Altered Mental Status Medication Review Lung Sounds MAD Device

1. Altered Mental StatusMedication ReviewLung SoundsMAD Device ECRN Module I 2010 CE Condell EMS System Prepared by Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the ECRN will be able to: • Describe elements of normal mental status. • Describe components of the neurological examination. • List the three components of the Glasgow coma scale. • Calculate the GCS. • List common causes of an altered mental status.

3. Objectives cont’d • Review Cincinnati Stoke Scale • Describe the FAST concept • Review Region X SOP Altered Mental Status • Explain the differences between the adult and the pediatric airway. • Describe the assessment of the airway and respiratory system. • Describe the various lung sounds auscultated during assessment.

4. Objectives cont’d • Discuss the methods for measuring oxygen and carbon dioxide in the blood in the prehospital setting. • Identify pre-hospital indications, contraindications, dosing, side effects, and special considerations of Dextrose, Glucagon, Narcan, Albuterol, Epinephrine 1:1000, Benadryl, Lasix, and Morphine.

5. Objectives cont’d • Describe the indications, contraindications, dosing, side effects, and special considerations for administering Narcan via the MAD tool. • Describe the MAD tool and the procedure for using the MAD tool. • Describe the indications, contraindications, complications, and the process for performing a cricothyrotomy in the field.

6. Normal Mental Status • Consciousness • Person is fully responsive to stimuli and demonstrates awareness of the environment • Altered level of consciousness • Some form of dysfunction or interruption in the central nervous system

7. Normal Mental Status • Patient is awake • Patient is alert – aware of surroundings • Patient is oriented to person, place, & time • Patient is cooperative • Patient carries on normal conversation • Patient able to follow/obey commands • Gait is even and steady

8. Altered Level of Consciousness Hallmark sign of central nervous system injury or illness

9. Did You Know? • When perfusion is declining, the first indicator is a changing level of consciousness • The last indicator is a falling blood pressure

10. Assessing Mental Status - AVPU • A – awake • V – responds to verbal stimuli • P – responds to painful stimuli • U- unresponsive

11. A – “Awake” • Patient is awake, alert and aware of surroundings • OR • Patient may be awake but confused • Report what the patient is oriented to • “Oriented to person but not place or time” • Key is watching for a change in level of consciousness from the baseline taken

12. V – Verbal Response • This would need to be evaluated prior to touching the “unconscious” patient • Problem: If trauma is involved, need to manually control the C-spine before causing the patient any movement of the c-spine • If possible, call the patient’s name to check for response to verbal stimuli prior to making physical contact

13. P – Painful Response • Does not necessarily mean you have to perform a painful task to check for response • Start with simple tactile contact – touch • Add deeper stimulation if needed • Sternal rub • Pinch of thumb web space • Trapezius muscle squeeze (near neck) • Do not cause so much trauma as to leave marks/bruises • Observe for some kind of response with muscles

14. Patient Response • Patient response can include: • Opening of eyelids even briefly • Fluttering of eyelids • Wrinkling of brows • Most important is looking for changes in the patient’s response from one evaluation/assessment to the next

15. U - Unresponsive • The patient has NO response at all • No moaning • No muscle twitch at all • No eyelid flutter • No wrinkling of the eyebrow • Muscles are flaccid with absolutely no response regardless of stimuli

16. Neurological Exam In the Field • AVPU – what is level of consciousness? • Pupillary response • Movement of distal extremities • Wiggling fingers and toes • Sensation of distal extremities • Ability to feel contact with fingers and toes • GCS • <10 or deteriorating mental status patient is considered critical and categorized as Category I trauma

17. Glasgow Coma Scale - GCS • The best score possible is given • More important is watching the trend than relying on any one score • Objective tool • All using the tool on the same patient should get the same score • Evaluate • Best eye opening • Best verbal response • Best motor response

18. GCS – Eye Opening • 4 – Spontaneous; patient’s eyes are open • Does not have to be focusing • 3 – Eyes open or motion is made to verbal stimuli • Start with soft voice, may have to yell at patient to open eyes • 2 – Eyes open with tactile or painful stimuli • Start with gentle touch; may need to add more intense stimuli • 1 – No eye opening; no muscle motion at all

19. GCS – Verbal Response • 5 – Oriented to person, place, and time • 4 – Pleasantly confused • 3 – Inappropriate words • You can understand the word(s) spoken but they are not within context • 2 – Incomprehensible words – sounds • No intelligible word understood; moans and groans; makes noises • 1 – Silent; no noise is made at all

20. GCS – Motor Response • 6 – Obeys commands • 5 – Localizes pain / purposeful movement • Can push you away or grab at the noxious stimuli (IV, collar, bandaging, your hands) • 4 – Withdrawal • No longer localizing, just withdraws/pulls away to get away from annoying/painful stimuli (IV, collar, bandaging, your hands)

21. Motor cont’d • 3 – Flexion to pain • Arms flex/bend slowly toward center of chest when any stimuli applied • 2 – Extension to pain • Arms slowly extend and curl inward and legs straighten when any stimuli applied • 1 – No movement at all

22. GCS Results • Score range 3 – 15 • Minor head injury – 13 – 15 • Moderate head injury – 9 – 12 • Severe head injury (coma) - <8 • Significant mortality risk • Consider intubation or other means to secure the airway

23. GCS Practice • Read the following case scenarios • Determine the best eye opening, verbal response, motor response • When the response is asymmetrical, award the highest points possible • Don’t guess or assume what you think they really can do • Award points for what is performed • Be objective • Note: Answers follow the practice slide

24. GCS Case #1 • Patient lying in the bed (no trauma), eyes are closed • You need to yell the patient’s name and then the eyelids flicker • They are mumbling • They are grabbing at your hands and pushing you away. They have pulled out the IV.

25. GCS Case #1 Score • Eye opening – 3 • Responded to loud voice • Verbal response – 2 • Mumbling is incomprehensible words/sounds • Motor response – 5 • Patient can recognize (localize) what feels obnoxious and what he wants to stop so they are grabbing at you and pulling at equipment • Total GCS - 10

26. GCS Case #2 • Patient is lying in the street watching you approach • They mumble as you talk to them • They are grabbing at your hands and pushing you away

27. GCS Case #2 Score • Eye opening – 4 • Spontaneous; doesn’t necessarily indicate focusing • Verbal response – 2 • Mumbling, moaning, groaning • Motor response – 5 • Purposeful movement by grabbing at what the patient perceives as noxious stimuli • Total GCS - 11

28. GCS Case #3 • Patient watches your approach and acknowledges your presence • Patient answers most questions and thinks you are their relative come to visit • Patient able to move left arm to command but not able to move right arm (new onset – possible stroke)

29. GCS Case #3 Score • Eye opening – 4 • Spontaneous • Verbal response – 4 • Pleasantly confused • Motor response – 6 • Highest possible score based on the arm that can and does move • Total GCS - 14

30. GCS Case #4 • Child’s eyelids flicker when deformed extremity is manipulated • Child moans out when painful areas are manipulated • Child pulls away when touched and tries to turn away from EMS

31. GCS Case #4 Score • Eye opening – 2 • Response to painful stimuli • Verbal response – 2 • Moans and groans are incomprehensible words / sounds • Motor response – 4 • Withdrawing from what is sensed as painful stimuli • Flexion would be slow flexing of arms toward center of chest – this patient’s response is not flexion • Total GCS – 8 (Protect airway; consider intubation)

32. GCS Case #5 • Patient’s eyes remain closed; no eyelid movement at all • There are no sounds heard from the patient • The patient straightens their arms, twists their wrists, arches their back, and straightens their legs when stimulated

33. GCS Case #5 Score • Eye opening – 1 (no response) • Verbal response – 1 (no response) • Motor response – 2 • Abnormal extension • The worse level of response prior to no response at all • Total GCS – 4 • Patient is critical; Category I • Patient usually needs some airway intervention

34. Common Causes of Altered Mental Status • A – acidosis, alcohol • E – Epilepsy • I – Infection (brain, sepsis) • O – Overdose • U – Uremia (kidney failure) • T – Trauma, tumor, toxins • I – Insulin – hypo or hyperglycemia • P – Psychosis, poison • S – Stroke, seizure

35. Initial Patient Assessment • Airway • Open or obstructed • Maneuvers needed to open • Head tilt / chin lift • With trauma, modified jaw thrust • Breathing • Quality • Quantity (eyeball assessment at this time)

36. Initial Assessment cont’d • Circulation • Quality • Quantity (don’t count; get estimate of range) • Disability – need to obtain baselines • AVPU • GCS • Expose to examine • Can’t evaluate or fix what you can’t see

37. Assessment Tools • AVPU • Alert (interpreted as an awake patient) • Responds to verbal stimuli • Responds to painful stimuli • Unresponsive

38. Assessment Tools • GCS • Best eye opening response • Best verbal response • Best motor response • Scores range from the lowest of 3 to highest of 15 • Obtain and document GCS on all patient calls

39. Cincinnati Stroke Scale • Obtain for suspicion of TIA or stroke • Evaluate for facial droop • Check the patient’s symmetry during a broad, big smile (teeth showing) • Evaluate for arm drift • Check for weakness in holding arms outstretched, palms up, for 10 seconds • Evaluate for clear speech • Have patient repeat words listening for clear speech patterns

40. Airway Protection and the Stroke Patient • Crucial - high mortality rate for aspiration • Is airway patent and can patient protect their own airway? • Check if patient is able to handle & swallow own saliva • Detailed/involved swallow study done in-hospital • Patient speaks in clear unobstructed voice • Interventions to consider • Have suction on and ready • Ability to quickly turn patient onto their side

41. FAST - Public Educational Tool • Tool developed by organizations for public recognition of stroke and to encourage FAST action

42. Region X SOP – Altered Mental Status • Consider etiology • If cause of problem can be identified, then interventions can be focused • Diabetes – check blood sugar • Drug overdose – what are the environmental clues • Poisoning – environmental evidence around • Alcohol related – environmental evidence; use your nose

43. SOP – Altered Mental Status • Maintain airway • Patency extremely important • Evaluate rate and quality • If respirations inadequate, ventilate • 1 breath every 5-6 seconds all patients – infancy to elderly • Intubate as necessary • Use C-spine precautions as indicated • If any doubt, err on side of extra precautions • Provide Routine Medical Care • IV – O2 - monitor

44. SOP – Altered Mental Status • Obtain blood glucose level • If <60 – treat • Adult - Dextrose 50% 50 ml IVP • Child 1 – 15 – Dextrose 25% 2 ml/kg • Infant <1 – Dextrose 12.5% 4 ml/kg • Dilute 1:1 ratio D 25% with normal saline • Equal amounts of product make 1:1 dilution (Dextrose and normal saline)

45. Treating Altered Mental Status • In absence of IV access • Adult – Glucagon 1 unit (1 ml) IM • Pediatrics < 15 – Glucagon 0.1 mg/kg IM • Max dose of 1 mg • Practice math: 44 pound child with no IV access • How many kg? • 44#  2.2 = 20 kg • 20 kg x 0.1mg/kg = 2 mg • How much Glucagon do you give? • Max of 1 mg (max drugs at adult dose)

46. Altered Mental Status cont’d • If patient not alert, respirations decreased, or narcotic overdose suspected: • Narcan 2mg IN/IVP/IO • Repeat every 5 minutes as needed until desired effect • Quality of respirations have improved • Don’t need patient to be 15 on GCS • Don’t need patient awake necessarily • Maximum total dose 10 mg • Transport

47. Altered Mental Status cont’d • Note: • Attempt to identify substances involved • If not a safety hazard, obtain and transport substance container with the patient • Consider use of restraints prior to administration of Narcan • Patient may become violent when level of consciousness improves

48. Adult Airway Pediatric airway • Note funnel shaping of pediatric airway

49. Notice Difference in Tongue Size • Adult airway • Pediatric airway tongue

50. Pediatric airway Differences • Jaw smaller • Teeth softer and more fragile • Tongue relatively larger • Potential to produce more obstruction • Epilgottis floppier and rounder • Recommend straight Miller blade over curved Macintosh for intubation • Larynx more superior & anterior • Higher and more forward • Funnel shaped due to underdeveloped cricoid cartilage • Under age 10 cricoid cartilage narrowest part of airway • Ribs and cartilage softer and more pliable • Children rely on diaphragm muscle for breathing