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Copyright © 2004, Mosby Inc. All rights reserved. Chapter 19 Altered Mental Status Slide 1 Copyright © 2004, Mosby Inc. All rights reserved. Case History The police are requesting your response for a semiconscious patient in the subway. On arrival, the police tell you that they found this 40-year-old male stumbling around the platform about 15 minutes ago. The patient is now lying down on the ground. While doing your initial assessment, you find a medical alert tag that says “Diabetic.” Slide 2 Copyright © 2004, Mosby Inc. All rights reserved. Central and Peripheral Nervous System Slide 3 Copyright © 2004, Mosby Inc. All rights reserved. Brain Slide 4 Copyright © 2004, Mosby Inc. All rights reserved. Blood Supply to the Brain Slide 5 Copyright © 2004, Mosby Inc. All rights reserved. Altered Mental Status • Structural problems Injury or damage to an area of the brain OR • Metabolic problems Affect the entire brain Slide 6 Copyright © 2004, Mosby Inc. All rights reserved. Structural • • • Stroke Head injury Characterized by “one-sided” signs Paralysis Facial droop Weakness on one side of the body Unequal pupils Slide 7 Copyright © 2004, Mosby Inc. All rights reserved. Metabolic • External • Poisoning Overdose Hypo- or hyperthermia Infections Internal Diabetes Hypoxia Hypotension Organ failure • Affects both sides of the brain equally • Primarily recognized on the basis of altered mental status and history Slide 8 Copyright © 2004, Mosby Inc. All rights reserved. Causes of Altered Mental Status • • • • • • Hypoglycemia, diabetic ketoacidosis Poisoning After seizure Infection Head trauma Decreased oxygen levels (hypoxia) Slide 9 Copyright © 2004, Mosby Inc. All rights reserved. Diabetes • • • Disease of the pancreas Caused by a partial or total lack of insulin production Symptoms of diabetes Increased urination Increased thirst Increased hunger Slide 10 Copyright © 2004, Mosby Inc. All rights reserved. Diabetes – Insulin • Insulin “escorts” glucose into cells. • Glucose provides fuel for basic energy needs. Excess glucose is stored as fat. Brain depends almost exclusively on glucose. » When glucose level is low, brain function is altered. o Unconsciousness, seizures, brain cell death Slide 11 Copyright © 2004, Mosby Inc. All rights reserved. Diabetes • Two major diabetic emergencies Hypoglycemia » Abnormally low blood glucose level Diabetic ketoacidosis » Blood glucose level too high and insulin level too low Slide 12 Copyright © 2004, Mosby Inc. All rights reserved. Hypoglycemia – Signs and Symptoms • Alteration of mental status (rapid onset) » Anxiety, confusion, intoxicated behavior, combativeness, bizarre behavior, or coma • • • • • Hunger Rapid pulse Pale, cool, and clammy skin Dilated pupils Seizures Slide 13 Copyright © 2004, Mosby Inc. All rights reserved. Hypoglycemia – Signs and Symptoms • Took prescribed insulin After missing a meal Vomiting after a meal After unusual exercise or physical work • Insulin in refrigerator • Medications found at scene Diabinese™ Orinase™ Micronase™ Slide 14 Copyright © 2004, Mosby Inc. All rights reserved. Hypoglycemia Signs and Symptoms • Can also occur in patients who do not have diabetes Infants with poor glycogen supplies Malnourished individuals » Alcoholics Slide 15 Copyright © 2004, Mosby Inc. All rights reserved. Diabetic Ketoacidosis • Blood glucose level is too high and insulin level is too low. When insulin level is low, body burns fat for fuel. » Acetone breath from fatty acids Excess glucose spills into urine, pulling water with it. » Increased urination, dehydration, hunger, thirst Slide 16 Copyright © 2004, Mosby Inc. All rights reserved. Diabetic Ketoacidosis • Increased acidity in blood Body tries to compensate by breathing deeply and rapidly. • Slow onset Slide 17 Copyright © 2004, Mosby Inc. All rights reserved. Emergency Medical Care History of Diabetes • Initial assessment • Focused history and physical exam • Vital signs • SAMPLE history Slide 18 Copyright © 2004, Mosby Inc. All rights reserved. Focused History and Physical Examination • • • • • • • • Description of episode Onset Duration Associated symptoms Evidence of trauma Interruptions Seizures Fever Slide 19 Copyright © 2004, Mosby Inc. All rights reserved. Vital Signs and SAMPLE History • History of diabetes Medical identification tags, etc. • • • • Last meal Last medication dose Related illness Determine if patient can swallow. Slide 20 Copyright © 2004, Mosby Inc. All rights reserved. Management – Diabetic Emergencies • Ensure patent airway. • Supplemental oxygen; consider positivepressure ventilation • Consider oral glucose administration. Per local protocol • Reassess patient en route to hospital. Slide 21 Copyright © 2004, Mosby Inc. All rights reserved. Glucose Administration • Administer if patient has altered mental status when hypoglycemia is suspected. Will save hypoglycemic patient from brain cell death Will not harm patient in diabetic ketoacidosis • Never administer oral glucose to patients who are unconsciousness or have no gag reflex. Slide 22 Copyright © 2004, Mosby Inc. All rights reserved. Side Effects and Reassessment • Side effects No side effects when given properly Glucose gel may be aspirated by the patient without a gag reflex. • Reassessment strategies If patient loses consciousness or has a seizure Slide 23 Copyright © 2004, Mosby Inc. All rights reserved. Seizures • • May be brief or prolonged Causes Fever Infections Poisoning Hypoglycemia Trauma Drug or alcohol withdrawal Hypoxia Idiopathic Slide 24 Copyright © 2004, Mosby Inc. All rights reserved. Seizures – Infants and Children • Chronic seizures in children are rarely life threatening. • Febrile seizures should be considered life-threatening. Slide 25 Copyright © 2004, Mosby Inc. All rights reserved. Types of Seizures • Grand mal • Focal • Status epilepticus • Febrile • Petit mal Slide 26 Copyright © 2004, Mosby Inc. All rights reserved. Grand Mal Seizures • Three phases Tonic Clonic Postictal Slide 27 Copyright © 2004, Mosby Inc. All rights reserved. Grand Mal Seizures – Tonic Phase • All voluntary muscles in sustained contraction Body and extremities are usually extended. • Lasts for up to 30 seconds • All respiratory muscles in contraction Ventilation can be compromised. Slide 28 Copyright © 2004, Mosby Inc. All rights reserved. Grand Mal Seizures – Clonic Phase • Skeletal muscles intermittently contract and relax. Rapid, jerking movements • • • Patient may be injured by striking surrounding objects. Clonic phase lasts a few seconds to a few minutes. Spasms may interfere with respirations. Patient may become cyanotic. • • Spasms may be followed by short periods of flaccid paralysis. Patient may urinate or bite tongue. Slide 29 Copyright © 2004, Mosby Inc. All rights reserved. Grand Mal Seizures – Postictal Phase • Decreased LOC and confusion • Slow awakening Patient may fall asleep for short period. • Afterward, may complain of headache Slide 30 Copyright © 2004, Mosby Inc. All rights reserved. Focal Seizures • May affect only a portion of the body OR • May present as altered mental status with bizarre behavior Slide 31 Copyright © 2004, Mosby Inc. All rights reserved. Status Epilepticus • Rapid succession of seizures without an intervening period of consciousness • Prolonged seizure • Life-threatening because of sustained respiratory compromise Slide 32 Copyright © 2004, Mosby Inc. All rights reserved. Febrile Seizures • Caused by fever • Children – 6 months to 6 years of age • Occur in up to 5% of children Slide 33 Copyright © 2004, Mosby Inc. All rights reserved. Petit Mal Seizures • Brief lapse of attention and awareness Staring Fluttering eyelids Eyes turned upward • Last from 10 to 20 seconds • More common in children Slide 34 Copyright © 2004, Mosby Inc. All rights reserved. Seizures – Emergency Medical Care • • • • • • Protect patient from harm. Position patient on side, if no possibility of cervical spine trauma. Ensure patent airway; suction as needed; administer high-concentration oxygen. Transport immediately. Obtain vital signs en route. Rule out trauma. Slide 35 Copyright © 2004, Mosby Inc. All rights reserved. Stroke • Permanent neurologic impairment caused by a disruption in blood supply to a region of the brain • Two causes Related to arteriosclerosis » Ischemic Weakened artery in brain ruptures » Hemorrhagic Slide 36 Copyright © 2004, Mosby Inc. All rights reserved. Stroke • Third leading cause of death in the U.S. 500,000 Americans are affected annually. » Nearly 25% die. Slide 37 Copyright © 2004, Mosby Inc. All rights reserved. Transient Ischemic Attack (TIA) • Symptoms are the same as for stroke. Lasts few minutes to a few hours » Resolves within 24 hours • Approximately 25% of patients presenting with stroke had a TIA. • Approximately 5% of patients with TIA will have stroke within 1 month, if untreated. Slide 38 Copyright © 2004, Mosby Inc. All rights reserved. Acute Stroke • Ischemic Approximately 75% of strokes May be eligible for treatment if in ED within 3 hours of onset • Hemorrhagic Can be fatal at onset Slide 39 Copyright © 2004, Mosby Inc. All rights reserved. Stroke – Initial Assessment • Ensure patent airway. • Support ventilations, as necessary. Slide 40 Copyright © 2004, Mosby Inc. All rights reserved. Stroke – Signs and Symptoms • Altered level of consciousness » Confusion, stupor, delirium, coma, seizures • Severe headache » “Worst headache of my life” • • • • • • • Aphasia Facial weakness or asymmetry Incoordination, weakness, paralysis, sensory loss of one or more limbs Ataxia Visual loss Dysarthria Intense vertigo, diplopia Slide 41 Copyright © 2004, Mosby Inc. All rights reserved. Stroke – Focused History and Physical Exam • Focused history Chief complaint Time of onset, if known » Accurate time of onset is crucial » If onset unknown, ask what time patient was last seen or went to bed. Gather SAMPLE history. Slide 42 Copyright © 2004, Mosby Inc. All rights reserved. Stroke – Focused History and Physical Exam • Physical examination If stroke is suspected, examine rapidly. » Cincinnati Prehospital Stroke Scale » Los Angeles Prehospital Stroke Screen » Glasgow Coma Scale Consider transport to appropriate facility without delay. » Notify receiving facility. » Monitor vital signs en route. Slide 43 Copyright © 2004, Mosby Inc. All rights reserved. Stroke – Cincinnati Prehospital Stroke Scale Slide 44 Copyright © 2004, Mosby Inc. All rights reserved. Stroke – Los Angeles Prehospital Stroke Screen Slide 45 Copyright © 2004, Mosby Inc. All rights reserved. Glasgow Coma Scale Slide 46 Copyright © 2004, Mosby Inc. All rights reserved. Altered Mental Status – Emergency Medical Care • Initial assessment Ensure patent airway. » Consider potential for head trauma; provide spinal immobilization. Consider hypoxia » Provide appropriate ventilatory support. Consider hypoglycemia. » Administer oral glucose, if appropriate. Slide 47 Copyright © 2004, Mosby Inc. All rights reserved. Altered Mental Status – Emergency Medical Care • Focused history Patient’s last normal level of function Associated complaints Chronology of events History of similar past experiences SAMPLE history Slide 48 Copyright © 2004, Mosby Inc. All rights reserved. Altered Mental Status – Emergency Medical Care • Physical examination Vital signs Abnormal smells Pupillary status Motor and sensory function » Asymmetry Check for medical alert tag. Slide 49 Copyright © 2004, Mosby Inc. All rights reserved.