Seizures & Psych Emergencies March 5, 2018

Bell Work 3-5-18 1. If a patient has an altered mental status, EMS use the mnemonic AEIOUTIPS to evaluate causes. What does that stand for? 2. In the initial assessment of a scene, how would you classify a patient’s mental capacity? 3. A cerebral thrombosis would be classified as what type of stroke? 4. Decreased blood flow to the brain that is only temporary would be called? 5. What hormone moves glucose from your blood into the cells for energy and storage? 6. What type of insulin would a patient use if they were about to eat? Regular or long-acting? 7. If a patient were hypoglycemic and had a patent IV, what type of fluids could you give them?

Altered Mental Status 6. Probable cause of the present condition. What is the underlying pathophysiology causing the patient's altered mental state? One commonly used mnemonic is AEIOUTIPS: Page 601 in book! Alcohol, Epilepsy Insulin Overdose, opioids or oxygen deprivation; Uremia Trauma Infection, inherited defects; Psychosis Stroke, shock

Altered Mental Status Assessment AVPU Assessment when doing initial assessment (Alert, Voice, Pain, Unresponsive)

Objectives What to do in an emergency if someone has a Seizure

Standard 19) Identify and perform skills to manage life threatening illnesses based on assessment findings of a pediatric, adult, and geriatric patient with medical emergencies identifying anatomical structures involved. Altered mental status Seizures Stroke Gastrointestinal bleeding Anaphylaxis Infectious diseases Diabetes Psychological emergencies Chest pain Poisoning Respiratory distress/Asthma Vaginal bleeding Nosebleeds

Seizures A seizure is a sudden surge or burst of electrical activity in your brain.  A seizure affects how you appear or act for a short time. Seizures aren’t always an either-or thing: Some people have seizures that start as one kind, then become another. And it’s not easy to classify some of them: These are called unknown-onset seizures, and they can cause both sensory and physical symptoms.

Types of Seizures Partial seizures: Seizure in small part of brain. cause both physical and emotional effects and make you feel, see, or hear things that aren’t there. About 60% of people with epilepsy have this type of seizure, which is sometimes called a focal seizure. Sometimes, the symptoms of a focal seizure can be mistaken for signs of mental illness or another kind of nerve disorder. Generalized seizures: These happen when nerve cells on both sides of your brain misfire. They can make you have muscle spasms, black out, or fall.

Types of Seizures Tonic-clonic (or grand mal) seizures: These are the most noticeable. When you have this type, your body stiffens, jerks, and shakes, and you lose consciousness. Sometimes you lose control of your bladder or bowels. They usually last 1 to 3 minutes -- if they go on longer, someone should call 911. That can lead to breathing problems or make you bite your tongue or cheek. Partial Seizure: seizure in a small portion of the brain. Can affect speech or motor function Absence or Petit- mal Seizures: Blank or absent stare, usually lasting only seconds. Febrile Seizures: Due to rapid rise in temperature. Common in children between 6 months and 6 years old.

Seizure Treatment Grand mal – do not restrain, but remove objects in way. Turn patient’s head to right side to allow drainage of saliva Don’t force anything in the mouth (no oral airway or bit block) Note the time of onset and when it ends. Most last 3-5 minutes Note what body parts are involved

Status Epilepticus Medical Emergency: Seizure over 5 minutes Requires airway management to prevent brain damage or death

Seizure Video https://www.youtube.com/watch?v=JAA_lo1eV0s

Work it Out Finish Friday Assignments Questions page 622, 1-12 Vocabulary page 623

Bell Work 3-6-18 1. What type of seizure occurs when a patient’s body stiffens, jerks, and shakes, and is a complete misfire of brain activity? 2. What type of seizure is in a small portion of the brain and can affect speech or motor function? 3. What steps do you take when someone has a seizure? 4. When should EMS be called for help with a seizure?

Psychiatric Emergency Patient’s behavior is disturbing to himself, his family, or his community

Behavioral Change Never assume patient has psychiatric illness until all possible physical causes are ruled out

Behavioral Change Causes Low blood sugar Hypoxia Inadequate cerebral blood flow Head trauma Drugs, alcohol Excessive heat, cold

Behavioral Change Clues suggesting physical causes Sudden onset Visual, but not auditory, hallucinations Memory loss, impairment Altered pupil size, symmetry, reactivity Excessive salivation Incontinence Unusual breath odors

Psychiatric Problems

Anxiety Most common psychiatric illness (10% of adults) Painful uneasiness about impending problems, situations Characterized by agitation, restlessness Frequently misdiagnosed as other disorders

Anxiety Panic attack Intense fear, tension, restlessness Patient overwhelmed, cannot concentrate May also cause anxiety, agitation among family, bystanders

Anxiety Dizziness Shortness of breath Panic attack Dizziness Tingling of fingers, area around mouth Carpal-pedal spasms Tremors Shortness of breath Irregular heartbeat Palpitations Diarrhea Sensation of choking, smothering

Phobias Closely related to anxiety Stimulated by specific things, places, situations Signs, symptoms resemble panic attack Most common is agoraphobia (fear of open places)

Depression Deep feelings of sadness, worthlessness, discouragement Factor in 50% of suicides

Depression Signs, Symptoms Sad appearance Listless, apathetic behavior Crying spells Withdrawal Pessimism Loss of appetite Sleeplessness Fatigue Severe restlessness

Ask all depressed patients about suicidal thoughts Depression Ask all depressed patients about suicidal thoughts Asking someone about suicide will NOT “put the idea in their head.”

Bipolar Disorder Manic-depressive Swings from one end of mood spectrum to other Manic phase: Inflated self-image, elation, feelings of being very powerful Depressed phase: Loss of interest, feelings of worthlessness, suicidal thoughts Delusions, hallucinations occur in either phase

Paranoia Exaggerated, unwarranted mistrust Often elaborate delusions of persecution Tend to carry grudges Cold, aloof, hypersensitive, defensive, argumentative Cannot accept fault Excitable, unpredictable

Schizophrenia Debilitating distortions of speech, thought Bizarre hallucinations Social withdrawal Lack of emotional expressiveness NOT the same as multiple personality disorder

Violence

Suicide Suicide attempt = Any willful act designed to end one’s own life 10th leading cause of death in U.S. Second among college students Women attempt more often Men succeed more often

People who kill themselves, DO talk about it in advance! Suicide 50% who succeed attempted previously 75% gave clear warning of intent People who kill themselves, DO talk about it in advance!

Take ALL suicidal acts seriously! Suicide Take ALL suicidal acts seriously!

Suicide Risk factors Men >40 y.o. Single, widowed, or divorced Drug, alcohol abuse history Severe depression Previous attempts, gestures Highly lethal plans

Suicide Risk factors Obtaining means of suicide (gun, pills, etc) Previous self-destructive behavior Current diagnosis of serious illness Recent loss of loved one Arrest, imprisonment, loss of job

Violence to Others 60 to 70% of behavioral emergency patients become assaultive or violent

Violence to Others Causes include Real, perceived mismanagement Psychosis Alcohol, drugs Fear Panic Head injury

Violence to Others Warning signs Nervous pacing Shouting Threatening Cursing Throwing objects Clenched teeth and/or fists

Dealing with Behavioral Emergencies

Basic Principles We all have limitations We all have a right to our feelings We have more coping ability than we think We all feel some disturbance when injured or involved in an extraordinary event

Basic Principles Emotional injury is as real as physical injury People who have been through a crisis do not just “get better” Cultural differences have special meaning in behavioral emergencies

Techniques Speak calmly, reassuringly, directly Maintain comfortable distance Seek patient’s cooperation Maintain eye contact No quick movements

Techniques Respond honestly Never threaten, challenge, belittle, argue Always tell the truth Do NOT “play along” with hallucinations

Techniques Involve trusted family, friends Be prepared to spend time NEVER leave patient alone Avoid using restraints if possible Do NOT force patient to make decisions

Techniques Encourage patient to perform simple, non- competitive tasks Disperse crowds that have gathered

Behavioral Emergencies Assessment

Scene Size-Up Pay careful attention to dispatch information for indications of potential violence Never enter potentially violent situations without police support If personal safety uncertain, stand by for police

Scene Size-Up In suicide cases, be alert for hazards Automobile running in closed garage Gas stove pilot lights blown out Electrical devices in water Toxins on or around patient

Scene Size-Up Quickly locate patient Stay between patient and door Scan quickly for dangerous articles If patient has weapon, ask him to put it down If he won’t, back out and wait for police

Scene Size-Up Look for Signs of possible underlying medical problems Methods, means of committing suicide Multiple patients

Initial Assessment Identification of life-threatening medical or traumatic problems has priority over behavioral problem.

Focused History, Physical Exam Be polite, respectful Preserve patient’s dignity Use open-ended questions Encourage patient to talk; Show you are listening Acknowledge patient’s feelings

Assessment: Suicidal Patients Injuries, medical conditions related to attempt are primary concern Listen carefully Accept patient’s complaints, feelings Do NOT show disgust, horror

Assessment: Suicidal Patients Do NOT trust “rapid recoveries” Do something tangible for the patient Do NOT try to deny that the attempt occurred NEVER challenge patient to go ahead, do it

Assessment: Violent Patients Find out if patient has threatened/has history of violence, aggression, combativeness Assess body language for clues to potential violence Listen to clues to violence in patient’s speech Monitor movements, physical activity Be firm, clear Be prepared to restrain, but only if necessary

Management Your safety comes first Trauma, medical problems have priority Calm the patient; NEVER leave him alone Use restraints as needed to protect yourself, the patient, others Transport to facility with appropriate resources

Restraining Patients A patient may be restrained if you have good reason to believe he is a danger to: You Himself Other people

Restraining Patients Have sufficient manpower Have a plan; Know who will do what Use only as much force as needed When the time comes, act quickly; Take the patient by surprise At least four rescuers; One for each extremity

Restraining Patients Use humane restraints (soft leather, cloth) on limbs Secure patient to stretcher with straps at chest, waist, thighs If patient spits, cover face with surgical mask Once restraints are applied, NEVER remove them!

Reasonable Force Minimum amount of force needed to keep patient from injuring self, others Force must NEVER be punitive in nature

video https://www.youtube.com/watch?v=T5bX5a8FZ9E

Finish Assignments Diabetes Packet – Scavenger Hunt, Article Review, Advertisement Book Work – Questions pg. 622, 1-12 Vocabulary – Page 623