Fixes of Altered Mental Quick Fixes of Altered Mental StatusStatus
Hypoglycemia – DextroseHypoglycemia – Dextrose Hypoxia – oxygenHypoxia – oxygen Pinpoint pupils – NarcanPinpoint pupils – Narcan Seizures – ValiumSeizures – Valium
Dextrose if seizure due to hypoglycemiaDextrose if seizure due to hypoglycemia Cold – warm the patient upCold – warm the patient up
Combative PatientCombative Patient
Talking down a patient is an art that requires effort Talking down a patient is an art that requires effort and skilland skill
Need enhanced people skills of listening and Need enhanced people skills of listening and observationobservation
Make sure the scene is safeMake sure the scene is safe Provide a calm and supportive environmentProvide a calm and supportive environment Treat any existing medical conditionsTreat any existing medical conditions Do not confront or argue with the patientDo not confront or argue with the patient Provide realistic reassuranceProvide realistic reassurance Respond to the patient in a direct, simple mannerRespond to the patient in a direct, simple manner
2 Extremes of Behavioral 2 Extremes of Behavioral EmergenciesEmergencies
Combative patientCombative patient Fidgeting, nervous Fidgeting, nervous
energyenergy Voice getting louderVoice getting louder PacingPacing Shouting, apparent Shouting, apparent
angeranger
Withdrawn patientWithdrawn patient Facing away from Facing away from
EMSEMS Decreasing eye Decreasing eye
contactcontact No eye contact or No eye contact or
conversationconversation Totally withdrawnTotally withdrawn
System Operating Guidelines – System Operating Guidelines – Use of RestraintsUse of Restraints
EMS personnel should contact Medical Control if EMS personnel should contact Medical Control if possible before restraining patientpossible before restraining patient May restrain patient first for patient and personnel safetyMay restrain patient first for patient and personnel safety
All attempts must be made to avoid injury to patient All attempts must be made to avoid injury to patient and EMS personneland EMS personnel
Do not compromise the patient’s ability to breath or Do not compromise the patient’s ability to breath or further aggravate any injury or illnessfurther aggravate any injury or illness
Clearly document the behavior leading to use of Clearly document the behavior leading to use of restraintsrestraints
Handcuffs applied by police onlyHandcuffs applied by police only Officer must accompany patient in the ambulance during Officer must accompany patient in the ambulance during
transporttransport
Methods of RestraintMethods of Restraint
Verbal de-escalationVerbal de-escalation First method to employFirst method to employ Avoids physical contact with the patient – saferAvoids physical contact with the patient – safer Watch “personal space”Watch “personal space”
1.5 – 4 feet in the United States1.5 – 4 feet in the United States Keep open an “escape route” for yourselfKeep open an “escape route” for yourself
Methods of Restraint cont’dMethods of Restraint cont’d Physical restraintPhysical restraint
Materials or techniques that will restrict the movement of a Materials or techniques that will restrict the movement of a patientpatient
Soft restraints: sheets, wristlets, chest PosySoft restraints: sheets, wristlets, chest Posy Hard restraints: plastic ties, handcuffs, leathersHard restraints: plastic ties, handcuffs, leathers
Police must be in ambulance for transport if patient is in Police must be in ambulance for transport if patient is in handcuffshandcuffs
Patients need frequent reassessment to evaluate for injury Patients need frequent reassessment to evaluate for injury or possible neurovascular compromise or airway or possible neurovascular compromise or airway compromisecompromise
Use a surgical mask placed loosely over the face to control Use a surgical mask placed loosely over the face to control spittingspitting
Physical RestraintsPhysical Restraints
Do not transport a restrained patient proneDo not transport a restrained patient prone Positional asphyxia may cause deathPositional asphyxia may cause death
Be prepared to protect the patient’s airwayBe prepared to protect the patient’s airway Do not secure straps to moving side railsDo not secure straps to moving side rails Restraining thighs just above knees often prevents Restraining thighs just above knees often prevents
kickingkicking Struggling against restraints may lead to severe Struggling against restraints may lead to severe
acidosis and fatal dysrhythmiasacidosis and fatal dysrhythmias NEVER leave restrained patient unattendedNEVER leave restrained patient unattended
Methods of Restraints cont’dMethods of Restraints cont’d
Chemical restraintChemical restraint Administration of specific pharmacological agentsAdministration of specific pharmacological agents
Decrease agitationDecrease agitation Increase cooperationIncrease cooperation Not alter a patient’s level of consciousnessNot alter a patient’s level of consciousness
Common agents used are haldol (in the ED) and/or Common agents used are haldol (in the ED) and/or benzodiazepinesbenzodiazepines
Diazepam (Valium)Diazepam (Valium) Lorazepam (Ativan)Lorazepam (Ativan) Midazolam (Versed)Midazolam (Versed)
SOP - Severe Anxiety or AgitationSOP - Severe Anxiety or Agitation
Valium 5 mg IVP slowly over 2 minutesValium 5 mg IVP slowly over 2 minutes Repeat as needed Repeat as needed Maximum total dose is 10 mgMaximum total dose is 10 mg In the absence of an IV, Valium 10 mg IM/rectallyIn the absence of an IV, Valium 10 mg IM/rectally Watch for respiratory depression with Watch for respiratory depression with
administration of a benzodiazepineadministration of a benzodiazepine Have a BVM ready to use as a precautionHave a BVM ready to use as a precaution
Documentation TipsDocumentation Tips All patients require a blood glucose level for altered All patients require a blood glucose level for altered
mental statusmental status Documentation should reflect serial monitoring of the Documentation should reflect serial monitoring of the
patient’s condition looking for changespatient’s condition looking for changes GCSGCS AVPUAVPU
If restraints are used, document objectively and in If restraints are used, document objectively and in detail the behavior that led to the need for restraintsdetail the behavior that led to the need for restraints Document distal circulation of any restrained Document distal circulation of any restrained
extremityextremity Patients with altered mental status cannot sign a Patients with altered mental status cannot sign a
releaserelease
Securing the Airway - QuickTrachSecuring the Airway - QuickTrach IndicationsIndications
Patient requires emergency assisted ventilation Patient requires emergency assisted ventilation when all other conventional methods have failedwhen all other conventional methods have failed
ContraindicationsContraindications Tracheal transectionTracheal transection
Other less invasive maneuver allows ventilationOther 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 ID22# – 77# (10 -35kg) use 2.0 mm ID <22# (10kg) – use needle cricothyrotomy<22# (10kg) – use needle cricothyrotomy
QuickTrach DeviceQuickTrach Device
Connecting Connecting tubetube
SyringeSyringe
Flanges to Flanges to attach ties attach ties
Stopper that is Stopper that is removed removed before final before final insertioninsertion
QuickTrach ProcedureQuickTrach Procedure
Position patient supine; hyperextend neck if no Position patient supine; hyperextend neck if no trauma)trauma)
Locate cricothyroid membrane and cleanse siteLocate cricothyroid membrane and cleanse site Palpate the soft indentation between Palpate the soft indentation between
the thyroid and cricothyroid cartilagesthe thyroid and cricothyroid cartilages Secure the larynx laterally between Secure the larynx laterally between
the thumb and forefingerthe thumb and forefinger Puncture the cricothyroid Puncture the cricothyroid
membrane at a 90membrane at a 9000 angle angle
Cricothyroid MembraneCricothyroid Membrane
Target areaTarget area
QuickTrach cont’dQuickTrach cont’d
Confirm entry into the trachea by aspirating air thru Confirm entry into the trachea by aspirating air thru the syringethe syringe If air is present, the needle is in the tracheaIf air is present, the needle is in the trachea
Now change the angle to 60Now change the angle to 6000 with the tip pointing with the tip pointing towards the feet and advance the device forward into towards the feet and advance the device forward into the trachea to the level of the stopperthe trachea to the level of the stopper Stopper to be snug against the skinStopper to be snug against the skin Stopper reduces risk of inserting the needle too Stopper reduces risk of inserting the needle too
deeplydeeply Remove the stopperRemove the stopper
QuickTrach cont’dQuickTrach cont’d Holding needle and syringe firmly, slide only Holding needle and syringe firmly, slide only
the plastic cannula into the trachea the plastic cannula into the trachea Stop when the flange rests snug against the Stop when the flange rests snug against the
neckneck Carefully remove the needle and syringeCarefully remove the needle and syringe Apply the connecting tube to the cannulaApply the connecting tube to the cannula Attach a BVM to the connecting tubeAttach a BVM to the connecting tube
Begin to bag the patient Begin to bag the patient Secure the cannula with the neck tape ties Secure the cannula with the neck tape ties
providedprovided
QuickTrach ComplicationsQuickTrach Complications
Puncture through of the tracheaPuncture through of the trachea During bagging attempts surrounding tissue will During bagging attempts surrounding tissue will
expand due to leakage of airexpand due to leakage of air Inadvertent puncture of a blood vesselInadvertent puncture of a blood vessel
Formation of a hematoma under the skin and Formation of a hematoma under the skin and surrounding the airwaysurrounding the airway
External bleedingExternal bleeding Inability to ventilate the patientInability to ventilate the patient
There may be an obstruction at a more distal siteThere may be an obstruction at a more distal site
QuickTrach DocumentationQuickTrach Documentation
Indicate the reason(s) an alternate airway Indicate the reason(s) an alternate airway devise was necessarydevise 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 placementDocument confirmation of airway placement Bilateral breath soundsBilateral breath sounds Bilateral chest wall rise and fallBilateral chest wall rise and fall
Case Study #1Case Study #1
57 year old patient found behind a garage 57 year old patient found behind a garage unresponsive.unresponsive.
Breathing and has a radial pulse. Dry blood on Breathing and has a radial pulse. Dry blood on lips.lips.
What are your impressions?What are your impressions? How does your assessment proceed?How does your assessment proceed?
Case Study #1 Case Study #1
Impression listImpression list Post-ictal from seizurePost-ictal from seizure HypoglycemiaHypoglycemia Alcohol intoxicationAlcohol intoxication Drug overdoseDrug overdose Acute MIAcute MI StrokeStroke Head traumaHead trauma
Case Study #1Case Study #1
AssessmentAssessment Control c-spine while palpating neck areaControl c-spine while palpating neck area Evaluate if respiratory assistance is neededEvaluate if respiratory assistance is needed
Check quality, depth, rate of respirations, SpOCheck quality, depth, rate of respirations, SpO22
Calculate GCS; obtain vital signsCalculate GCS; obtain vital signs Consider IV-OConsider IV-O22-monitor-monitor
Assess for need for fluid challengeAssess for need for fluid challenge Assess cardiac rhythm; consider obtaining a 12 Assess cardiac rhythm; consider obtaining a 12
lead EKGlead EKG Obtain a blood glucose sampleObtain a blood glucose sample
Case Study #2Case Study #2
Patient’s spouse called EMSPatient’s spouse called EMS Patient dropping silverware at lunch, unable to Patient dropping silverware at lunch, unable to
sit up straight, unable to complete sentencessit up straight, unable to complete sentences Vital signs: 170/110; P – 64; R – 16; GCS -14Vital signs: 170/110; P – 64; R – 16; GCS -14 EKG monitor - EKG monitor -
Case Study #2Case Study #2
What is your impression?What is your impression? What is the cardiac rhythm?What is the cardiac rhythm?
Atrial fibrillationAtrial 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 Blood sugar level for all patients with altered level
of consciousnessof consciousness Cincinnati stroke scaleCincinnati stroke scale
Case Study #2Case Study #2
Cincinnati stroke scaleCincinnati stroke scale Ask the patient to smile real big showing you their Ask the patient to smile real big showing you their
teethteeth Ask the patient to put their hands out in front, Ask the patient to put their hands out in front,
palms up, and close their eyes palms up, and close their eyes Hold the position for 10 secondsHold the position for 10 seconds
Ask the patient to repeat a sayingAsk the patient to repeat a saying ““You can’t teach an old dog new tricks”You can’t teach an old dog new tricks”
Case Study #2Case Study #2
What’s the most important question to ask the What’s the most important question to ask the patient?patient?
When did the symptoms begin?When did the symptoms begin?
Case Study #3Case Study #3
Your 18 year-old patient is found under the Your 18 year-old patient is found under the bleachers at school unresponsive with shallow bleachers at school unresponsive with shallow respirations.respirations.
AVPU - responds to painful stimuliAVPU - responds to painful stimuli Vital signs: 110/70; P – 110; R – 4; pupils Vital signs: 110/70; P – 110; R – 4; pupils
constrictedconstricted GCS – 8GCS – 8 What are your impressions?What are your impressions?
Case Study #3Case Study #3
Impression listImpression list Drug overdoseDrug overdose
Opiates – constricted pupils, depressed respirationsOpiates – constricted pupils, depressed respirations Head injuryHead injury HypoglycemiaHypoglycemia Post-ictalPost-ictal
Case Study #3Case Study #3
TreatmentTreatment Control c-spine Control c-spine
Consider c-spine injury until proven otherwiseConsider c-spine injury until proven otherwise Secure airwaySecure airway
Frequency to ventilate?Frequency to ventilate? Once every 5 – 6 secondsOnce every 5 – 6 seconds
Gain IV accessGain IV access Peripheral site? Peripheral site? IO if peripheral unobtainableIO if peripheral unobtainable
Evaluate cardiac rhythmEvaluate cardiac rhythm
Case Study #3Case Study #3 Medications to administerMedications to administer
If blood sugar < 60 give 50 ml of 50% DextroseIf blood sugar < 60 give 50 ml of 50% Dextrose As a diagnostic tool give NarcanAs a diagnostic tool give Narcan
2 mg IVP every 5 minutes as needed for desired effect2 mg IVP every 5 minutes as needed for desired effect Maximum total of 10 mgMaximum total of 10 mg
Consider need to protect the airway with intubation Consider need to protect the airway with intubation following conscious sedationfollowing conscious sedation No indication for lidocaineNo indication for lidocaine Versed to relax the patientVersed to relax the patient Morphine alternated with Versed to potentiate the Morphine alternated with Versed to potentiate the
effects of both medicationseffects of both medications Benzocaine if a blink reflex is presentBenzocaine if a blink reflex is present
Case Study #4Case Study #4
You are called to the scene for an unknown You are called to the scene for an unknown medical emergencymedical emergency
Police have secured the scenePolice have secured the scene Your patient is a 54 year-old male who is Your patient is a 54 year-old male who is
combativecombative What are your impressions?What are your impressions? What actions are indicated?What actions are indicated?
Case Study #4Case Study #4
ImpressionsImpressions Psychiatric problemPsychiatric problem Altered blood sugarAltered blood sugar Head injuryHead injury Electrolyte imbalanceElectrolyte imbalance
Case Study #4Case Study #4
Action to takeAction to take Make sure the scene is safe and remains safe for Make sure the scene is safe and remains safe for
the rescuers 1the rescuers 1stst and then the patient and then the patient Will need a blood sugar at some pointWill need a blood sugar at some point A cardiac monitor to evaluate rhythm could be A cardiac monitor to evaluate rhythm could be
important assessment informationimportant assessment information May need to restrain the patient for crew safety May need to restrain the patient for crew safety
and patient safetyand patient safety
Case Study #4Case Study #4 Methods to restrain patientsMethods to restrain patients
Verbal de-escalationVerbal de-escalation Soft restraintsSoft restraints
Wrist and ankle restraintsWrist and ankle restraints Chest posey or sheetChest posey or sheet
Hard restraintsHard restraints If police handcuff the patient, police must If police handcuff the patient, police must
ride with the patient in the ambulance ride with the patient in the ambulance Police are not allowed to hand off cuff Police are not allowed to hand off cuff
keys to EMSkeys to EMS
Case Study #4Case Study #4
DocumentationDocumentation Patient’s behavior in descriptive, objective terms Patient’s behavior in descriptive, objective terms
that indicated the need for restraintthat indicated the need for restraint If no time to contact Medical Control before If no time to contact Medical Control before
restraining patient, contact them after the patient is restraining patient, contact them after the patient is restrainedrestrained
Document distal circulation, motion, and sensation Document distal circulation, motion, and sensation periodically after restraining the patientperiodically after restraining the patient
Case Study #5Case Study #5
32 year-old patient who was found combative 32 year-old patient who was found combative at work. This is very unusual behavior for this at work. This is very unusual behavior for this patientpatient
Vital signs: 110/70; P – 80; R – 18; skin dampVital signs: 110/70; P – 80; R – 18; skin damp Impression?Impression? Further assessment?Further assessment? Treatment?Treatment?
Case Study #5Case Study #5
ImpressionImpression HypoglycemiaHypoglycemia Head injuryHead injury Drug / alcohol influenceDrug / alcohol influence
AssessmentAssessment Blood sugar levelBlood sugar level Cardiac monitorCardiac monitor Neurological evaluationNeurological evaluation
Case Study #5Case Study #5
Blood sugar was 25Blood sugar was 25 Treatment indicatedTreatment indicated
50 ml 50% Dextrose IVP50 ml 50% Dextrose IVP Patient now alert and orientedPatient now alert and oriented Repeat blood sugar 56Repeat 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 >60No release until the blood sugar is >60 Stay on the scene and continue to reassess as the Stay on the scene and continue to reassess as the
patient takes in food or liquidspatient takes in food or liquids
BibliographyBibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles and Practices 3Principles and Practices 3rdrd Edition. Prentice Hall. Edition. Prentice Hall. 20092009
Limmer, D. O’Keefe, M. Emergency Care. 10Limmer, D. O’Keefe, M. Emergency Care. 10thth Edition. Prentice Hall. 2005.Edition. Prentice Hall. 2005.
Region X SOP’s March 2007. Amended January 1, Region X SOP’s March 2007. Amended January 1, 2008.2008.
En.wikipedia.org/wiki/Endocrine_systemEn.wikipedia.org/wiki/Endocrine_system En.wikipedia.org/wiki/Electrolyte_systemEn.wikipedia.org/wiki/Electrolyte_system En.wikipedia.org/wiki/Encephalopathy_systemEn.wikipedia.org/wiki/Encephalopathy_system En.wikipedia.org/wiki/Opiate_systemEn.wikipedia.org/wiki/Opiate_system En.wikipedia.org/wiki/Uremia_systemEn.wikipedia.org/wiki/Uremia_system
Bibliography cont’dBibliography cont’d www.chems.alaska.gov/EMS/documents/GCS_Activity_www.chems.alaska.gov/EMS/documents/GCS_Activity_
2003.pdf2003.pdf www.doi.gov/nbc/eps/signsymptoms.htmlwww.doi.gov/nbc/eps/signsymptoms.html www.en.wikibooks.org.wiki/Emergency_Medicine/alteredwww.en.wikibooks.org.wiki/Emergency_Medicine/altered
_mental_status_mental_status www.nursingtimes.netwww.nursingtimes.net www.opiates.com/opiateswww.opiates.com/opiates staff.washington.edu/momus/PB/comachan.htmstaff.washington.edu/momus/PB/comachan.htm www.ucsfcme.com/2008/slides/MDM08Q05/01-sporer.pdwww.ucsfcme.com/2008/slides/MDM08Q05/01-sporer.pd
ff www.uic.edu/com/ferne/slides/Delerium.ppswww.uic.edu/com/ferne/slides/Delerium.pps
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