September 2012 Silver Cross EMD CE Silver Cross EMS System

 Sudden or gradual decrease in the patient’s level of responsiveness  Use the AVPU scale to assess mental status: ◦ Alert - are they awake and talking ◦ Verbal – do they respond to your voice ◦ Pain – do they respond to physical stimulation ◦ Unresponsive – are they not responding to anything

 When assessing the patient’s mental status, consider two factors: ◦ The patient’s initial level of consciousness ◦ Any change in that level of consciousness  What’s their orientation? ◦ Do they know:  Person, Place, Time & Events

 Conditions causing an altered level of consciousness ◦ Head injury ◦ Shock ◦ Decreased level of oxygen to the brain ◦ Stroke ◦ Slow or irregular heart rate ◦ High fever or extreme temperature changes

 Conditions causing an altered level of consciousness (cont’d) ◦ Infection or Sepsis ◦ Poisoning or Substance Abuse ◦ Low level of blood glucose ◦ Insulin reaction ◦ Psychiatric condition ◦ Fainting (Syncopal Episodes)

 What are some of the Chief Complaints in your EMDPRS that you would refer to for AMS until you get more specific information?

 Unconscious  Unknown Problem  Sick Person  With more specific information ◦ Bleeding/Shock ◦ Chest Pain ◦ Heat/Cold Exposure ◦ Diabetic Problems ◦ DIB ◦ Drug Overdose ◦ Psychiatric ◦ Seizure ◦ Stroke ◦ Traumatic Injuries, etc.

The following slides will review some of the more common causes of Altered Mental Status

 Caused by sudden episodes of uncontrolled electrical impulses in the brain  Generalized seizures ◦ Produce shaking movements ◦ Involve the entire body ◦ Last 1 to 2 minutes ◦ Usually leave patients unconscious and incontinent  Postictal State ◦ Period of time after seizure when patient is drowsy, confused and trying to recover.

 Generalized seizures caused by a sudden high fever ◦ Called febrile seizures ◦ Occur in infants and young children  Absence seizures ◦ Result in only a brief lapse of consciousness ◦ Patients may blink, stare vacantly, or jerk one part of their body

 Seizures can be caused by: ◦ Epilepsy ◦ Trauma ◦ Head injury ◦ Stroke ◦ Shock ◦ Low Blood Sugar ◦ Low Oxygen Levels

 Seizures can be caused by: (cont’d) ◦ High fever ◦ Infection ◦ Poisoning ◦ Brain tumor or infection ◦ Complication of pregnancy ◦ Substance Abuse or Withdrawal

 Treatment ◦ Usually, the seizure will be over by the time you receive the call. ◦ If it has not ended, focus on protecting the patient from injury. Do not advise caller to hold patient or put anything in their mouth. Items should be moved away from patient to make area safe. ◦ Once the seizure stops, ensure an open airway and place the patient in the recovery position. ◦ If no breathing, begin steps of CPR.

 Leading cause of brain injury and disability in adults  Most strokes are caused by a blood clot that blocks blood supply to a part of the brain, but can also be cause by bleeding in brain.  Signs and symptoms ◦ Dizziness ◦ Confusion ◦ Facial Droop ◦ Unsteady Gait ◦ Weakness

 Signs and symptoms (cont’d) ◦ Drooling/Difficulty Swallowing ◦ Severe Headache ◦ Numbness/paralysis on one side of the body ◦ Difficulty seeing ◦ Unequal pupil size ◦ Patient may be alert, confused, unresponsive, or unable to speak ◦ Seizures

 Signs and symptoms (cont’d) ◦ Unconsciousness ◦ Incontinence ◦ Respiratory arrest  Cincinnati Prehospital Stroke Scale ◦ Used by EMS providers and hospital staff to determine whether a patient may have experienced a stroke ◦ Requires no special equipment

Stroke Stroke Cincinnati Stroke Scale Test for arm drift by having patient hold arms straight out with eyes closed. Test for slurred speech by having them repeat a simple phrase. Test for facial droop by having them smile. Any abnormal findings, indicate possible stroke.

 Treatment ◦ The first priority is to maintain an open and clear airway. ◦ Make sure head and shoulders are elevated. ◦ Provide emotional support. ◦ If the patient is having a seizure, follow that protocol. ◦ Be prepared to administer rescue breathing.

 Treatment (cont’d) ◦ Place an unresponsive patient in the recovery position. ◦ Some patients can be treated with drugs to dissolve the blood clot in their brain. ◦ Arrange for prompt transport. ◦ Monitor the patient until EMS arrives.

 Caused by the body’s inability to process and use glucose  The body produces insulin, which enables glucose to move into individual cells. ◦ If the body does not produce enough insulin, the cells become “starved” for sugar and diabetes results.

 Insulin shock (Low Blood Sugar) ◦ Occurs if the body has enough insulin but not enough blood glucose ◦ Signs and symptoms  Pale, moist, cool skin  Rapid, weak pulse  Dizziness or headache  Confusion or unconsciousness  Sweating  May appear intoxicated

 Insulin shock ◦ Signs and symptoms (cont’d)  Hunger  Rapid onset of symptoms (within minutes) ◦ A person experiencing insulin shock may appear to be drunk or have personality changes. ◦ If the patient is able to swallow, have him or her eat or drink something sweet. ◦ Nothing by mouth if they are unconscious or unable to follow directions.

 Diabetic coma ◦ Occurs when the body has too much blood glucose and not enough insulin ◦ Signs and symptoms  History of diabetes  Warm, dry skin  Rapid pulse  Deep, rapid breathing  Fruity odor on the patient’s breath

 Diabetic coma (cont’d) ◦ Signs and symptoms (cont’d)  Weakness, nausea, and vomiting  Increased hunger, thirst, and urination  Slow onset of symptoms (days) ◦ Misdiagnosis is common—it is not always easy to distinguish between insulin shock and diabetic coma. ◦ In general, give conscious diabetic patients sugar by mouth and arrange for prompt transport. ◦ If the diabetic patient is unconscious, arrange for prompt transport. ◦ WHEN IN DOUBT, GIVE SUGAR!

May result from… Patient stands up too quickly after being dehydrated, illness, giving blood, heat stress, etc. Severe emotional challenge, fear or stress. Medications that lower blood pressure Sudden cardiac arrhythmias which can cause a lack of oxygen to the brain

 When patient stands up, momentary decrease in perfusion to the brain.  Patient faints.  Once flat on ground, circulation is restored to the brain, and patient wakes up. Treatment: Rule out injury from the fall Open airway & assess breathing Elevate feet if patient’s face is pale and cool Do not allow the patient to stand immediately. Could be a symptom of something more serious!

Sepsis Sepsis The body's response to an overwhelming infection. Can be limited to a particular body region (tooth abscess) or can be widespread in the bloodstream ("septicemia" or "blood poisoning"). More likely to affect: Very young (premature babies) or very old Weakened immune system Have wounds or injuries, such as those from burns or trauma Abusers of alcohol or drugs Receiving IV’s, wound drainage, urinary catheters Chronically ill patients Follow a recent illness Genetic factors

Sepsis Sepsis Cool, pale extremities High or very low temperature, chills Lightheadedness Low blood pressure, especially when standing Low or absent urine output Palpitations Rapid heart rate Altered mental status: restlessness, agitation, lethargy, or confusion Shortness of breath Skin rash or discoloration

 Extreme changes in body temperature can cause AMS. ◦ Patients with heat exhaustion or heat stroke ◦ Patients with hypothermia ◦ Fever  Treatment includes: ◦ Monitor patient’s ABCs ◦ Try to restore normal body temperature

 Behavioral emergencies are situations in which a person exhibits abnormal, unacceptable behavior that cannot be tolerated by the patient themselves or by family, friends, or the community.  Psychiatric illnesses ◦ Depression ◦ Panic/Anxiety ◦ Psychotic behavior  Mind-altering substances ◦ Alcohol ◦ A wide variety of chemical substances

Potential for violence! Responder safety is important. ◦ Maintain the patient’s ABCs and normal body temperature. ◦ Keep the patient from additional harm. ◦ Provide emotional support.

 Traumatic Injuries and blood loss can cause shock, which will cause a lack of oxygen to the brain.  Injuries to the head can cause brain injuries and AMS.  An overview of these problems will be review in the following slides.

 Shock deprives the body of sufficient blood to function normally. ◦ As shock progresses, the body alters its functions in an attempt to maintain sufficient blood supply.  Signs and symptoms of shock ◦ Confusion, restlessness, or anxiety ◦ Cold, clammy, sweaty, pale skin ◦ Rapid breathing ◦ Rapid, weak pulse ◦ Nausea and vomiting ◦ Weakness or fainting ◦ Thirst

 Head and spinal cord injuries are common causes of death. Account for approximately 50% of all traumatic deaths. ◦ Can also lead to irreversible paralysis and permanent brain damage ◦ In a closed head injury, bleeding and swelling within the skull may increase pressure on the brain, leading to brain damage and death. ◦ An open head injury usually bleeds profusely

 A blow to the head or face may cause concussion of the brain. ◦ Closed injury with a temporary loss or alteration of part or all of the brain’s abilities to function without demonstrable physical damage to the brain ◦ About 90% of patients do not experience a loss of consciousness.  A patient with a concussion may be confused or have amnesia. ◦ Retrograde (can’t remember events before) ◦ Anterograde (can’t remember events after) ◦ Repetitive questioning  Usually a concussion lasts only a short time.

 Far more serious than a concussion  Involves physical injury to brain tissue  May sustain long-lasting and even permanent damage  A patient may exhibit any or all of the signs of brain injury.

 Signs and symptoms of head injuries ◦ Confusion ◦ Unusual behavior ◦ Unconsciousness ◦ Nausea or vomiting ◦ Blood from an ears or nose ◦ Decreasing consciousness ◦ Unequal pupils ◦ Paralysis ◦ Seizures ◦ External head trauma (bleeding, bumps, bruises) ◦ Bruising under eyes or behind ears (late signs)

◦ Keep the head in a neutral position and advise patient not to move. ◦ Maintain an open airway and Monitor ABCs; be prepared to perform CPR if necessary. ◦ Control bleeding from all wounds with dry, sterile dressings. ◦ Examine and treat other serious injuries. ◦ Arrange for prompt transport.

 Altered Mental Status can be the result of medical, environmental, psychological, chemical or traumatic problems. Gather signs, symptoms and information about the scene to determine underlying causes and appropriate treatment.  Treatment will be focused on maintaining ABCs, providing emotional support and preventing injury.  Refer to appropriate flipcharts in the EMDPRS for specific instructions.

 AAOS Emergency Medical Responder: Your First Response in Emergency Care, 5 th Edition  Will County EMDPRS, June 2012