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TRANSCRIPT
9/10/2012
1
Altered Mental Status
Lesson Goal
Identify, approach, & care for patients with altered mental status or changes in level of consciousness
Lesson Objectives
Discuss importance of appropriate airway management in patient with altered mental status
Discuss approach & care of patient with altered mental status
Identify patient with altered mental status who has history of diabetes
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9/10/2012
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Lesson Objectives
Identify patient with altered mental status who is taking diabetic medications
Outline steps in caring for patient with altered mental status who has diabetes
Lesson Objectives
Outline characteristics of oral glucose: generic name, trade name, dosage forms, dose, method of administration, action & contraindications
Discuss assessment of and treatment approach for patient experiencing seizure
Lesson Objectives
Identify patient who may be experiencing stroke
Discuss role of medical direction in emergency care of patient with altered mental status
Explain rationale for administering oral glucose
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9/10/2012
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Altered Mental Status
Altered mental status (AMS)
Level of consciousness (LOC)
Altered Mental Status
Possible causes Hypoxia Respiratory problems Head trauma Poisoning Diabetes Syncope Seizures Stroke Central nervous system (CNS) or general body
infection
Altered Mental Status
General initial care same regardless of cause: Proper patient positioning
Maintain airway
Oxygenation & ventilation
Maintain body temperature
Expeditious transport
ALS care if available
Consultation with medical control, if appropriate
Glucose administration, if cause is known & allowed in protocol, especially with diabetes
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9/10/2012
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Altered Level of Consciousness
Normal Awake, alert, able to converse appropriately
Assessment Person, place, time, event Patient’s baseline mental status
Patients with altered LOC need rapid evaluation & treatment
Assessment Tools
AVPU Alert
Verbal
Painful
Unresponsive
Glasgow Coma Scale
Eye opening4 Spontaneously3 To verbal command2 To pain1 No response
Verbal response5 Oriented and converses4 Disoriented and converses3 Inappropriate words2 Incomprehensible sounds1 No response
Motor response6 Obeys verbal commands5 Localizes painful stimulus4 Flexion—withdraws to painful stimulus3 Abnormal flexion to painful stimulus2 Abnormal extension to painful stimulus 1 No response
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9/10/2012
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Assessment
Combine mental status finding with other assessment findings
Abnormal VS may cause or be caused by AMS
Diabetes
Glucose provides energy
Insulin required for glucose to enter cells
Brain cannot store glucose, requires constant supply
Without constant perfusion with oxygenated blood containing glucose, brain cells begin to die within minutes
Diabetes
Hyperglycemia When insulin is inadequate, glucose remains in
blood & cannot enter cells
Hypoglycemia Too much insulin causes glucose to be used too
quickly, leaving inadequate glucose in blood
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9/10/2012
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Diabetes
Type I Pancreas produces little
or no insulin
Usually develops in childhood
Patient must take injected insulin
Type II Insufficient insulin or
faulty receptors
Adult onset
Associated with obesity
Controlled with diet, exercise, and/or oral medications
Assessment
Critical questions History of diabetes?
• Taking medication for it?
• Insulin or oral medication?
• Medication taken as scheduled?
Did you eat recently?
Any unusual activity or illness?
Hypoglycemia
Hypoglycemia develops quickly Can occur for several reasons:
• Regular dose of insulin without food
• Too much exercise
• Too much insulin or oral medication
• Illness
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9/10/2012
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Hyperglycemia
Too little insulin or faulty insulin receptors
Glucose cannot enter cells Blood glucose increases
Glucose may enter urine
Water follows glucose
Dehydration
Breakdown of fats leads to ketoacidosis
Signs & Symptoms
AMS Rapid pulse Deep, rapid respirations (hyperglycemia) Warm dry skin (hyperglycemia) Cool, moist skin (hypoglycemia) Nausea, vomiting Headache Seizure
Treatment
Check blood glucose level if allowed & possible
Hyperglycemia requires hospital treatment
Hypoglycemia requires increase in blood glucose level Food, drink, glucose gel
Monitor airway in patients with ↓ LOC
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9/10/2012
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Skill 20-1: Oral Glucose
1. Consult medical direction for authorization to administer oral glucose
2. Check patient's responsiveness & ability to swallow
Skill 20-1: Oral Glucose
3. Place glucose on tongue depressor; administer full tube between patient's cheek & gum, allowing mucous membranes to absorb glucose
4. Reassess patient; document time of administration & any changes in patient condition
Skill 20-1: Oral Glucose
Video Clip coming soon
Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
9/10/2012
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Syncope
Temporary loss of consciousness
Caused by ↓ blood flow to brain Rapidly changing positions
Dilation of blood vessels
↓ cardiac output
Signs & Symptoms
Patient may be recovering on EMS arrival
Preceding symptoms Lightheadedness or dizziness
Tunnel vision
Nausea
Pale, cool, moist skin
Abnormal heart rate or respirations
Numbness or tingling of extremities
Treatment
Supine position Consider causes Evaluate for injuries if patient fell Loosen tight clothing Administer O2 if appropriate ↑ heart rate may indicate hypovolemia Call for ALS if patient is elderly or cardiac
problems are suspected Transport for evaluation
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9/10/2012
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Seizures
Abnormal electrical activity in brain
Depending on how brain is affected, seizure may include: Full body seizure
Seizure of isolated body parts
Staring into space
Bizarre behavior
Causes of Seizures
Fever
Infection
Hypoglycemia
Hypoxia
Head injury
Epilepsy
Types of Seizures
Partial Simple
Complex
Generalized
Absence
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9/10/2012
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Signs & Symptoms
Possible aura
Loss of consciousness
Loss of bladder/bowel control
May last several minutes
May be followed by AMS
Treatment
Protect patient from injury
Recovery position
Do not place anything in patient’s mouth
Provide O2
ALS for prolonged seizures
Transport
Stroke
3rd leading cause of death
Can lead to permanent disability
Caused by interruption of blood flow to brain Ischemic
Hemorrhagic
Signs & symptoms depend on area of brain deprived of blood flow
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9/10/2012
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Transient Ischemic Attack
Stroke symptoms last from few minutes to hours due to reduced blood flow to an area of the brain
TIA—warning sign of impending stroke
TIA patients must be evaluated at hospital
Thrombolytics
Some patients with ischemic stroke can be treated with thrombolytic drugs
Treatment must take place within specified period after stroke onset
Transport to designated stroke center when possible
Signs & Symptoms
Sudden behavior change
AMS
Difficulty speaking
Numbness or tingling
Facial droop
Vision changes
Pupil differences
Difficulty swallowing
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9/10/2012
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Treatment
Recognize signs & symptoms!
Provide supportive care ABCs, O2
Talk to patient
Make patient comfortable
Request ALS if available
Stroke Centers
EMS systems may have specifically designated stroke centers where patients can receive rapid assessment, diagnosis, & treatment
Summary
Many conditions can cause AMS
Use structured approach to assessment & treatment
Provide stabilizing care
Transport
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