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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