Download Altered Mental Status

Region 8 EMSS
April 2017
Altered Mental Status / Stroke
Objectives
• Define altered mental status
– Review Causes
– Review Corrections
– Review Treatment
• Define stroke
– Review Causes
– Review Treatment
Introduction
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Region Updates
System Updates
SME video of the month
Review of altered mental status SOP’s
Review of Stroke SOP
Scenarios
Announcements
• Region
• System
– CDH
• Reminder that all patients with a GCS less than 15 require
capnography to be used during care.
SME video
Altered Mental Status Defined
• Altered mental status is defined as a change in level of
consciousness and cognitive function from normal
baseline
• Mental status has several components arousal,
awareness and cognitive function
Altered Mental Status Defined
• Arousal:
– The level of alertness, spontaneous eye opening, stimulation to
wake, inattention
• Awareness:
– Perception of the environment
• Cognitive function:
– Includes reasoning, memory, attention and language
Altered Mental Status
• What may be considered altered level of consciousness?
– Patient is not awake
– Patient is unaware of their environment
– Patient is not oriented to person, place or time
– Patient is confused
– Patient is unable to comprehend commands
– Knowing the baseline mental status of the patient is important
in detecting subtle changes in mentation
Altered Mental Status Tools
• Glasgow Coma Score (GCS)
– Using a GCS vs. AVPU will allow EMS providers to more
accurately monitor subtle changes in mental status from
baseline and during reassessment.
Eyes
Verbal
Motor
4
Opens Spontaneously
5
Alert X 4/4
6
Spontaneous Movement
3
Opens to Voice
4
Confused
5
Localizes Pain
2
Opens to Pain
3
Inappropriate
4
Withdraws From Pain
1
No Opening
2
Incomprehensible Sounds
3
Decorticate Posturing
1
No Verbal Sounds
2
Decerebrate Posturing
1
No Movement
Altered Mental Status Tools
• Using AVPU will allow providers to obtain a rapid “sick or
not sick” assessment, however, subtle changes in mental
status may not be noticed if only relying in AVPU.
– Alert
– Verbal
– Painful
– Unresponsive
Altered Mental Status Tools
• AVPU vs. GCS
AVPU
Alert
GCS Ranges
15
Verbal
4-14
Painful
4-10
Unresponsive
3
• Using AVPU alone may not capture acute changes in
mental status
Altered Mental Status Causes
• To ensure proper treatment the EMS provider should
attempt to identify the cause of the mental status change.
Using the pneumonic AEIOU-TIPS and the H’s and T’s
can be useful tools in the initial assessment process if a
obvious cause is not easily identified.
Altered Mental Status TIPS
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A
E
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T
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P
S
Alcohol
Epilepsy or seizure, endocrine
Infection
Overdose (opiates)
Uremia
Trauma, blood loss, shock
Insulin
Poisoning/psychiatric
Stroke, syncope
Altered Mental Status H’s and T’s
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H
H
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H
T
T
T
T
T
Hypovolemia
Hypoxia
Hydrogen Ion
Hypo/Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade / cardiac
Toxins
Thrombosis, pulmonary (PE)
Thrombosis, cardiac / neuro
Altered Mental Status Tools
• AEIOU-TIPS vs H’s and T’s
AEIOU-TIPS
H’s and T’s
Corresponding
H’s and T’s
A
Alcohol
T
Toxins
E
Epilepsy or seizure, endocrine
H/T
Hydrogen / Thrombosis (neuro)
I
Infection
N/A
N/A
O
Overdose
T
Toxins
U
Uremia
N/A
N/A
T
Trauma, blood loss, shock
H
Hypovolemia
I
Insulin
H
Hypoglycemia
P
Poisoning / Psychiatric
T
Toxins
S
Stroke, Syncope
T
Thrombosis
Stroke / CVA
• Annually, more than 795,000 people in the
United States have a stroke.
– Of these 610,000 are first or new strokes
• More than 130,000 Americans die each year as
a result of stroke
• Every 40 seconds, someone in the U.S. has a
stroke, and every 4 minutes someone in the
U.S. dies from a stroke
• Hypertension, high cholesterol, and smoking
are the leading causes of stroke
– Symptom presentation alone is not definitive in
differentiating ischemic from hemorrhagic stroke
FAST Exam
• Rapid, 4-step approach to evaluation for
potential stroke
• Should be performed on any patient
presenting with stroke-like symptoms,
regardless of time of onset
• Research has shown that the FAST exam
has up to an 85% sensitivity for stroke
• Other stroke screening methods include the
Los Angeles Prehospital Stroke Screen
(LAPSS), Cincinnati Prehospital Stroke
Scale (CPSS), and the NIH Stroke Scale
(NIHSS)
FAST Exam - Components
• Face
– Ask the patient to smile. Observe for facial droop
• Arm
– Have the patient raise both arms out in front of them and
close their eyes. Observe for arm drift or fall
• Speech
– Ask the patient to repeat a simple phrase. Observe for
slurring of speech or other speech abnormalities
• Time
– Remember that TIME IS BRAIN! If possible, obtain the
time of symptom onset or the time last known well.
– For the general public, this component instructs them to
call 911 if any of the other components of the screening
are abnormal.
Ischemic vs Hemorrhagic Stroke
• Ischemic strokes result from interruption
of blood flow to the brain tissues caused
by a clot
• Hemorrhagic stroke results from a
vascular defect that causes bleeding
around or into the brain tissue.
– Aneurysmal
• Berry / Saccular
– Form along the artery, including bifurcations, and
resemble a berry growing from a twig
• Fusiform
– Form along the artery and encompass the vessel
circumferentially
– Traumatic injury with vascular rupture
– Spontaneous
Ischemic Stroke
• Accounts for 80% of all strokes
– 2 Sub-types
• Thrombotic
– Result from the formation of a clot within the vasculature of
the brain itself, often caused by atherosclerosis or plaque
build up (much like myocardial infarction)
• Embolic
– Result from the formation of a clot somewhere in the body
that travels to the brain and occludes blood flow
– Characterized by an area of acute ischemia due to
lack of blood flow, and a surrounding area of limited
or decreased perfusion called the ischemic
penumbra
– In 5% of cases, hemorrhagic conversion occurs as
a result of capillary leaking or disruption of the
blood-brain barrier
– Initially, CT may appear normal due to lack of
sensitivity for infarcted tissue. Later CT studies will
show areas of infarct and loss of gray/white mater
differentiation
Ischemic Stroke
• History, Signs, & Symptoms
– Patients with risk factors for cardiac and
atherosclerotic disease are also at risk for ischemic
stroke
• Hypertension, diabetes, tobacco use, high cholesterol,
and history of CAD, CABG, and/or Atrial fibrillation
– Stroke should be considered in any patient with
acute neurologic deficit (global or focal), or altered
level of consciousness
– Abrupt onset of the following:
• Hemiparesis, monoparesis, hemisensory deficits,
monocular or binocular vision loss, visual field deficits,
diplopia (double vision), dysarthria (difficult or unclear
articulation of speech), facial droop, ataxia (loss of full
control of body movements), vertigo, aphasia (loss of
ability to understand or express speech), and/or sudden
decrease in level of consciousness
– Symptoms can appear alone, however they are
more likely to appear in combination
– History of Transient Ischemic Attack (TIA) increases
a patient’s risk of a true ischemic stroke
Post-mortem exam of an ischemic stroke. Note
the obviously infarcted brain tissue.
Ischemic Stroke
• Treatment
– Thorough history and physical
– OBTAIN TIME LAST KNOWN WELL
• Thrombolytic therapy must be done within 4-6 hours postonset of symptoms. This window is being extended by some
facilities, but typically <4 hours is standard.
– GLASGOW COMA SCORE
– FAST EXAM
– Initial Medical Care
– Blood glucose level
– 12-lead ECG
– Vascular Access / Cardiac Monitoring
– Be alert for subtle mental status changes
– Rapid transport and notification of receiving facility
• Stroke Alert
Ischemic Stroke - tPA
• A pharmacologic option for treating
ischemic stroke patients is the use of
tissue plasminogen activator (tPA),
a.k.a Activase®
• Not routinely administered in the prehospital environment
• Works by promoting thrombolysis
through the conversion of
plasminogen to plasmin; plasmin
degrades fibrin and fibrinogen,
resulting in breakdown of the clot.
Ischemic Stroke - tPA
• Contraindications:
– Active internal bleeding
– Current intracranial hemorrhage
– Intracranial neoplasm, arteriovenous
malformation, aneurysm, or any other
condition that may increase bleeding risk
– Recent intracranial or spinal surgery
(within 3 months)
– Recent head trauma (within 3 months)
– Severe uncontrolled hypertension
Ischemic Stroke - tPA
• Dosing:
– 0.9 mg/kg IV
• 10% of total dose is given as a bolus
over one minute
• Remainder is administered via IV
infusion over 60 minutes
• MAX total dose 90mg
– Should be administered with 3 – 4.5
hours of symptom onset, although can
be given up to 6 hours post-symptom
onset in certain situations as deemed
appropriate by a physician
Ischemic Stroke - tPA
• Adverse Effects
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Hemorrhage
Anaphylaxis
CVA / Intracranial hemorrhage
Seizure
Angioedema
Cardiac dysrhythmia
Cardiac tamponade
Cerebral herniation
Pulmonary edema
Types of Hemorrhagic Stroke
• Epidural
– Usually results from trauma to the
temporal region of the skull
– Commonly caused by a rupture of the
middle meningeal artery
– Causes bleeding between the skull and
dura mater (hence epidural, meaning
above the dura)
– Only accounts for roughly 2% of strokes
– CT shows ‘typical’ crescent shaped area
of bleeding
Epidural Hematoma
• History, Signs, & Symptoms
– Trauma is usually involved, but not always
• History of direct blow to the head, usually to the temporal
or parietal area
• Can also be related to hypertension, vascular
malformation, anticoagulant therapy
– “Classic” presentation is immediate loss of
consciousness, followed by a lucid interval during
which the patient is conscious, and then a precipitous
decline in mental status and level of consciousness,
progressing to coma
– Symptoms may include headache, nausea, vomiting,
seizures, focal neurologic deficit, weakness,
numbness, and urinary or fecal incontinence
– Bradycardia, hypertension, and irregular respirations
(Cushing’s Triad) may be present as intracranial
pressure increases
Note the dura mater is still intact, and the
hematoma is resting on it
Epidural Hematoma
• Treatment
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Thorough history and physical
Spinal motion restriction as required and needed
Ascertain the mechanism and time of injury
Obtain time last known well
GLASGOW COMA SCORE
FAST exam
Initial Medical Care
Vascular Access / Cardiac Monitoring
Be alert for subtle mental status changes
Rapid transport and notification of receiving
facility
– Acute epidural hematomas, depending on size
and neurologic deficit, are a surgical emergency
Types of Hemorrhagic Stroke
• Subdural
– Commonly caused by trauma, but not always!
– Can be acute, subacute, or chronic
– Bleeding occurs below the dura mater but above
the arachnoid mater
• Usually venous bleeding, but can be arterial
• Damage to the bridging vessels between the
surface of the brain and the dura
– Accounts for 5 – 25% of hemorrhagic strokes and
cerebral hematomas
– CT shows bleeding that follows the contour of the
brain in a ‘wavy’ appearance
Subdural Hematoma
• History, Signs, & Symptoms
– Commonly caused by trauma, but not always!
• Rapid acceleration / deceleration forces cause shearing
of vasculature
• Can also be caused by hypertension, anticoagulant
therapy, cerebral aneurysms, arteriovenous
malformations, or spontaneous
– Clinical presentation depends on the location of the
lesion and the rate at which it develops
– Signs and symptoms resemble other hemorrhagic
strokes
• Headache, nausea, vomiting, drowsiness, dizziness, confusion,
unequal pupil size, slurred speech, hypertension, lethargy,
seizures, coma
– Bradycardia, hypertension, and irregular respirations
(Cushing’s Triad) may be present as intracranial
pressure increases
Note the dura mater has been surgically
resected, revealing the subdural hematoma
Subdural Hematoma
• Treatment
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Thorough history and physical
Spinal motion restriction as required and needed
Ascertain the mechanism and time of injury if applicable
Obtain time last known well
GLASGOW COMA SCORE
FAST exam
Initial Medical Care
Vascular Access / Cardiac Monitoring
Be alert for subtle mental status changes
Rapid transport and notification of receiving facility
Symptom onset will vary based on the rate of progression of the
bleed
• Acute
– Typical symptom onset immediately following injury up to 4 days postinjury
• Sub-Acute
– Typical symptom onset 4 – 21 days after injury
• Chronic
– Typical symptom onset > 21 days post-injury
Types of Hemorrhagic Stroke
• Subarachnoid Hemorrhage
– Can be caused by trauma or
spontaneous aneurysmal rupture
– Results in bleeding beneath the
arachnoid mater but above the pia
mater
– CT shows blood present in the
fissures of the brain, giving the bleed
a spider-like appearance
Subarachnoid Hemorrhage
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History, Signs, & Symptoms
– Can be traumatic or caused by rupture of a cerebral
aneurysm or arteriovenous malformation, or
neoplastic growth
• 80% are due to ruptured berry or saccular aneurysms
– “Classic” presentation is a sudden onset headache
(‘thunderclap headache’) often described as the
worst of their life, nausea, vomiting, and signs of
meningeal irritation (nuchal rigidity, neck pain, back
pain, and/or bilateral leg pain)
– Dizziness, orbital pain, diplopia (double vision),
visual loss, sensory or motor disturbances, seizures,
ptosis (drooping of the upper eyelid), memory loss,
dysphasia, and/or seizure
– Hypertension is common
– Bradycardia, hypertension, and irregular respirations
(Cushing’s Triad) may be present as intracranial
pressure increases
Post-mortem examination of a SAH. Note blood is present
around the Circle of Willis, outside the pia mater.
Subarachnoid Hemorrhage
• Treatment
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Thorough history and physical
Spinal motion restriction as required and needed
Ascertain the mechanism and time of injury if applicable
Obtain time last known well
GLASGOW COMA SCORE
FAST exam
Initial Medical Care
Vascular Access / Cardiac Monitoring
Monitor blood pressure closely
Be alert for subtle mental status changes
Rapid transport and notification of receiving facility
Symptom onset will vary based on the rate of progression
of the bleed
Types of Hemorrhagic Stroke
• Intraparenchymal / Intracerebral
Hemorrhage
– Most commonly caused by leaking blood
vessels within the brain tissue itself; can also
be caused by spontaneous rupture of blood
vessels
– Results in bleeding within the brain tissue
itself, under the pia mater
– Accounts for 10% of all hemorrhagic strokes
– CT shows accumulation of blood in the
intracerebral space that does not follow the
contour of the meninges and may appear
circular in shape
Intraparenchymal / Intracerebral
Hemorrhage
• History, Signs, & Symptoms
– Often due to spontaneous rupture or leak from an
intracerebral vessel
– Hemiparesis, hemisensory loss, right or left gaze
preference, visual field cut, aphasia, atypical
neglect, gait or limb ataxia, vertigo, nausea,
vomiting, seizure, and coma
– Hypertension is common, with measurements of
200/120mmHg seen
– Bradycardia, hypertension, and irregular
respirations (Cushing’s Triad) may be present as
intracranial pressure increases
Post-mortem exam of an intracerebral hemorrhage.
Note the accumulation of blood in a spherical shape
within the brain tissue.
Intraparenchymal / Intracerebral
Hemorrhage
• Treatment
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Thorough history and physical
Spinal motion restriction as required and needed
Ascertain the mechanism and time of injury if applicable
Obtain time last known well
GLASGOW COMA SCORE
FAST exam
Initial Medical Care
Vascular Access / Cardiac Monitoring
Monitor blood pressure closely
Be alert for subtle mental status changes
Rapid transport and notification of receiving facility
Applying SOP’s to Altered Mental Status
• Adult IMC (SOP p. 4-5)
– Initial baseline assessment of
patient and care of life-threatening
emergencies.
– Begin more in-depth assessment
of patient to identify causes of
emergency / mental status
changes.
• i.e. MI / Hypoxia / Hypoglycemia
Applying SOP’s to Altered Mental Status
• Adult Suspected Cardiac Patient with
Chest Pain (SOP p. 12)
– BLS
• Adult IMC (SOP p. 4-5)
• Rapid transport
– ALS
• Chest pain mental status change
causes
– Bradydysrhythmia (SOP p. 15)
– Cardiogenic shock (SOP p. 23)
Applying SOP’s to Altered Mental Status
• Adult Bradydysrhythmia (SOP p. 15)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Decreased perfusion (CO = SV x HR)
• Treatment: Supraventricular bradycardia/ 2nd degree
Type 1 blocks
• Atropine until pacing available
• Corrective goal = Increased HR
• Transcutaneous pacing
• Corrective goal = Increased HR
Applying SOP’s to Altered Mental Status
• Adult Bradydysrhythmia cont. (SOP p. 15)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Decreased perfusion (CO = SV x HR)
• Treatment: 2nd degree Type 2 / 3rd degree blocks
• Transcutaneous pacing
• Corrective goal = Increased HR
• Transcutaneous pacing
• Corrective goal = Increased HR
Applying SOP’s to Altered Mental Status
• Adult Supraventricular Tachycardia (SOP
p. 16)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Decreased preload in the heart (not enough
filling time)
• Treatment: HR > 150 BPM
• Synchronized cardioversion(s)
• Corrective goal = Allow the heart to restart
at a normal intrinsic rate (60-100 BPM), thus
increased the preload timing of the heart.
Applying SOP’s to Altered Mental Status
• Adult Ventricular Tachycardia with a pulse
(SOP p. 17)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Decreased preload in the heart (not enough filling time)
• Treatment: HR > 150 BPM wide complex
• Synchronized cardioversion(s)
• Corrective goal = Allow the heart to restart at a
normal intrinsic rate (60-100 BPM), thus increased
the preload timing of the heart.
• Amiodarone 150mg / 10 minutes IV/IO
• Corrective goal = Increasing preload / ventricular
filling time by increasing the cardiac refractory
period.
Applying SOP’s to Altered Mental Status
• Adult Ventricular Tachycardia without a pulse /
Ventricular Fibrillation (SOP p. 19)
– Unstable: Altered Mental Status / Cardiac Arrest
• Causes of altered mental status
– Cardiac arrest / no heartbeat
• Treatment
• Defibrillation / CPR
• Corrective goal = Restart the heart / increase
cerebral perfusion.
• Amiodarone 300 mg IV/IO
• Corrective goal = Increasing preload / ventricular
filling time by increasing the cardiac refractory
period.
Applying SOP’s to Altered Mental Status
• Adult Asystole / PEA (SOP p. 21)
– Unstable: Altered Mental Status / Cardiac Arrest
• Causes of altered mental status
– Cardiac arrest / no heartbeat
• Treatment
• CPR
• Corrective goal = Restart the heart / increase
cerebral perfusion.
• Epinephrine 1mg 1:10000 IV/IO
• Corrective goal = Stimulates alpha and beta
receptors, can also increase coronary and cerebral
perfusion pressures during CPR.
Applying SOP’s to Altered Mental Status
• Adult Pulmonary Edema (due to heart failure)
(SOP p. 22)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Hypoxia
• Treatment
• High FiO2 or ventilation
• Corrective goal = increasing adequate ventilation
and positive end expiratory pressures
• Depending on HR
• Bradydysrhythmia SOP (HR < 60 BMP)
• Cardiogenic Shock SOP (HR > 60 BPM)
Applying SOP’s to Altered Mental Status
• Adult Cardiogenic Shock (SOP p. 23)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Hypoxia / Decreased cardiac output
• Treatment
• IV Fluid bolus, 200 ml increments
• Corrective goal = Increase cardiac output by
increasing preload
• Dopamine infusion
• Corrective goal = Increase HR (chronotropic
effect), thus increase CO ( CO= SV x HR)
• Corrective goal = Increase CO (intopropic effect)
by increasing cardiac contractility
Applying SOP’s to Altered Mental Status
• Adult Airway Obstruction (SOP p. 24)
– Stable / Unstable with Altered Mental Status
• Causes of altered mental status
– Hypoxia / hypercarbia
• Treatment
• Clear airway / bypass obstruction
• Corrective goal = Increase ventilation and removal
of hypercarbic gases
Applying SOP’s to Altered Mental Status
• Adult Asthma / COPD (SOP p. 27)
– Stable / Unstable with Altered Mental Status
• Causes of altered mental status
– Hypoxia / hypercarbia
• Treatment
• Albuterol 2.5 mg / 3ml
• Corrective goal = Increase pulmonary structures to
allow better gas exchange
• CPAP / NIPPV
• Corrective goal = Decrease work of breathing, aid
ventilation, increase positive end expiratory
pressures (PEEP)
• Epinephrine 1:1000 0.3 mg IM
• Corrective goal = Increase bronchodilation
Applying SOP’s to Altered Mental Status
• Adult Partial Upper Airway Obstruction /
Epiglottitis (SOP p. 28)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Hypoxia / hypercarbia
• Treatment
• Epinephrine 1:1000 3 mg (3ml) via nebulizer
• Corrective goal = Increase bronchodilation by
relaxing smooth muscles.
• Non-breathing
• High FiO2 ventilation
• Corrective goal = Increase ventilations, increase
oxygenation and gas exchange
Applying SOP’s to Altered Mental Status
• Adult Allergic Reaction / Anaphylaxis (SOP p.
29)
– Stable / Unstable with Altered Mental Status
• Causes of altered mental status
– Hypoxia / hypercarbia / Vasodilation
• Treatment
• IV Fluid Bolus
• Corrective goal = Increase BP / CO
• Epinephrine 1:10000 IV/IO 0.1 mg IV/IO up to 0.5 mg
total q 3 minutes based on Pt. condition
• Corrective goal = Vasodilation / Bronchodilation
• Epinephrine 1:1000 0.3 mg IM
• Corrective goal = Increase bronchodilation
Applying SOP’s to Altered Mental Status
• Adult Allergic Reaction / Anaphylaxis cont.
(SOP p. 29)
• Treatment
• Benadryl 50 mg IV / IO (IM if no IV/IO)
• Corrective goal = Blocking histamine-1 uptake at
the receptor sites
• Albuterol 2.5 mg / 3 ml via nebulizer
• Corrective goal = Bronchodilation
• Dopamine
• Corrective goal = Increase HR (chronotropic
effect), thus increase CO ( CO= SV x HR)
• Corrective goal = Increase CO (inotropic effect) by
increasing cardiac contractility
• Corrective goal = Increase vasoconstriction
Applying SOP’s to Altered Mental Status
• Adult Diabetic / Glucose (SOP p. 30)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Hypo / Hyperglycemia
• Treatment
• Hypoglycemia
• Dextrose 50% 25 g IV or Glucagon 1 mg IM no IV
• Corrective goal = Increase blood glucose
levels to facilitate metabolic energy production
• Hyperglycemia
• IV fluid bolus(es)
• Dilute blood glucose levels
Applying SOP’s to Altered Mental Status
• Adult Syncope / Near Syncope (SOP p. 31)
– Unstable: Altered Mental Status
• Causes of altered mental status
– H’s and T’s / AEIOU-TIPS
– Opioids
• Treatment
• Narcan
• BLS 2 mg IN / ALS 1 mg IV/IN repeated at 0.5 mg
q 2 minutes up to 2 mg total
• Corrective goal = Increase ventilatory rates
without causing withdrawal
Applying SOP’s to Altered Mental Status
• Adult Seizure / Status Epilepticus (SOP p. 32)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Seizure activity causing inadequate respirations / non
coordinated neurological activities
• Treatment
• If actively seizing
• Versed 2 mg slow IV/IO q 2 minutes up to 10 mg
as needed. No IV, < 70 lbs 5 mg IM, > 70 lbs 10
mg IM.
• Corrective goal = Stop the seizure by acting as
a CNS depressant with anticonvulsant effects.
Applying SOP’s to Altered Mental Status
• Adult Stroke (SOP p. 33)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Ischemic stoke causing cerebral hypoxia
– Hemorrhagic stroke causing compression or changes
in blood flow
• Treatment
• Maintain head in neutral alignment
• Corrective goal = Facilitate blood flow for ischemic
strokes (increase cerebral perfusion pressures).
Hemorrhagic stoke, increase bilateral venous
drainage
• Elevate head of bed 15-30 degrees
• prevent excessive drainage / flow
Applying SOP’s to Altered Mental Status
• Adult Stroke cont. (SOP p. 33)
• Treatment
• Obtain last know normal
• Corrective goal = Allow receiving facility to better
prepare if the patient is eligible for intervention
• Elevate head of bed 15-30 degrees
• Corrective goal = Prevent excessive drainage /
flow
• Intubation (GCS < 8)
• Corrective goal = Protect the patient against
aspiration and ensure adequate ventilation and
gas exchange
Applying SOP’s to Altered Mental Status
• Adult Acute Abdominal Pain (SOP p. 34)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Decreases in adequate circulation preventing
oxygenation
• Treatment
• Large bore IV – IV Fluid Bolus(es) of 200 ml
• Corrective goal = Increase volume to ensure
proper global circulation of hemoglobin to help
perfuse vital organs.
Applying SOP’s to Altered Mental Status
• Adult Toxicological (SOP p. 35)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Substances causing decreased mentation
– Inadequate cardiac activities decreasing circulation
• Treatment / Opioids
• Narcan
• BLS 2 mg IN / ALS 1 mg IV/IN repeated at 0.5 mg
q 2 minutes up to 2 mg total
• Corrective goal = Increase ventilatory rates
without causes withdrawal
Applying SOP’s to Altered Mental Status
• Adult Toxicological cont. (SOP p. 35)
• Treatment: Cyclic antidepressants / Sodium channel
blocker overdose
• Normal Saline 1 L IV Bolus
• Corrective goal = Increase circulating volume to
increase blood pressures
• Corrective goal = Slowing the uptake of
antidepressants are the receptor sites.
• Treatment: Beta-Blocker / Calcium channel blockers
• Glucagon 1 mg slow IV
• Corrective goal = Positive inotropic (increase
contractility) and chronotropic (increase rate)
effects
Applying SOP’s to Altered Mental Status
• Adult Toxicological cont. (SOP p. 36)
• Treatment: Cyanide Poisoning
• Consider NIPPV / CPAP / Advanced Airway
• Corrective goal = Increase intrathoracic pressures
and aid in ventilation / respiration
• Hydroxocobalamin 5 g over 15 minutes IV (if available)
• Corrective goal = Rapid resolution of cyanideinduced lactic acidemia.
Applying SOP’s to Altered Mental Status
• Adult Chronic Renal Failure (SOP p. 43)
– Unstable: Altered Mental Status
• Causes of altered mental status
– Electrolyte imbalances / changes in cardiac output
– Acidosis impeding the hemoglobin's ability to bind with
oxygen
• Treatment
• Sodium Bicarbonate 1 mEq/kg IV/IO
• Corrective goal = Buffer acidosis and raises
serum pH (hyperkalemia causes acidosis)
Glucagon
MEDICATION OF THE MONTH
Medication Of The Month
• Glucagon (GlucaGen)
– Classification
• Hormone, anti-hypoglycemic agent
– Indications
• Hypoglycemia patients without venous access
• Beta or calcium channel blocker overdose with symptomatic bradycardias
including AV blocks (dosage required usually exceeds that available in
pre-hospital setting)
– Actions
• Causes a breakdown of stored glycogen into glucose
• Independent of beta blockage, positive inotropic and chronotropic and
improved AV conduction.
Medication Of The Month
• Glucagon (GlucaGen)
– Diabetic / Glucose Emergencies
• Adult
– 1 mg IM
• Pediatric
– > 8 years: 1 mg IM
– < 8 years: 0.5 mg IM
– Beta / Calcium Channel Blocker Overdose
• Adult
– 1 mg slow IV/IO, may repeat x 1
• Pediatric
– 0.5 mg IV/IO, may repeat x 1
Medication Of The Month
• Glucagon (GlucaGen)
– Contraindications
•
Hypersensitivity to glucagon or proteins
– Side Effects
•
•
•
•
Nausea
Vomiting
Dizziness
Headache
CARDIAC RHYTHM OF THE MONTH
Dysrhythmias
• Hyperkalemic ECG changes
– As serum potassium rises (may be seen in chronic renal failure
patients) the hearts ability to correctly depolarize becomes
impaired. If uncorrected, cardiac arrest may occur as
potassium levels continue to rise.
CAPNO WAVEFORM OF THE MONTH
Capno Waveform
• ETCO2 monitoring
–
–
–
–
A-B = no air movement / respiratory baseline
B-C = expiratory upslope -> “dead space” air, followed by distal bronchi
C-D = expiratory plateau -> alveolar gases being measured
D-E = inspiratory downstroke -> inhalation begins
Capno Waveform
• ETCO2 monitoring
– Reverse “shark-fin”
• Can only be seen on non-intubated patients
– Expiration is less impaired than inspiration
• Inspiratory downstoke is delayed secondary to underlying condition
Capno Waveform
• ETCO2 monitoring
– Causes
• Epiglottis
• Stridor secondary to:
– Anaphylaxis
– Allergic Reaction
– Upper airway inhalation injuries
Scenario
• You are dispatched for a 48 year old male, reported to be
unresponsive. You have no history at this address. PD is with the
patient and the scene is secure. You have your partner and an
engine company (1 Paramedic, 2 EMT-B’s) with you.
• When you arrive the patient is noted to be laying on the floor.
–
–
–
–
A - snoring respirations.
B - Irregular respirations.
C - Pt. has a bounding pulse, no obvious hemorrhage
D - Eyes open to pain, Verbal incomprehensible sounds, M withdraws
Scenario
• Wife states that the Pt. was “acting weird” then collapsed
– No medications
– No allergies
– No history
• Head to toe
– No obvious S/S of trauma. Cap refill 3 seconds. Global inspection unremarkable with
the exception of the head with:
• Pupils pinpoint. All other findings WNL
– When asked about drug use wife states she has never known the Pt. to use drugs
•
V/S obtained
–
–
–
–
–
–
–
–
Resp:
B/P:
HR:
Skin:
Pupils:
Lungs:
Dexi:
ETCO2:
26 Irregular
204/120
58
WNL X 3
Pinpoint at 2mm bilaterally, minimally reactive
Clear
102
32 mmHg
Scenario
• What is your initial course of action for this patient after Adult IMC (Sop. 4)?
Ventilations
Narcan
CPR
Stroke Care
Rapid Transport
Intubation
Refusal
Dextrose
Ventilations
• You assist the patient with a BMV utilizing the C and E clamp method
– Respiratory depth and quality improves
– Practice ventilating a mannequin with the C-E clamp technique
Narcan
• You consider the use of Narcan with the decrease mental status and pinpoint
pupils, however, your index of suspicion of drug use is low.
– Should you administer Narcan, what is your dose and route
– Practice administering Narcan with a MAD device
CPR
• Since the patient has a pulse and blood pressure, CPR is not indicated for
this patient.
https://vimeo.com/172042262
– Remember, 100 compressions / minute is the goal
Stroke Care
• This patient exhibits S/S of a possible stroke, including crushing's triad.
What are the BLS and ALS interventions for this patient?
–
–
–
–
HOB elevation
Neutral alignment of neck
Obtaining last know well
Airway protection (decrease GCS)
• What medications for DAI?
• What is your targeted ETCO2 levels?
Intubation
• Adult IMC (SOP pg 4)
• High FIO2 ventilation assist
– CE Clamp
• Benzocaine spray (0.5-1 second spray x 2)
• CDH / Edward
– Ketamine
• 1mg/kg slow IV/IO
• Loyola / Good Sam
– Etomidate
• 0.6 mg/kg IV/IO push over 30-60 seconds, max dose 40 mg
•
•
•
Confirm ETT placement, secure
Apply ETCO2 monitoring, ventilate to ETCO2 of 35-45 (30-35
with S/S of herniation.
Post intubation sedation
Rapid Transport
• Adult IMC (SOP pg 4)
• Ensure that your basic life threats are addressed
prior to transporting.
–
Ensure your ABCD’s are sustainable to life
•
•
•
•
A – Airway – Assist Ventilations
B – Breathing – Ensure adequate rate and quality
C – Circulation - Pulse is present
D – Disability – Establish a baseline mental status
• Document last know well
• Ensure the right patient is going to the right
facility
Refusal
• Based on the initial assessment, this patient is
not able to obtain a refusal.
Dextrose
• Based on the patient having no history of
diabetes and a blood sugar of 102, dextrose is
not indicated for this patient.