The Patient With An Altered Mental Status ECRN Mod IV 2009 CE Advocate Condell Medical Center...

The Patient With An Altered The Patient With An Altered Mental StatusMental Status

ECRN Mod IV 2009 CEECRN Mod IV 2009 CE

Advocate Condell Medical CenterAdvocate Condell Medical Center

Objectives by Jeremy Lockwood FFPM Mundelein Fire DepartmentPrepared by Sharon Hopkins, RN, BSN, EMT-P

ObjectivesObjectives Upon successful completion of this module, the ECRN Upon successful completion of this module, the ECRN

will be able to:will be able to:

1. Identify components evaluated in determining a 1. Identify components evaluated in determining a patient’s mental status and orientation.patient’s mental status and orientation.

2. Define altered mental status.2. Define altered mental status. 3. Identify the possible causes of altered mental 3. Identify the possible causes of altered mental

status. status. 4. Identify signs and symptoms of altered mental 4. Identify signs and symptoms of altered mental

status.status. 5. Identify elderly considerations related to altered 5. Identify elderly considerations related to altered

mental status.mental status.

Objectives cont’dObjectives cont’d 6. Identify assessment procedures related to 6. Identify assessment procedures related to

patients with altered mental status.patients with altered mental status. 7. Describe how to obtain an accurate Glasgow 7. Describe how to obtain an accurate Glasgow

Coma Scale assessment.Coma Scale assessment. 8. Describe the procedure to obtain a blood 8. Describe the procedure to obtain a blood

glucose determinant.glucose determinant. 9. Identify the components of the Cincinnati 9. Identify the components of the Cincinnati

Stroke Scale.Stroke Scale. 10. Identify Region X field treatment of patients 10. Identify Region X field treatment of patients

with altered mental status.with altered mental status.

Objectives cont’dObjectives cont’d

11. Describe methods of restraining the 11. Describe methods of restraining the combative patient.combative patient.

12. Identify the indications, 12. Identify the indications, contraindications, complications, and contraindications, complications, and documentation when using the QuickTrach documentation when using the QuickTrach airway device.airway device.

13. 13. Given a scenario obtain the GCS.Given a scenario obtain the GCS.

Normal MentationNormal Mentation

To identify abnormal mental status, need to To identify abnormal mental status, need to understand what is normalunderstand what is normal

We all practice a number of means and ways to We all practice a number of means and ways to identify the mental statusidentify the mental status General appearance General appearance Orientation to person, place, and timeOrientation to person, place, and time AVPUAVPU

AlertAlert Responds to verbal stimuliResponds to verbal stimuli Responds to painful stimuliResponds to painful stimuli UnresponsiveUnresponsive

General AppearanceGeneral Appearance Can gain important information looking at the Can gain important information looking at the

“big picture”“big picture” Observe hygieneObserve hygiene Observe clothingObserve clothing Observe overall appearanceObserve overall appearance Observe verbal and nonverbal behaviorObserve verbal and nonverbal behavior

Facial expressionsFacial expressions Tone of voice, volume, quality, speech patternTone of voice, volume, quality, speech pattern Eye contactEye contact

Memory intact for recent and long-term events?Memory intact for recent and long-term events? Is the patient focused; paying attention?Is the patient focused; paying attention?

Orientation to Person, Place, TimeOrientation to Person, Place, Time

Can be insulting to a patient to ask pointedly Can be insulting to a patient to ask pointedly “what’s your name?” “who’s the president?”“what’s your name?” “who’s the president?”

Often helpful to state:Often helpful to state: ““Since I don’t know your condition very well, I Since I don’t know your condition very well, I

need to ask some very basic questions.”need to ask some very basic questions.” Person – patient can state their namePerson – patient can state their name Place – patient can recognize they are at home, Place – patient can recognize they are at home,

in a store, in an ambulance, at a hospitalin a store, in an ambulance, at a hospital Time – patient can tell what year it is and time Time – patient can tell what year it is and time

of year (by month or season)of year (by month or season)

AVPUAVPU A – alert meaning the patient is awakeA – alert meaning the patient is awake

““A” is not meant to indicate orientation; just level of A” is not meant to indicate orientation; just level of awakenessawakeness

V – responding to verbal stimuli onlyV – responding to verbal stimuli only Any response including fluttering of eyelids is a positive Any response including fluttering of eyelids is a positive

response to calling the patient’s name or asking a commandresponse to calling the patient’s name or asking a command P – responding to “pain”P – responding to “pain”

Could also indicate responding to tactile stimuli so do not Could also indicate responding to tactile stimuli so do not always need to inflict a painful stimulialways need to inflict a painful stimuli

Any response including fluttering of eyelids or any body Any response including fluttering of eyelids or any body twitch is a positive response twitch is a positive response

U – unresponsiveU – unresponsive Patient is flaccid with no responses at allPatient is flaccid with no responses at all

Stimulating a Painful ResponseStimulating a Painful Response Acceptable methods Acceptable methods

Pressing on supraorbital ridge (bone below eyebrow) Pressing on supraorbital ridge (bone below eyebrow) Trapezium squeeze – twisting muscle where neck and Trapezium squeeze – twisting muscle where neck and

shoulder meetshoulder meet Rubbing sternum with knucklesRubbing sternum with knuckles Pressing on finger nail bedPressing on finger nail bed

Unacceptable methodsUnacceptable methods Any technique that would leave bruisingAny technique that would leave bruising

Discouraged methodsDiscouraged methods Any stimuli that may cause movement of the c-spine in Any stimuli that may cause movement of the c-spine in

a trauma patient by pulling away from the stimulia trauma patient by pulling away from the stimuli

Altered Mental StatusAltered Mental Status

Patient not awake, not alert or not orientedPatient not awake, not alert or not oriented Patient not aware of their environmentPatient not aware of their environment Patient not oriented to person, place, timePatient not oriented to person, place, time Patient confusedPatient confused Patient unable to demonstrate an understanding of Patient unable to demonstrate an understanding of

what is being saidwhat is being said

Most important is noting any change over the Most important is noting any change over the course of time in level of consciousnesscourse of time in level of consciousness

Level of ConsciousnessLevel of Consciousness

One of the One of the firstfirst indicators to change when the indicators to change when the level of perfusion is diminishing is level of level of perfusion is diminishing is level of consciousnessconsciousness

FYI – The blood pressure is one of the FYI – The blood pressure is one of the lastlast indicators to change when the level of indicators to change when the level of perfusion diminishes perfusion diminishes

Possible Cause of Altered Mental Possible Cause of Altered Mental StatusStatus

Many lists have been createdMany lists have been created Mnemonics have been created to trigger listsMnemonics have been created to trigger lists

AEIOU-TIPSAEIOU-TIPS SMASHEDSMASHED

EMS should think outside the box and look for EMS should think outside the box and look for all potential causesall potential causes When you find one cause, keep looking in case When you find one cause, keep looking in case

there are more than one cause associated with the there are more than one cause associated with the altered mental statusaltered mental status

Thinking Outside The BoxThinking Outside The Box

How many squares do you see?How many squares do you see?

Thinking Outside The BoxThinking Outside The Box

30 squares:30 squares:

1 large 4 x 4 square1 large 4 x 4 square 16 small 1 x 1 squares16 small 1 x 1 squares 4 – 3 x 3 squares in each corner4 – 3 x 3 squares in each corner 9 – 2 x 2 squares9 – 2 x 2 squares

Mnemonic - AEIOU-TIPSMnemonic - AEIOU-TIPS

A – alcoholA – alcohol E – endocrine, electrolytes, encephalopathyE – endocrine, electrolytes, encephalopathy I – insulinI – insulin O – opiatesO – opiates U – uremiaU – uremia T – trauma – head injury, blood loss (shock)T – trauma – head injury, blood loss (shock) I – intracranial, infectionI – intracranial, infection P – poisoning; psychiatricP – poisoning; psychiatric S – seizures; syncopeS – seizures; syncope

Mnemonic - SMASHEDMnemonic - SMASHED

S – substrates, sepsisS – substrates, sepsis Hyper/hypoglycemia, thiamineHyper/hypoglycemia, thiamine

M- meningitis, mental illness (ie: psychosis)M- meningitis, mental illness (ie: psychosis) A – alcohol (intoxication/withdrawal)A – alcohol (intoxication/withdrawal) S – seizure, stimulantsS – seizure, stimulants H- hyper/hypothyroidism, hyper/hypothermia, H- hyper/hypothyroidism, hyper/hypothermia,

hypotension, hypoxia, hypercarbiahypotension, hypoxia, hypercarbia E – electrolyte imbalance, encephalopathyE – electrolyte imbalance, encephalopathy D- drugs of any sortD- drugs of any sort

A - AlcoholA - Alcohol

Includes beer, wine, and spiritsIncludes beer, wine, and spirits Alcohol is a psychoactive drug with depressant Alcohol is a psychoactive drug with depressant

effectseffects Decreases attention and slows reaction speedDecreases attention and slows reaction speed Short term effects: intoxication, dehydration, alcohol Short term effects: intoxication, dehydration, alcohol

poisoningpoisoning Long term effects: changes to metabolism in the liver Long term effects: changes to metabolism in the liver

and brain; possible addictionand brain; possible addiction Binge drinkingBinge drinking

Men- 5 or more drinks in a rowMen- 5 or more drinks in a row Women – 4 or more drinks in a rowWomen – 4 or more drinks in a row

A- AlcoholA- Alcohol Evaluate Evaluate

Clarity of speechClarity of speech Ability to comprehend the conversationAbility to comprehend the conversation GaitGait

Not all persons drinking alcohol have altered mental Not all persons drinking alcohol have altered mental states states

EMS to contact Medical Control if the patient with EMS to contact Medical Control if the patient with alcohol “on board” wants to sign a releasealcohol “on board” wants to sign a release ECRN needs to involve MD in dialogue and ECRN needs to involve MD in dialogue and

decision makingdecision making

E - EndocrineE - Endocrine

Endocrine system is an informational system Endocrine system is an informational system much like the nervous systemmuch like the nervous system

Chemical messengers, hormones, travel Chemical messengers, hormones, travel mainly via blood vessels to trigger responsesmainly via blood vessels to trigger responses

Common conditions involving the endocrine Common conditions involving the endocrine systemsystem Diabetes mellitusDiabetes mellitus Thyroid diseaseThyroid disease ObesityObesity

E - ElectrolytesE - Electrolytes Electrically conductive mediumElectrically conductive medium

Principally: sodium, potassium, calcium, Principally: sodium, potassium, calcium, magnesium, chloridemagnesium, chloride

Activates muscles and neuronsActivates muscles and neurons Homeostasis of electrolytes regulated by hormonesHomeostasis of electrolytes regulated by hormones Generally kidneys flush out excess levels of Generally kidneys flush out excess levels of

electrolyteselectrolytes Electrolyte disturbance (ie: dehydration or Electrolyte disturbance (ie: dehydration or

overhydration) may lead to cardiac and neurological overhydration) may lead to cardiac and neurological complications (ie: medical emergencies)complications (ie: medical emergencies) Dehydration: exercise, diaphoresis, diarrhea, Dehydration: exercise, diaphoresis, diarrhea,

vomiting, intoxication, starvationvomiting, intoxication, starvation

E- EncephalopathyE- Encephalopathy A syndrome of brain dysfunctionA syndrome of brain dysfunction Brain function and/or structure is alteredBrain function and/or structure is altered CausesCauses

Brain infection, tumor, increased intracranial Brain infection, tumor, increased intracranial pressure, exposure to toxins, radiation, tumor, poor pressure, exposure to toxins, radiation, tumor, poor nutrition, hypoxia, decreased blood flow to the brainnutrition, hypoxia, decreased blood flow to the brain

Hallmark – altered mental statusHallmark – altered mental status Common signs and symptoms include loss of Common signs and symptoms include loss of

cognitive function and subtle personality cognitive function and subtle personality changeschanges More signs and symptoms listed in the notes sectionMore signs and symptoms listed in the notes section

I - InsulinI - Insulin Diabetes mellitusDiabetes mellitus

The brain is very dependant on a set glucose The brain is very dependant on a set glucose level to functionlevel to function

If the glucose level falls, the brain cannot If the glucose level falls, the brain cannot function normallyfunction normally

Rapid change in behavior, level of Rapid change in behavior, level of consciousness when the blood sugar level consciousness when the blood sugar level dropsdrops

All persons with altered level of consciousness All persons with altered level of consciousness need to have their blood sugar level checkedneed to have their blood sugar level checked

O - OpiatesO - Opiates

Used for pleasure and pain reliefUsed for pleasure and pain relief Depresses body functions and reactionsDepresses body functions and reactions Taken in pill form, smoked, injectedTaken in pill form, smoked, injected Single dose effect can last 3 – 6 hoursSingle dose effect can last 3 – 6 hours Detection time lasts usually up to 2 daysDetection time lasts usually up to 2 days High physical and psychological dependenceHigh physical and psychological dependence Develop physical symptoms, behavioral Develop physical symptoms, behavioral

symptoms, health effects, increased pain symptoms, health effects, increased pain tolerancetolerance

Examples of OpiatesExamples of Opiates

CodeineCodeine DarvocetDarvocet Demerol Demerol Dilaudid Dilaudid Fentanyl Fentanyl Heroin Heroin Hydrocodone Hydrocodone Lorcet Lorcet

Lortab Lortab MethadoneMethadone Morphine Morphine Percocet Percocet Percodan Percodan OxycodoneOxycodone Oxycontin Oxycontin Ultram Ultram VicodinVicodin

Signs and Symptoms - OpiatesSigns and Symptoms - Opiates

Constricted pupilsConstricted pupils SweatingSweating Nausea/vomiting/diarrheaNausea/vomiting/diarrhea Needle marksNeedle marks Loss of appetiteLoss of appetite Slurred speechSlurred speech Slowed reflexesSlowed reflexes Depressed breathingDepressed breathing

Depressed pulse rateDepressed pulse rate DrowsinessDrowsiness FatigueFatigue Mood swingsMood swings Impaired coordinationImpaired coordination DepressionDepression ApathyApathy StuporStupor EuphoriaEuphoria

U - UremiaU - Uremia

Urea and waste products not eliminated from Urea and waste products not eliminated from the bloodthe blood

Accompanies kidney failure/renal failureAccompanies kidney failure/renal failure Usually diagnosed when kidney function Usually diagnosed when kidney function

< 50% of normal< 50% of normal Early symptoms: anorexia and lethargyEarly symptoms: anorexia and lethargy Late symptoms: decreased mental acuity and Late symptoms: decreased mental acuity and

comacoma

Causes of Uremia (besides kidney Causes of Uremia (besides kidney failure)failure)

Increased production of urea in the liverIncreased production of urea in the liver High protein diet; GI bleed; drugs; increased High protein diet; GI bleed; drugs; increased

protein breakdown (surgery, infection, trauma, protein breakdown (surgery, infection, trauma, cancer)cancer)

Decreased elimination of ureaDecreased elimination of urea Decreased blood flow through the kidneys (ie: Decreased blood flow through the kidneys (ie:

hypotension); urinary outflow obstructionhypotension); urinary outflow obstruction DehydrationDehydration Chronic kidney infections (chronic Chronic kidney infections (chronic

pyelonephritis)pyelonephritis)

T - TraumaT - Trauma Head injuryHead injury

Epidural bleedEpidural bleed Rapid bleeding with unresponsiveness often Rapid bleeding with unresponsiveness often

following a lucid interval following a lucid interval Subdural bleed Subdural bleed

Slow bleeding with subtle changesSlow bleeding with subtle changes Intracerebral bleedIntracerebral bleed

Ruptured blood vessel releases blood into brain Ruptured blood vessel releases blood into brain tissue with resulting tissue edematissue with resulting tissue edema

Blood loss Blood loss shock shock

I - IntracranialI - Intracranial

TumorTumor Symptoms/neurological deficits often point to the Symptoms/neurological deficits often point to the

area of brain affectedarea of brain affected Right sided brain insult affects left sided body Right sided brain insult affects left sided body

functionfunction Left sided brain insult affects right sided body Left sided brain insult affects right sided body

functionfunction

Intracranial cont’dIntracranial cont’d

Head injuryHead injury Pupillary changes reflect same side of brain insultPupillary changes reflect same side of brain insult

Right pupillary change reflects right sided brain Right pupillary change reflects right sided brain insultinsult

Left pupillary change reflects left sided brain Left pupillary change reflects left sided brain insultinsult

Consider acute vs chronic conditionConsider acute vs chronic condition Chronic conditions:Chronic conditions:

Elderly with frequent fallsElderly with frequent falls Chronic alcoholism with frequent fallsChronic alcoholism with frequent falls

I - InfectionI - Infection MeningitisMeningitis

Bacterial is highly contagiousBacterial is highly contagious Mask the patient and all medical personnel caring for Mask the patient and all medical personnel caring for

patientpatient Urinary tract infection (UTI)Urinary tract infection (UTI)

Elderly often do not present with high feversElderly often do not present with high fevers SepsisSepsis

Newborns/very young infants will be very illNewborns/very young infants will be very ill EncephalitisEncephalitis Pneumonia – viral and bacterialPneumonia – viral and bacterial Liver abscessLiver abscess

P - PoisoningP - Poisoning

Drug overdoseDrug overdose IntentionalIntentional

Assume you are not getting the full storyAssume you are not getting the full story Mixing any meds with alcohol increases the risk Mixing any meds with alcohol increases the risk

of worsening conditionsof worsening conditions AccidentalAccidental

Assume young children will not be truthful (fear Assume young children will not be truthful (fear of being punished)of being punished)

EMS to bring in all containersEMS to bring in all containers

P - PsychiatricP - Psychiatric

SchizophreniaSchizophrenia Common mental health problemCommon mental health problem Hallmark – significant change in behavior and loss Hallmark – significant change in behavior and loss

of contact with realityof contact with reality Hallucinations, delusions, depressionHallucinations, delusions, depression

BipolarBipolar Not particularly common mental health problemNot particularly common mental health problem One or more manic episodes with or without One or more manic episodes with or without

subsequent or alternating periods of depressionsubsequent or alternating periods of depression

S - SeizureS - Seizure

EpilepsyEpilepsy Head injuryHead injury HypoglycemiaHypoglycemia Hypertensive crisisHypertensive crisis

Rapid increase in diastolic B/P >130mmHgRapid increase in diastolic B/P >130mmHg Hypertensive disorder of pregnancyHypertensive disorder of pregnancy

Formerly referred to as toxemiaFormerly referred to as toxemia

S- SyncopeS- Syncope

Brief loss of consciousness with spontaneous Brief loss of consciousness with spontaneous recoveryrecovery

““Fainting”Fainting” Typically a very short episode resolved when the Typically a very short episode resolved when the

patient lies flat (as in when they pass out)patient lies flat (as in when they pass out) Often warning signs &/or symptomsOften warning signs &/or symptoms

LightheadednessLightheadedness Vision changesVision changes DizzinessDizziness Sudden pallorSudden pallor NauseaNausea SweatingSweating WeaknessWeakness

Causes of SyncopeCauses of Syncope Hypovolemia – fluid &/or blood lossHypovolemia – fluid &/or blood loss Metabolic – alteration in brain chemistryMetabolic – alteration in brain chemistry

HypoglycemiaHypoglycemia Inner/ middle ear problemInner/ middle ear problem

EnvironmentalEnvironmental Room temperature, carbon monoxideRoom temperature, carbon monoxide

Screen patient with RAD 57 tool if carbon Screen patient with RAD 57 tool if carbon monoxide suspectedmonoxide suspected

Toxicological – excessive alcoholToxicological – excessive alcohol Cardiovascular - dysrhythmiasCardiovascular - dysrhythmias

Elderly ConsiderationsElderly Considerations

Contributing factors to confusionContributing factors to confusion StressStress Fear of removal from their homeFear of removal from their home Talking with strangers (ie: EMS, hospital staff)Talking with strangers (ie: EMS, hospital staff) Answering questions they do not know the Answering questions they do not know the

answers toanswers to

Elderly ConsiderationsElderly Considerations

Altered mental status possibly due to:Altered mental status possibly due to: Medical insult or traumatic head injuryMedical insult or traumatic head injury Heart rhythm disturbance; AMIHeart rhythm disturbance; AMI DementiaDementia InfectionInfection Related to prescription medicationsRelated to prescription medications Decreased blood volume – shockDecreased blood volume – shock Respiratory disorders and/or hypoxiaRespiratory disorders and/or hypoxia Hypo/hyperthermiaHypo/hyperthermia Decreased blood sugar levelDecreased blood sugar level

Distinguishing Dementia From Distinguishing Dementia From DeliriumDelirium

DementiaDementia Chronic, slow Chronic, slow

progressionprogression Irreversible disorderIrreversible disorder

Impaired memoryImpaired memory Global cognitive deficitsGlobal cognitive deficits Most commonly caused Most commonly caused

by Alzheimer’sby Alzheimer’s

Does not require Does not require immediate treatmentimmediate treatment

DeliriumDelirium Rapid in onset (hours to days), Rapid in onset (hours to days),

fluctuating coursefluctuating course May be reversed esp if treated May be reversed esp if treated

earlyearly Greatly impairs attentionGreatly impairs attention Focal cognitive deficitsFocal cognitive deficits Most commonly caused by Most commonly caused by

systemic disease, drug systemic disease, drug toxicity, or metabolic changestoxicity, or metabolic changes

Requires immediate treatmentRequires immediate treatment

DementiaDementia

Causes of this progressive disorientationCauses of this progressive disorientation Small strokesSmall strokes AtherosclerosisAtherosclerosis Age related neurological changesAge related neurological changes Neurological changesNeurological changes Certain hereditary diseases (ie: Huntington’s)Certain hereditary diseases (ie: Huntington’s) Alzheimer’s diseaseAlzheimer’s disease

DeliriumDelirium

Disorganized thinking with reduced ability to Disorganized thinking with reduced ability to maintain attention and to shift attentionmaintain attention and to shift attention

Synonyms:Synonyms: Acute confusional stateAcute confusional state Acute cognitive impairmentAcute cognitive impairment Acute encephalopathyAcute encephalopathy Acute altered mental statusAcute altered mental status

Patient AssessmentPatient Assessment

ABC’sABC’s Is ventilation/breathing adequate?Is ventilation/breathing adequate? Does supplemental oxygen need to be given?Does supplemental oxygen need to be given?

Room air contains 21 % ORoom air contains 21 % O22

Nasal cannula delivers 24% - 44% ONasal cannula delivers 24% - 44% O2 2 (2 – 6 (2 – 6 L/min)L/min)

Non-rebreather can deliver up to 100% ONon-rebreather can deliver up to 100% O2 2 (12-15 (12-15 L/min)L/min)

Does the C-spine need to be controlled?Does the C-spine need to be controlled? Can the patient protect their own airway?Can the patient protect their own airway?


Adequacy of circulationAdequacy of circulation What is the blood pressure?What is the blood pressure? Does the blood pressure equate with the patient Does the blood pressure equate with the patient

assessment?assessment? Is there a peripheral pulse?Is there a peripheral pulse? What is the peripheral pulse rate and quality?What is the peripheral pulse rate and quality?

Do you need to gain IV access?Do you need to gain IV access? Is IV access necessary?Is IV access necessary? Is IV access needed as a precaution?Is IV access needed as a precaution?


Cardiac monitorCardiac monitor Is there a dysrhythmia present?Is there a dysrhythmia present?

What is the blood sugar level?What is the blood sugar level? Does the patient require isolation for potential Does the patient require isolation for potential

infectious disease?infectious disease? HistoryHistory

From the patient, caregiver, bystanderFrom the patient, caregiver, bystander History of present illnessHistory of present illness Pertinent past medical historyPertinent past medical history


AllergiesAllergies Current medicationsCurrent medications Use of drugs or other substancesUse of drugs or other substances Physical examPhysical exam

Vital signs – B/P – P – R – SpOVital signs – B/P – P – R – SpO2 2

Hands-on assessment head to toeHands-on assessment head to toe Skin examSkin exam

Rashes? Evidence of infection?Rashes? Evidence of infection?

Patient Assessment - NeurologicalPatient Assessment - Neurological

Evaluate appearance, behavior, attitudeEvaluate appearance, behavior, attitude Thought disorders – logical and realistic?Thought disorders – logical and realistic?

False beliefs/delusions?False beliefs/delusions? Suicidal/homicidal thoughts?Suicidal/homicidal thoughts? Perception disorders?Perception disorders? Hallucinations present?Hallucinations present?

Mood and affectMood and affect Insight and judgement – can patient understand Insight and judgement – can patient understand

circumstances and identify surroundings?circumstances and identify surroundings? Sensorium and intelligence – normal level of Sensorium and intelligence – normal level of

consciousness? Impaired cognition/intellectual consciousness? Impaired cognition/intellectual functioning?functioning?

Neurological Assessment cont’dNeurological Assessment cont’d

Level of consciousnessLevel of consciousness AVPUAVPU

Pupillary responsePupillary response Ability to identify person, place, timeAbility to identify person, place, time Glasgow coma scaleGlasgow coma scale

Scores 3 – 15Scores 3 – 15 More important than any one score is the trend the More important than any one score is the trend the

score is makingscore is making

Glasgow Coma ScaleGlasgow Coma Scale

Evaluates wakefulness and awarenessEvaluates wakefulness and awareness Wakefulness Wakefulness

The state of being aware of the environmentThe state of being aware of the environment AwarenessAwareness

A demonstrated understanding of what is being A demonstrated understanding of what is being saidsaid

GCS TipsGCS Tips

Always give the patient the best score possibleAlways give the patient the best score possible If the patient can move the right extremity and not If the patient can move the right extremity and not

the left, score for the movement of the right the left, score for the movement of the right extremityextremity

Deteriorations will be noted faster as the score Deteriorations will be noted faster as the score drops by awarding the highest points possibledrops by awarding the highest points possible

Pediatric componentPediatric component Used for the young patient who is not yet verbal Used for the young patient who is not yet verbal

due to agedue to age

Glasgow Coma ScaleGlasgow Coma Scale

EYE OPENING

VERBAL RESPONSE

MOTOR RESPONSE

4--Spontaneous 5--Oriented 6--Obeys

3—Verbal stimuli

4--Confused/ disoriented

5—Localizes/purposeful

2--Pain3--Inappropriate

words4--Withdraws

1--None2--Incomprehensible

sounds3--Abnormal flexion

1--None 2--Extensor posturing

1--None

GCS ScoreGCS Score

GCS 13 – 15GCS 13 – 15 Mild brain injuryMild brain injury

GCS 9 – 12GCS 9 – 12 Moderate brain injuryModerate brain injury

GCS GCS <<88 Severe brain injurySevere brain injury Most patients with this score are in comaMost patients with this score are in coma Evaluate for the need to assist in protecting the Evaluate for the need to assist in protecting the

patient’s airwaypatient’s airway

Evaluating Eye OpeningEvaluating Eye Opening

Best response is obtained, if at all possible, Best response is obtained, if at all possible, before physical contact is made with patientbefore physical contact is made with patient This is not always possible when the C-spine needs This is not always possible when the C-spine needs

to be controlled as c-spine control occurs to be controlled as c-spine control occurs immediately before other interaction with patientimmediately before other interaction with patient

Patient gets credit if eyelids open even for a Patient gets credit if eyelids open even for a brief moment or just flickerbrief moment or just flicker

Always consider need to control the C-spine Always consider need to control the C-spine over the verbal response of the GCSover the verbal response of the GCS

Evaluating Verbal ResponseEvaluating Verbal Response

5 – uses appropriate words/conversation5 – uses appropriate words/conversation 4 – speaks but is confused and disoriented4 – speaks but is confused and disoriented 3 – speaking and you can understand the 3 – speaking and you can understand the

wordswords spoken but the words do not contribute spoken but the words do not contribute to the current conversationto the current conversation

2 – making 2 – making soundssounds like grunts and moans; no like grunts and moans; no intelligible wordsintelligible words

1 – no response; no speech; no noise1 – no response; no speech; no noise

Modifying GCS for PediatricsModifying GCS for Pediatrics

Adult GCS must be modified to match the Adult GCS must be modified to match the developmental age of the young nonverbal childdevelopmental age of the young nonverbal child

Best eye opening remains unchangedBest eye opening remains unchanged Best verbal response for non-verbal patientBest verbal response for non-verbal patient

5 – Smiles, coos, follows objects5 – Smiles, coos, follows objects 4 – Irritable cry but is consolable4 – Irritable cry but is consolable 3 – Inappropriate crying; cries to pain3 – Inappropriate crying; cries to pain 2 – Inconsolable, agitated; moans or groans to pain2 – Inconsolable, agitated; moans or groans to pain 1 – No response1 – No response

Evaluating Motor ResponseEvaluating Motor Response

6 – Obeys commands6 – Obeys commands 5 – Localizes/Purposeful movement5 – Localizes/Purposeful movement

Hits at you, grabs at your hands, pulling equipment Hits at you, grabs at your hands, pulling equipment off, pushing you awayoff, pushing you away

4 – Withdraws from pain (unable to localize)4 – Withdraws from pain (unable to localize) 3 – Flexing with internal rotation and 3 – Flexing with internal rotation and

adduction of shoulders and flexion of elbowsadduction of shoulders and flexion of elbows 2 – Extension with elbows straightened and 2 – Extension with elbows straightened and

possible internal shoulder and wrist rotationpossible internal shoulder and wrist rotation

Pediatric GCS Motor ResponsePediatric GCS Motor Response

Best motor response for non-verbal patientBest motor response for non-verbal patient 6 – obeys commands6 – obeys commands

May be difficult to determine if child understandsMay be difficult to determine if child understands 5 – localizes pain by withdrawing to 5 – localizes pain by withdrawing to touchtouch stimuli stimuli 4 – withdraws to 4 – withdraws to painpain (more stimuli than touch) (more stimuli than touch) 3 – same – abnormal flexion3 – same – abnormal flexion 2 – same – abnormal extension2 – same – abnormal extension 1 – no motor response; patient flaccid1 – no motor response; patient flaccid

GCS Practice (answers at end)GCS Practice (answers at end)Score the Following Patients:Score the Following Patients:

Patient #1Patient #1 The patient is watching you approachThe patient is watching you approach The patient speaks normally and answers questionsThe patient speaks normally and answers questions The patient raises their arm when you ask to take The patient raises their arm when you ask to take

their B/Ptheir B/P Patient #2Patient #2

The patient is looking around the environmentThe patient is looking around the environment The patient speaks normally but is confusedThe patient speaks normally but is confused When you ask the patient to raise their arm, they When you ask the patient to raise their arm, they

are slow to do so but eventually raises their armare slow to do so but eventually raises their arm

GCS PracticeGCS Practice

Patient #3Patient #3 The patient’s eyes are closed and there is no The patient’s eyes are closed and there is no

movement even after squeezing the trapeziusmovement even after squeezing the trapezius The patient groans when the trapezius is squeezedThe patient groans when the trapezius is squeezed The patient flexes their arms to the chest wallThe patient flexes their arms to the chest wall

Patient #4Patient #4 Patient eyes open briefly when their name is calledPatient eyes open briefly when their name is called Patient groans while being pinchedPatient groans while being pinched Patient does not follow commands and pushes you Patient does not follow commands and pushes you

away whenever you try to treat the patientaway whenever you try to treat the patient

GCS PracticeGCS Practice

Patient #5Patient #5 Eyes are closed but open when calling the patientEyes are closed but open when calling the patient The patient yells “don’t” and “stop it” when being The patient yells “don’t” and “stop it” when being

touched, assessed, and treated but is not speakingtouched, assessed, and treated but is not speaking Patient pushes your hands away and is trying to pull Patient pushes your hands away and is trying to pull

off the cervical collar and IVoff the cervical collar and IV Patient #6Patient #6

Eyes open briefly when asked to open themEyes open briefly when asked to open them The patient moans weakly when being touchedThe patient moans weakly when being touched The patient tries to pull away when care is being The patient tries to pull away when care is being

provided (ie: IV start)provided (ie: IV start)

GCS PracticeGCS Practice Patient #7Patient #7

Patient refused to open eyes due to pain and squeezes them Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyestighter when asked to open eyes

The patient responds verbally saying their head hurts and The patient responds verbally saying their head hurts and the lights make it hurt worsethe lights make it hurt worse

Patient follows commands except for opening eyesPatient follows commands except for opening eyes Patient #8Patient #8

Eyes are open looking straight aheadEyes are open looking straight ahead When asked what month it is, the patient responds “he, When asked what month it is, the patient responds “he,

umm, he, my jacket, don’t…”umm, he, my jacket, don’t…” Does not follow commands. Pulls one hand away and the Does not follow commands. Pulls one hand away and the

other hand is pushing you awayother hand is pushing you away

GCS Practice – Pediatrics < 1y/oGCS Practice – Pediatrics < 1y/o

Patient #9 (6 month old)Patient #9 (6 month old) Infant’s eyes flutter when touchedInfant’s eyes flutter when touched Patient cries when gently touched; is consolablePatient cries when gently touched; is consolable Patient withdraws when first touching themPatient withdraws when first touching them

Patient #10 (9 month old)Patient #10 (9 month old) Eyelids flutter when the IO needle is placedEyelids flutter when the IO needle is placed Patient moans during the IO insertion and when Patient moans during the IO insertion and when

deformed extremity is handleddeformed extremity is handled The patient pulls their arms tightly into their chest The patient pulls their arms tightly into their chest

wall curling shoulders and wrists inwardwall curling shoulders and wrists inward

GCS AnswersGCS Answers

Patient # 1 - 4, 5, 6 = 15Patient # 1 - 4, 5, 6 = 15 Patient # 2 – 4, 4, 6 = 14Patient # 2 – 4, 4, 6 = 14 Patient # 3 – 1, 2, 3 = 6Patient # 3 – 1, 2, 3 = 6 Patient # 4 – 3, 2, 5 = 10Patient # 4 – 3, 2, 5 = 10 Patient # 5 – 3, 3, 5 = 11Patient # 5 – 3, 3, 5 = 11 Patient # 6 – 3, 2, 4 = 9Patient # 6 – 3, 2, 4 = 9 Patient # 7 – 3, 5, 6 = 14Patient # 7 – 3, 5, 6 = 14 Patient # 8 – 4, 3, 5 = 12Patient # 8 – 4, 3, 5 = 12 Patient # 9 – 2, 4, 5 = 11Patient # 9 – 2, 4, 5 = 11 Patient # 10 – 2, 2, 3 = 7Patient # 10 – 2, 2, 3 = 7

Blood Glucose LevelBlood Glucose Level To be obtained in the field when:To be obtained in the field when:

Patient is known diabetic with diabetic related Patient is known diabetic with diabetic related problemproblem

Patient has an altered level of consciousness for Patient has an altered level of consciousness for unknown reasonsunknown reasons

Patient is unresponsive (includes post-ictal patients)Patient is unresponsive (includes post-ictal patients) Consider the patient to have more than one problem at a Consider the patient to have more than one problem at a

timetime Make sure a 2Make sure a 2ndnd or 3 or 3rdrd issue is not present once you issue is not present once you

find the first issue (ie: hypoglycemia)find the first issue (ie: hypoglycemia) Be aware: Peds patients can drop their blood sugar level Be aware: Peds patients can drop their blood sugar level

fastfast

Blood Glucose MonitorBlood Glucose Monitor

Machines calibrated for capillary specimenMachines calibrated for capillary specimen Keep the site hanging dependentlyKeep the site hanging dependently

Can use side of finger tips or the forearmCan use side of finger tips or the forearm Once the site is wiped with an alcohol prep pad, let Once the site is wiped with an alcohol prep pad, let

the site air dry before obtaining a samplethe site air dry before obtaining a sample Use a lancet to obtain a blood sample from the finger Use a lancet to obtain a blood sample from the finger

or forearmor forearm Patient should not sign a release until EMS can Patient should not sign a release until EMS can

document a blood sugar level >60 in the fielddocument a blood sugar level >60 in the field

Stroke CareStroke Care Rapid detection of signs and symptoms with Rapid detection of signs and symptoms with

rapid diagnosis is essentialrapid diagnosis is essential Need to avoid delays Need to avoid delays

3 hour time limit to administer a fibrinolytic 3 hour time limit to administer a fibrinolytic from time of first onset of signs and from time of first onset of signs and symptomssymptoms Increase risk of cerebral bleeding beyond Increase risk of cerebral bleeding beyond

a 3 hour time framea 3 hour time frame Most important question to ask:Most important question to ask:

What time did symptoms begin?What time did symptoms begin?

Cincinnati Stroke ScaleCincinnati Stroke Scale

Quick and simple evaluation toolQuick and simple evaluation tool DocumentationDocumentation

Facial droopFacial droop Right/left facial droop or no droopRight/left facial droop or no droop

Arm driftArm drift Right/left arm drift or no driftRight/left arm drift or no drift

Speech Speech Clear or not clearClear or not clear

Facial DroopingFacial Drooping

Ask the patient to smile real big and show you Ask the patient to smile real big and show you their teeththeir teeth Best way to see if a droop is presentBest way to see if a droop is present

Arm DriftArm Drift

Demonstrate first and then have patient hold Demonstrate first and then have patient hold their hands out in front, palms up, for 10 their hands out in front, palms up, for 10 secondsseconds

Clarity of SpeechClarity of Speech

Most likely you’ll know by now if there is a Most likely you’ll know by now if there is a speech problemspeech problem

Can have the patient repeat after you any Can have the patient repeat after you any words or a sentence you give themwords or a sentence you give them ““You can’t teach an old dog new tricks”You can’t teach an old dog new tricks”

7 D’S Of Stroke Care7 D’S Of Stroke Care

Detection – of signs and symptomsDetection – of signs and symptoms Dispatch – patient to call 911Dispatch – patient to call 911 Delivery – by EMS to the appropriate facilityDelivery – by EMS to the appropriate facility Door – emergent triage in the EDDoor – emergent triage in the ED Data – appropriate testsData – appropriate tests Decision – to administer a fibrinolytic or not after Decision – to administer a fibrinolytic or not after

diagnostic tests and assessment completeddiagnostic tests and assessment completed Drug – must administer the fibrinolytic within 3 Drug – must administer the fibrinolytic within 3

hours of onset of symptomshours of onset of symptoms

Quick Fixes of Altered Mental Quick Fixes of Altered Mental StatusStatus

Hypoglycemia – DextroseHypoglycemia – Dextrose Hypoxia – oxygenHypoxia – oxygen Pinpoint pupils – NarcanPinpoint pupils – Narcan Seizures – ValiumSeizures – Valium

Dextrose if seizure due to hypoglycemiaDextrose if seizure due to hypoglycemia Cold – warm the patient upCold – warm the patient up

Combative PatientCombative Patient

Talking down a patient is an art that requires effort Talking down a patient is an art that requires effort and skilland skill

Need enhanced people skills of listening and Need enhanced people skills of listening and observationobservation

Make sure the scene is safeMake sure the scene is safe Provide a calm and supportive environmentProvide a calm and supportive environment Treat any existing medical conditionsTreat any existing medical conditions Do not confront or argue with the patientDo not confront or argue with the patient Provide realistic reassuranceProvide realistic reassurance Respond to the patient in a direct, simple mannerRespond to the patient in a direct, simple manner

2 Extremes of Behavioral 2 Extremes of Behavioral EmergenciesEmergencies

Combative patientCombative patient Fidgeting, nervous Fidgeting, nervous

energyenergy Voice getting louderVoice getting louder PacingPacing Shouting, apparent Shouting, apparent

angeranger

Withdrawn patientWithdrawn patient Facing away from Facing away from

care providercare provider Decreasing eye Decreasing eye

contactcontact No eye contact or No eye contact or

conversationconversation Totally withdrawnTotally withdrawn

System Operating Guidelines – System Operating Guidelines – Use of RestraintsUse of Restraints

EMS personnel should contact Medical Control if EMS personnel should contact Medical Control if possible before restraining patientpossible before restraining patient May restrain patient first for patient and personnel safetyMay restrain patient first for patient and personnel safety

All attempts must be made to avoid injury to patient All attempts must be made to avoid injury to patient and EMS personneland EMS personnel

Do not compromise the patient’s ability to breath or Do not compromise the patient’s ability to breath or further aggravate any injury or illnessfurther aggravate any injury or illness

EMS to clearly document the behavior leading to use EMS to clearly document the behavior leading to use of restraintsof restraints

Handcuffs applied by police onlyHandcuffs applied by police only Officer must accompany patient in the ambulance during Officer must accompany patient in the ambulance during

transport if handcuffs are in placetransport if handcuffs are in place

Methods of RestraintMethods of Restraint

Verbal de-escalationVerbal de-escalation First method to employFirst method to employ Avoids physical contact with the patient – saferAvoids physical contact with the patient – safer Watch “personal space”Watch “personal space”

1.5 – 4 feet in the United States1.5 – 4 feet in the United States Keep open an “escape route” for yourselfKeep open an “escape route” for yourself

Methods of Restraint cont’dMethods of Restraint cont’d Physical restraintPhysical restraint

Materials or techniques that will restrict the movement of a Materials or techniques that will restrict the movement of a patientpatient

Soft restraints: sheets, wristlets, chest PosySoft restraints: sheets, wristlets, chest Posy Hard restraints: plastic ties, handcuffs, leathersHard restraints: plastic ties, handcuffs, leathers

Police must be in ambulance for transport if patient is in Police must be in ambulance for transport if patient is in handcuffshandcuffs

Patients need frequent reassessment to evaluate for injury Patients need frequent reassessment to evaluate for injury or possible neurovascular compromise or airway or possible neurovascular compromise or airway compromisecompromise

Use a surgical mask placed loosely over the face to control Use a surgical mask placed loosely over the face to control spittingspitting

Physical RestraintsPhysical Restraints

EMS to not transport a restrained patient proneEMS to not transport a restrained patient prone Positional asphyxia may cause deathPositional asphyxia may cause death

Be prepared to protect the patient’s airwayBe prepared to protect the patient’s airway Do not secure straps to moving side railsDo not secure straps to moving side rails Restraining thighs just above knees often prevents Restraining thighs just above knees often prevents

kickingkicking Struggling against restraints may lead to severe Struggling against restraints may lead to severe

acidosis and fatal dysrhythmiasacidosis and fatal dysrhythmias NEVER leave restrained patient unattendedNEVER leave restrained patient unattended

Methods of Restraints cont’dMethods of Restraints cont’d

Chemical restraintChemical restraint Administration of specific pharmacological agentsAdministration of specific pharmacological agents

Decrease agitationDecrease agitation Increase cooperationIncrease cooperation Not alter a patient’s level of consciousnessNot alter a patient’s level of consciousness

Common agents used are haldol (in the ED) and/or Common agents used are haldol (in the ED) and/or benzodiazepinesbenzodiazepines

Diazepam (Valium)Diazepam (Valium) Lorazepam (Ativan)Lorazepam (Ativan) Midazolam (Versed)Midazolam (Versed)

Region X SOP - Severe Anxiety or Region X SOP - Severe Anxiety or AgitationAgitation

Valium 5 mg IVP slowly over 2 minutesValium 5 mg IVP slowly over 2 minutes Repeat as needed Repeat as needed Maximum total dose is 10 mgMaximum total dose is 10 mg In the absence of an IV, Valium 10 mg IM/rectallyIn the absence of an IV, Valium 10 mg IM/rectally Watch for respiratory depression with Watch for respiratory depression with

administration of a benzodiazepineadministration of a benzodiazepine Have a BVM ready to use as a precautionHave a BVM ready to use as a precaution

Documentation TipsDocumentation Tips All patients require a blood glucose level for altered All patients require a blood glucose level for altered

mental statusmental status Documentation should reflect serial monitoring of the Documentation should reflect serial monitoring of the

patient’s condition looking for changespatient’s condition looking for changes GCSGCS AVPUAVPU

If restraints are used, document objectively and in If restraints are used, document objectively and in detail the behavior that led to the need for restraintsdetail the behavior that led to the need for restraints Document distal circulation of any restrained Document distal circulation of any restrained

extremityextremity Patients with altered mental status cannot sign a Patients with altered mental status cannot sign a

release in the fieldrelease in the field

Airway Control MeasuresAirway Control Measures

Region X EMS use the QuickTrach deviceRegion X EMS use the QuickTrach device ED tools available:ED tools available:

ACMC – QuicktrachACMC – Quicktrach - Melker (especially being used for large- Melker (especially being used for large necksnecks - Surgical tray for surgical cric- Surgical tray for surgical cric NLFH – QuickTrachNLFH – QuickTrach - Melker- Melker - Arndt- Arndt

Securing the Airway - QuickTrachSecuring the Airway - QuickTrach IndicationsIndications

Patient requires emergency assisted ventilation Patient requires emergency assisted ventilation when all other conventional methods have failedwhen all other conventional methods have failed

ContraindicationsContraindications Tracheal transectionTracheal transection

Other less invasive maneuver allows ventilationOther less invasive maneuver allows ventilation >77# (35kg) – use 4.0mm ID device>77# (35kg) – use 4.0mm ID device 22# – 77# (10 -35kg) use 2.0 mm ID22# – 77# (10 -35kg) use 2.0 mm ID <22# (10kg) – use needle cricothyrotomy<22# (10kg) – use needle cricothyrotomy

QuickTrach DeviceQuickTrach Device

Connecting Connecting tubetube

SyringeSyringe

Flanges to Flanges to attach ties attach ties

Stopper that is Stopper that is removed removed before final before final insertioninsertion

QuickTrach ProcedureQuickTrach Procedure

Patient positioned supine; neck hyperextended if Patient positioned supine; neck hyperextended if no trauma)no trauma)

Cricothyroid membrane located and site cleansed Cricothyroid membrane located and site cleansed Palpate the soft indentation between Palpate the soft indentation between the thyroid and cricothyroid cartilagesthe thyroid and cricothyroid cartilages

Larynx secured laterally between Larynx secured laterally between the thumb and forefingerthe thumb and forefinger

Cricothyroid membrane punctured Cricothyroid membrane punctured at a 90at a 9000 angle angle

Cricothyroid MembraneCricothyroid Membrane

Target areaTarget area

QuickTrach cont’dQuickTrach cont’d

Entry into the trachea confirmed by aspirating air thru Entry into the trachea confirmed by aspirating air thru the syringethe syringe If air is present, the needle is in the tracheaIf air is present, the needle is in the trachea

Now angle changed to 60Now angle changed to 6000 with the tip pointing with the tip pointing towards the feet and device advanced forward into the towards the feet and device advanced forward into the trachea to the level of the stoppertrachea to the level of the stopper Stopper to be snug against the skinStopper to be snug against the skin Stopper reduces risk of inserting the needle too Stopper reduces risk of inserting the needle too

deeplydeeply Stopper removedStopper removed

QuickTrach cont’dQuickTrach cont’d Needle and syringe held firmly, only the plastic Needle and syringe held firmly, only the plastic

cannula is slid into the trachea cannula is slid into the trachea Advancement stopped when the flange rests Advancement stopped when the flange rests

snug against the necksnug against the neck Needle and syringe carefully removedNeedle and syringe carefully removed Connecting tube attached to the cannulaConnecting tube attached to the cannula

Can be preattached to BVM and then attached to Can be preattached to BVM and then attached to cannula when needle and syringe are removedcannula when needle and syringe are removed

BVM attached to the connecting tubeBVM attached to the connecting tube Patient can be bagged Patient can be bagged

Cannula secured with the neck tape ties Cannula secured with the neck tape ties providedprovided

QuickTrach ComplicationsQuickTrach Complications

Puncture through of the tracheaPuncture through of the trachea During bagging attempts surrounding tissue will During bagging attempts surrounding tissue will

expand due to leakage of airexpand due to leakage of air Inadvertent puncture of a blood vesselInadvertent puncture of a blood vessel

Formation of a hematoma under the skin and Formation of a hematoma under the skin and surrounding the airwaysurrounding the airway

External bleedingExternal bleeding Inability to ventilate the patientInability to ventilate the patient

There may be an obstruction at a more distal siteThere may be an obstruction at a more distal site

QuickTrach DocumentationQuickTrach Documentation

Reason(s) an alternate airway devise was Reason(s) an alternate airway devise was necessarynecessary

Size of airway placed Size of airway placed 4.0 mm for persons over 77#4.0 mm for persons over 77# 2.0 mm for persons 22# - 77#2.0 mm for persons 22# - 77#

Confirmation of airway placementConfirmation of airway placement Bilateral breath soundsBilateral breath sounds Bilateral chest wall rise and fallBilateral chest wall rise and fall

Melker Airway DeviceMelker Airway Device

Arndt Airway DeviceArndt Airway Device

Case StudiesCase Studies

Read the following case studiesRead the following case studies Can be a patient found by EMSCan be a patient found by EMS Can be a walk-in Ed patientCan be a walk-in Ed patient

How would you respond?How would you respond? More information may be provided in the More information may be provided in the

notes sectionnotes section

Case Study #1Case Study #1

57 year old patient found behind a garage 57 year old patient found behind a garage unresponsive.unresponsive.

Breathing and has a radial pulse. Dry blood on Breathing and has a radial pulse. Dry blood on lips.lips.

What are your impressions?What are your impressions? How does your assessment proceed?How does your assessment proceed?

Case Study #1 Case Study #1

Impression listImpression list Post-ictal from seizurePost-ictal from seizure HypoglycemiaHypoglycemia Alcohol intoxicationAlcohol intoxication Drug overdoseDrug overdose Acute MIAcute MI StrokeStroke Head traumaHead trauma


AssessmentAssessment Control c-spine while palpating neck areaControl c-spine while palpating neck area Evaluate if respiratory assistance is neededEvaluate if respiratory assistance is needed

Check quality, depth, rate of respirations, SpOCheck quality, depth, rate of respirations, SpO22

Calculate GCS; obtain vital signsCalculate GCS; obtain vital signs Consider IV-OConsider IV-O22-monitor-monitor

Assess for need for fluid challengeAssess for need for fluid challenge Assess cardiac rhythm; consider obtaining a 12 Assess cardiac rhythm; consider obtaining a 12

lead EKGlead EKG Obtain a blood glucose sampleObtain a blood glucose sample


Patient brought to ED by spousePatient brought to ED by spouse Patient dropping silverware at lunch, unable to Patient dropping silverware at lunch, unable to

sit up straight, unable to complete sentencessit up straight, unable to complete sentences Vital signs: 170/110; P – 64; R – 16; GCS -14Vital signs: 170/110; P – 64; R – 16; GCS -14 EKG monitor - EKG monitor -


What is your impression?What is your impression? What is the cardiac rhythm?What is the cardiac rhythm?

Atrial fibrillationAtrial fibrillation How does this rhythm relate to any impressions?How does this rhythm relate to any impressions?

What assessments need to be done?What assessments need to be done? Blood sugar level for all patients with altered level Blood sugar level for all patients with altered level

of consciousnessof consciousness Cincinnati stroke scaleCincinnati stroke scale


Cincinnati stroke scaleCincinnati stroke scale Ask the patient to smile real big showing you their Ask the patient to smile real big showing you their

teethteeth Ask the patient to put their hands out in front, Ask the patient to put their hands out in front,

palms up, and close their eyes palms up, and close their eyes Hold the position for 10 secondsHold the position for 10 seconds

Ask the patient to repeat a sayingAsk the patient to repeat a saying ““You can’t teach an old dog new tricks”You can’t teach an old dog new tricks”


What’s the most important question to ask the What’s the most important question to ask the patient?patient?

When did the symptoms begin?When did the symptoms begin?


An 18 year-old patient is found under the An 18 year-old patient is found under the bleachers at school unresponsive with shallow bleachers at school unresponsive with shallow respirations.respirations.

AVPU - responds to painful stimuliAVPU - responds to painful stimuli Vital signs: 110/70; P – 110; R – 4; pupils Vital signs: 110/70; P – 110; R – 4; pupils

constrictedconstricted GCS – 8GCS – 8 What are your impressions?What are your impressions?


Impression listImpression list Drug overdoseDrug overdose

Opiates – constricted pupils, depressed respirationsOpiates – constricted pupils, depressed respirations Head injuryHead injury HypoglycemiaHypoglycemia Post-ictalPost-ictal

Case Study #3Case Study #3 TreatmentTreatment

Control c-spine Control c-spine Consider c-spine injury until proven otherwiseConsider c-spine injury until proven otherwise

Secure airwaySecure airway Frequency to ventilate via BVM to support Frequency to ventilate via BVM to support

respirations?respirations? Once every 5 – 6 secondsOnce every 5 – 6 seconds

Gain IV accessGain IV access Peripheral site? Peripheral site? IO if peripheral unobtainableIO if peripheral unobtainable

Evaluate cardiac rhythmEvaluate cardiac rhythm

Case Study #3Case Study #3 Medications to administer in the field (Region X EMS)Medications to administer in the field (Region X EMS)

If blood sugar < 60 give 50 ml of 50% DextroseIf blood sugar < 60 give 50 ml of 50% Dextrose As a diagnostic tool give NarcanAs a diagnostic tool give Narcan

2 mg IVP every 5 minutes as needed for desired effect2 mg IVP every 5 minutes as needed for desired effect Maximum total of 10 mgMaximum total of 10 mg

Consider need to protect the airway with intubation Consider need to protect the airway with intubation following conscious sedationfollowing conscious sedation No indication for lidocaineNo indication for lidocaine Versed to relax the patientVersed to relax the patient Morphine alternated with Versed to potentiate the Morphine alternated with Versed to potentiate the

effects of both medicationseffects of both medications Benzocaine if a blink reflex is presentBenzocaine if a blink reflex is present


EMS is called to the scene for an unknown EMS is called to the scene for an unknown medical emergencymedical emergency

Police have secured the scenePolice have secured the scene The patient is a 54 year-old male who is The patient is a 54 year-old male who is

combativecombative What are your impressions?What are your impressions? What actions are indicated?What actions are indicated?


ImpressionsImpressions Psychiatric problemPsychiatric problem Altered blood sugarAltered blood sugar Head injuryHead injury Electrolyte imbalanceElectrolyte imbalance


Action to takeAction to take Make sure the scene is safe and remains safe for Make sure the scene is safe and remains safe for

the rescuers and the patientthe rescuers and the patient Will need a blood sugar at some pointWill need a blood sugar at some point A cardiac monitor to evaluate rhythm could be A cardiac monitor to evaluate rhythm could be

important assessment informationimportant assessment information May need to restrain the patient for staff safety and May need to restrain the patient for staff safety and

patient safetypatient safety

Case Study #4Case Study #4 Methods to restrain patientsMethods to restrain patients

Verbal de-escalationVerbal de-escalation Soft restraintsSoft restraints

Wrist and ankle restraintsWrist and ankle restraints Chest posey or sheetChest posey or sheet

Hard restraints with EMS in the fieldHard restraints with EMS in the field If police handcuff the patient, police must If police handcuff the patient, police must

ride with the patient in the ambulance ride with the patient in the ambulance Police are not allowed to hand off cuff Police are not allowed to hand off cuff

keys to EMSkeys to EMS


DocumentationDocumentation Patient’s behavior in descriptive, objective terms Patient’s behavior in descriptive, objective terms

that indicated the need for restraintthat indicated the need for restraint If no time to contact Medical Control before If no time to contact Medical Control before

restraining patient, EMS to contact Medical restraining patient, EMS to contact Medical Control after the patient is restrainedControl after the patient is restrained

Document distal circulation, motion, and sensation Document distal circulation, motion, and sensation periodically after restraining the patientperiodically after restraining the patient


32 year-old patient was found combative at 32 year-old patient was found combative at work. This is very unusual behavior for this work. This is very unusual behavior for this patientpatient

Vital signs: 110/70; P – 80; R – 18; skin dampVital signs: 110/70; P – 80; R – 18; skin damp Impression?Impression? Further assessment?Further assessment? Treatment?Treatment?


ImpressionImpression HypoglycemiaHypoglycemia Head injuryHead injury Drug / alcohol influenceDrug / alcohol influence

AssessmentAssessment Blood sugar levelBlood sugar level Cardiac monitorCardiac monitor Neurological evaluationNeurological evaluation


Blood sugar was 25Blood sugar was 25 Treatment indicatedTreatment indicated

50 ml 50% Dextrose IVP50 ml 50% Dextrose IVP Patient now alert and orientedPatient now alert and oriented Repeat blood sugar 56Repeat blood sugar 56 Patient wants to sign a release. Can EMS Patient wants to sign a release. Can EMS

allow a release to be obtained?allow a release to be obtained? No release until the blood sugar is >60No release until the blood sugar is >60 EMS to stay on the scene and continue to reassess EMS to stay on the scene and continue to reassess

as the patient takes in food or liquidsas the patient takes in food or liquids

BibliographyBibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Bledsoe, B., Porter, R., Cherry, R. Paramedic Care

Principles and Practices 3Principles and Practices 3rdrd Edition. Prentice Hall. Edition. Prentice Hall. 20092009

Limmer, D. O’Keefe, M. Emergency Care. 10Limmer, D. O’Keefe, M. Emergency Care. 10thth Edition. Prentice Hall. 2005.Edition. Prentice Hall. 2005.

Region X SOP’s March 2007. Amended January 1, Region X SOP’s March 2007. Amended January 1, 2008.2008.

En.wikipedia.org/wiki/Endocrine_systemEn.wikipedia.org/wiki/Endocrine_system En.wikipedia.org/wiki/Electrolyte_systemEn.wikipedia.org/wiki/Electrolyte_system En.wikipedia.org/wiki/Encephalopathy_systemEn.wikipedia.org/wiki/Encephalopathy_system En.wikipedia.org/wiki/Opiate_systemEn.wikipedia.org/wiki/Opiate_system En.wikipedia.org/wiki/Uremia_systemEn.wikipedia.org/wiki/Uremia_system

Bibliography cont’dBibliography cont’d www.chems.alaska.gov/EMS/documents/GCS_Activity_www.chems.alaska.gov/EMS/documents/GCS_Activity_

2003.pdf2003.pdf www.doi.gov/nbc/eps/signsymptoms.htmlwww.doi.gov/nbc/eps/signsymptoms.html www.en.wikibooks.org.wiki/Emergency_Medicine/alteredwww.en.wikibooks.org.wiki/Emergency_Medicine/altered

_mental_status_mental_status www.nursingtimes.netwww.nursingtimes.net www.opiates.com/opiateswww.opiates.com/opiates staff.washington.edu/momus/PB/comachan.htmstaff.washington.edu/momus/PB/comachan.htm www.ucsfcme.com/2008/slides/MDM08Q05/01-sporer.pdwww.ucsfcme.com/2008/slides/MDM08Q05/01-sporer.pd

ff www.uic.edu/com/ferne/slides/Delerium.ppswww.uic.edu/com/ferne/slides/Delerium.pps

The Patient With An Altered Mental Status ECRN Mod IV 2009 CE Advocate Condell Medical Center...

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