Altered Mental Status

1. Chapter 19 Altered Mental Status

2. 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.”

3. Central and Peripheral Nervous System

4. Brain

5. Blood Supply to the Brain

6. Altered Mental Status • Structural problems • Injury or damage to an area of the brain OR • Metabolic problems • Affect the entire brain

7. Structural • Stroke • Head injury • Characterized by “one-sided” signs • Paralysis • Facial droop • Weakness on one side of the body • Unequal pupils

8. 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

9. Causes of Altered Mental Status • Hypoglycemia, diabetic ketoacidosis • Poisoning • After seizure • Infection • Head trauma • Decreased oxygen levels (hypoxia)

10. Diabetes • Disease of the pancreas • Caused by a partial or total lack of insulin production • Symptoms of diabetes • Increased urination • Increased thirst • Increased hunger

11. 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. • Unconsciousness, seizures, brain cell death

12. Diabetes • Two major diabetic emergencies • Hypoglycemia • Abnormally low blood glucose level • Diabetic ketoacidosis • Blood glucose level too high and insulin level too low

13. 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

14. 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™

15. Hypoglycemia - Signs and Symptoms • Can also occur in patients who do not have diabetes • Infants with poor glycogen supplies • Malnourished individuals • Alcoholics

16. 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

17. Diabetic Ketoacidosis • Increased acidity in blood • Body tries to compensate by breathing deeply and rapidly. • Slow onset

18. Emergency Medical Care - History of Diabetes • Initial assessment • Focused history and physical exam • Vital signs • SAMPLE history

19. Focused History and Physical Examination • Description of episode • Onset • Duration • Associated symptoms • Evidence of trauma • Interruptions • Seizures • Fever

20. Vital Signs and SAMPLE History • History of diabetes • Medical identification tags, etc. • Last meal • Last medication dose • Related illness • Determine if patient can swallow.

21. Management – Diabetic Emergencies • Ensure patent airway. • Supplemental oxygen; consider positive-pressure ventilation • Consider oral glucose administration. • Per local protocol • Reassess patient en route to hospital.

22. 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.

23. 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

24. Seizures • May be brief or prolonged • Causes • Fever • Infections • Poisoning • Hypoglycemia • Trauma • Drug or alcohol withdrawal • Hypoxia • Idiopathic

25. Seizures – Infants and Children • Chronic seizures in children are rarely life threatening. • Febrile seizures should be considered life-threatening.

26. Types of Seizures • Grand mal • Focal • Status epilepticus • Febrile • Petit mal

27. Grand Mal Seizures • Three phases • Tonic • Clonic • Postictal

28. 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.

29. 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.

30. Grand Mal Seizures – Postictal Phase • Decreased LOC and confusion • Slow awakening • Patient may fall asleep for short period. • Afterward, may complain of headache

31. Focal Seizures • May affect only a portion of the body OR • May present as altered mental status with bizarre behavior

32. Status Epilepticus • Rapid succession of seizures without an intervening period of consciousness • Prolonged seizure • Life-threatening because of sustained respiratory compromise

33. Febrile Seizures • Caused by fever • Children – 6 months to 6 years of age • Occur in up to 5% of children

34. 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

35. 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.

36. 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

37. Stroke • Third leading cause of death in the U.S. • 500,000 Americans are affected annually. • Nearly 25% die.

38. 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.

39. 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

40. Stroke – Initial Assessment • Ensure patent airway. • Support ventilations, as necessary.

41. 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

42. 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.

43. 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.

44. Stroke – Cincinnati Prehospital Stroke Scale

45. Stroke – Los Angeles Prehospital Stroke Screen

46. Glasgow Coma Scale

47. 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.

48. 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

49. Altered Mental Status – Emergency Medical Care • Physical examination • Vital signs • Abnormal smells • Pupillary status • Motor and sensory function • Asymmetry • Check for medical alert tag.