Download Altered Mental Status - INHS Health Training

Objectives
Altered Mental Status
Tamara Drapeau
Paramedic
• Organic Brain Disease
– Delirium
– Dementia
• Diabetes
– Hypoglycemia
• Overdose
– Narcotics
Epidemiology
Pathophysiology
• AMS, or disorders of consciousness, can be
divided into processes that affect
• Arousal
Organic Brain Disease
Delirium accounts for about 10%–15% of
hospital admissions.
• Level of consciousness
• Cognitive functions
• Mental status
Approximately 60% of nursing-home beds
are occupied by patients with dementia.
• Combination of both
• Often termed “organic brain syndrome
(OBS)”
3
Pathophysiology
• Two major subgroups of OBS
– Delirium
– Dementia
• Delirium and dementia are quite distinct from
one another.
5
4
Pathophysiology
• Delirium
– Acute onset
– Decreased level of consciousness,
confusion, cognitive impairment
– Course of confusion fluctuates
– Reversible
– Irregular sleep-wake patterns
6
1
Pathophysiology
• Delirium always has an organic cause.
– Drug withdrawal
– Systemic diseases affecting the central
nervous system
• Diabetes, hypertension
– Primary intracranial disease
• Cerebrovascular accident (CVA), brain
tumor, or abscess
Pathophysiology
• Dementia
– Gradual, insidious onset
– Normal level of consciousness, loss of
mental capacity
– Progressive decline
– Usually irreversible
– Regular sleep-wake patterns
7
8
Pathophysiology
• Alzheimer’s is the most common cause of
dementia in U.S.
• Dementia is associated with difficulties in
social relationships and normal everyday
activities.
Assessment
• History
– Determine characteristics of impairment
• Rapid onset or chronic?
– Similar episodes in past?
– Illicit drug or alcohol use?
– Medication overdose a possibility?
– Prior psychiatric illness?
9
10
Assessment
Treatment
• AEIOU-TIPS for AMS
– A = alcohol, other drugs, apnea, arrhythmia,
anaphylaxis
– E = endocrine, exocrine, electrolytes, epilepsy
– I = insulin (diabetes)
– O = oxygen (lack of), opioids, OD
– U = uremia, underdose
– T = trauma, temperature
– I = infection (systemic, central nervous system)
– P = psychiatric, poisoning
– S = space-occupying lesions, shock, subarachnoid
hemorrhage, stroke
11
• All patients with
AMS should receive
supplemental, highflow oxygen.
• Additional
treatments depend
on the etiology of
AMS.
12
2
Epidemiology
• Diabetic Emergencies
• In 2011 approximately 25.8 million people
(8.3% of population) in U.S. have diabetes.
– 18.8 million diagnosed
– 7.0 million undiagnosed
– Type 2 diabetes accounts for 90%–95% of
all cases of diabetes
13
Epidemiology
• About 73% of adults with diabetes have
hypertension.
• Diabetes is the leading cause of new
blindness in adults aged 20–74 years.
• Diabetes is the leading cause of kidney
failure.
• 60%–70% of diabetics have mild to severe
forms of nervous system damage.
15
Epidemiology
• About 25% of diabetics experience
hypoglycemia on a regular basis.
• Studies have shown that up to 50% of
patients presenting to ED with hypoglycemia
were
– Acutely intoxicated
– Chronic alcohol abusers
• Risk of death increases with prolonged
hypoglycemia.
17
Epidemiology
• In 2007, diabetes was listed as the
underlying cause on 71,382 death
certificates.
• Overall, among people of similar age, risk of
death for those with diabetes is about twice
that of those without diabetes.
• Heart disease and stroke account for 65% of
deaths in people with diabetes.
– Stroke risk is two to four times higher for
diabetics.
14
Epidemiology
• Up to 20% of patients with Diabetes using
insulin or oral hypoglycemics will experience
a hypoglycemic event requiring ED
evaluation and treatment.
• Of all patients in ED with AMS, about 7% are
found to have hypoglycemia.
16
A&P Review
• Requirements for proper insulin and glucose
activity
– Insulin must be produced and secreted in
adequate amounts by pancreatic beta
cells.
– There must be sufficient BG levels.
– Cell membranes must be nonresistant to
insulin binding for facilitation of glucose
into cell.
18
3
Pathophysiology
• No universally accepted definition of
hypoglycemia
• Generally accepted that hypoglycemia exists
if
– Signs and symptoms consistent with
hypoglycemia are present
– BG <50–60 mg/dL
– Signs and symptoms resolve following
glucose administration
Pathophysiology
• Hypoglycemia occurs when there is
– Too much insulin, or
– Too little dietary carbohydrate intake to
meet energy demands, or
– Combination of both
19
Clinical Assessment
• Signs and symptoms
– Central nervous system dysfunction
• AMS, decreased level of consciousness
• Focal neurologic deficits, seizures
– Anxiety, irritability, nervousness, tremors
– Nausea, vomiting
– Tachycardia, palpitations
– Cool, pale, diaphoretic skin
– Dilated pupils
20
Clinical Assessment
• History
– History of diabetes?
– Insulin or oral hypoglycemic use?
• Possibility of accidental or intentional
overdose?
– New medications?
– Recent illness?
– Increased activity or decreased food
intake/missed meals?
– Recent alcohol ingestion?
21
Clinical Assessment
• Remember, patients with hypoglycemia are
often poor historians due to their AMS.
– Use the following to gather a history:
•
•
•
•
•
Family
Friends
Witnesses
Records
Clues found on
scene
• Medical
identification tags
22
Treatment
•Ensure adequate airway and breathing.
– Open the airway and keep it open.
• BLS airway adjuncts
• Intubation, if airway uncontrollable BLS
– Provide BVM assist, if necessary.
23
24
4
Treatment
• Administer 100% oxygen
via delivery method
appropriate for patient
presentation.
• Glucose
Treatment
• Confirm elevation of BG to normal values
– Confirm that signs and symptoms resolve
with increased BG
• Ensure continued nutritional intake
– Simple sugar administered during
treatment will be used quickly; BG may fall
– Attempt to provide complex carbohydrates,
proteins, fats
– Oral glucose for patients
who are able to protect
their own airway
• Prepared oral glucose
• Orange juice or soda
with table sugar
25
26
Pathophysiology
• Overdose
• Opioid is a broad term encompassing a wide
range of compounds that bind to opioid
receptors and produce opioid effects.
Pathophysiology
• Opiate refers specifically to opioids derived
from the opium poppy.
– Morphine
– Codeine
– Natural opiates
• Morphine, codeine
– Semisynthetic opioids
• Heroin, Oxycodone, Hydrocodone, Hydromorphone
– Synthetic opioids
• Methadone, Fentanyl, Meperidine, Propoxyphene
27
28
Pathophysiology
• Narcotic has historically been used to describe
illicit drugs of abuse.
– All classes, not only opioids
– From Greek narcosis
– Refers to any drug that produces a somnolent
state
• All opioids produce dose-dependent respiratory
depression.
– Ventilation decreases.
• Death by opioid overdose is almost exclusively
the result of respiratory depression.
29
Clinical Assessment
• Signs and symptoms
– “Big three”
• Central nervous
system depression
• Respiratory depression
• Miosis
– Bradycardia,
hypotension
– Altered mental status
– Nausea/vomiting
– Decreased GI motility
– Urinary retention
30
5
Clinical Assessment
• History
Treatment
• Airway and breathing a priority
– Attempt to determine if patient has a history of
illicit drug use.
• Family members, friends
• Track marks on arms, burns to fingers/mouth
– Does patient have past medical history that
may require the use of opioid analgesics?
• Chronic back pain, end-stage cancer, and so
on
– Are there opioids in household?
• Family member with illicit drugs or medications
– Open the airway and keep it open.
– Ensure adequate ventilation with 100% oxygen.
• Nonrebreather, BVM, intubation
• BVM is a “bridging” treatment to the administration
of naloxone.
• Patient should be intubated if
– Airway uncontrollable with BLS maneuvers and
adjuncts
– Unresponsive to naloxone
– Correct insults to airway and breathing prior to the
administration of naloxone.
31
Treatment
• Closely monitor
patient for need
of
readministration
of Naloxone
• Decreasing level
of consciousness
• Increasing
respiratory
depression
32
Test Questions
1. The Glasgow Coma Scale assesses eye opening,
verbal response, and motor response. Which of the
following correlations of score and outcome are correct?
A. score of 3 or 4, 10 percent favorable outcome
B. score of 8 or higher, 94 percent favorable outcome
C. score of 5-7 that increases to 8 or higher, 80 percent
favorable outcome
D. score of 5-7, 50 percent favorable outcome in adults
and 90 percent in children
E. score of 5-7 that decreases by one point, 10 percent
favorable outcome3
33
2. The most important sign or symptom associated
with hypoglycemia is:
A. tachycardia
C. altered mentation
E. polyphagia
B. cool, clammy skin
D. polydipsia
4. Which of the following usually describes
Diabetes type II?
A. The blood glucose level is usually diet
controlled
B. No insulin is produced by the body
C. It is commonly acquired during the
childhood years
D. Insulin must be injected daily
3. Alcohol is a:
A. depressant
C. narcotic
E. opiate
34
B. stimulant
D. oxidant
35
36
6
5. Which of the following are the goals at the
scene of a drug or an alcohol emergency?
A. Identify and reverse effects of the abused
substance.
B. Identify and treat potential life threats.
C. Notify police of illegal drug use.
D. Identify abused substance and control
behavior of patient.
Questions?
Contact: Carolyn Stovall
509-242-4264
1-866-630-4033
[email protected]
Fax: 509-232-8344
37
38
Open House and EMS Appreciation
Special thanks to
We would like to invite you to come tour our new facility and
learn about the new MedStar EMS Application for your
Smartphone
Sheila Crow
Stitchin’ Dreams Embroidery
When: Wednesday, May 23
2 – 6 p.m.
[email protected]
For providing our Secret Question prize
39
Where: HTN Training Facility
1610 North Rebecca
Spokane, WA
40
7