1. Chapter 11
Altered Mental Status

2. Objectives
11.1 Define altered mental status List nine causes of altered mental status using the mnemonic AEIOU-TIPS List and compare the four major types of diabetes.
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3. Objectives
11.4 List the signs and symptoms and demonstrate the treatment of the following medical conditions:
hypoglycemia
hyperglycemia
partial seizure
generalized seizure
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4. Objectives 11.5 Compare and contrast the three types of stroke:
ischemic stroke
hemorrhagic stroke
transient ischemic attack
11.6 Describe how to assess a patient with altered mental status.
11.7 Describe and demonstrate the treatment of a patient with altered mental status.

5. Topics Anatomy and Physiology Altered Mental Status (AMS)
Violent Behavior and Altered Mental Status
Chapter Summary

6. Case Presentation
In a convenience store, you hear the manager call for help and state that a customer is “really out of it” in the bathroom. You identify yourself as an OEC technician and offer to help as you suspect this might be a case of AMS. You find a middle-aged man lying on the floor. He is confused and responds only to loud verbal stimuli. His radial pulse is fast and strong. His skin is pale, cool to the touch, and diaphoretic.
Discussion Points:
What should you do?
After determining that the scene is safe, tell the manager to stabilize the man’s head and neck.
Instruct the clerk to call for a middle-aged man with altered mental status.
Introduce yourself to the patient and ask permission to help.
Perform a secondary assessment, looking for injuries, signs and symptoms.

7. Anatomy and Physiology
CNS: Brain and spinal cord
Brain: three main parts protected by skull and CSF:
Brain stem – controls life functions, (i.e., breathing, swallowing, responsiveness, and cardiovascular system)
Cerebellum – controls balance and coordination
Cerebrum – controls emotion, thought, speech, integration, memory, sensation and motor function.
Review CNS with your students. If necessary, return to Ch 6 Anatomy and Physiology.

8. Anatomy and Physiology
Spinal Cord:
Connects the peripheral nervous system to the brain, transmitting information to and from the brain.
Part of the Central Nervous System
Peripheral nervous system: All other neural elements not included in the CNS.
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9. Anatomy and Physiology
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10. Anatomy and Physiology
Endocrine system regulates level of glucose available to nervous system.
Endocrine organs produce and secrete hormones.
Pancreas secretes insulin and glucagon to regulate levels of circulating glucose.
Too high or too low blood glucose affects level of awareness or responsiveness.
Discussion Point: Ask students if anyone has family members who have diabetes. Discuss any experiences they’ve had with their family members’ levels of awareness or responsiveness.

11. Altered Mental Status AMS malfunction can be:
Global – affecting all parts of the central nervous system equally.
Decreased levels of responsiveness or abnormally stimulated states.
Localized or focal – affecting a portion of the body.
Motor weakness, balance problems, vision loss, or speech abnormalities.
Explain AMS and how it is affected by different illness and conditions.

12. Causes of Altered Mental Status
Causes of AMS: AEIOU-TIPS
A: alcohol and acidosis
Alcohol – most commonly abused drug in US; CNS depressant.
Acidosis – decrease in body pH, affecting homeostasis; numerous causes, e.g. decreased respiratory or cardiac function, renal disease, severe hyperglycemia, and various gastrointestinal disorders.
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13. Causes of Altered Mental Status
Causes of AMS: AEIOU-TIPS
E: epilepsy, environment, and electrolytes
Epilepsy –disorder resulting in sudden, recurrent seizures.
Environment – extreme variation from normal body temperature; results in changes in level of responsiveness; also toxic bites/stings.
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14. Causes of Altered Mental Status
Causes of AMS: AEIOU-TIPS
E: epilepsy, environment, and electrolytes
Electrolytes – imbalance disrupts homeostasis; levels affected by diet, exercise, medications, ill health, sweating, vomiting, or diarrhea.
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15. Causes of Altered Mental Status
I: insulin
Any condition that adversely affects production or use of insulin or regulation of blood glucose level.
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16. Causes of Altered Mental Status
O: oxygen and overdose
Oxygen – any decrease in cerebral O2 level will result in decrease of global CNS function and responsiveness; most common cause of AMS.
Overdose – due to overuse or abuse of prescription or illicit drug; depressants may negatively affect both CNS and respiratory function.
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17. Causes of Altered Mental Status
U: uremia
Poor kidney function results in toxic build-up of waste products, lethargy, coma, and death.
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18. Causes of Altered Mental Status
T: trauma and tumors
Trauma – traumatic brain injury causes brain swelling and increased intra-cranial pressure; results in focal or global AMS.
Tumors – abnormal growth of cells in brain: malignant or benign; focal or global AMS.
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19. Causes of Altered Mental Status
MOIs that can cause AMS
Discussion Point: Move to slide 20 and discuss the three MOIs resulting in head and neck trauma and that may cause ALS.
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20. Causes of Altered Mental Status
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21. Causes of Altered Mental Status
I: infection
Presence of foreign microorganisms that cause tissue damage.
When spread throughout the body by blood it is called sepsis.
AMS associated with infection is a grave sign.
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22. Causes of Altered Mental Status
I: infection
Meningitis
Inflammation of meninges of the brain/spinal cord caused by infection.
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23. Causes of Altered Mental Status
P: poisoning and psychiatric causes
Poisoning – poison is a substance that, when taken into the body, can cause AMS, injury, or death.
Psychiatric causes – examples are schizophrenia, manic-depressive disorder, depression, and dementia.
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24. Causes of Altered Mental Status
S: seizure, stroke, and syncope
Seizure – electrical disturbance in the brain; focal or global.
Stroke – loss of blood supply to part of brain, resulting in neurological impairment.
Syncope (fainting) – temporary loss of responsiveness due to disrupted blood flow to the brain.
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25. Conditions Associated With AMS
Epilepsy – chronic condition causing recurrent seizures.
Factors associated with epilepsy – head injury, brain trauma, brain tumors, genetic conditions, and chemical imbalance.
Chronic epileptics treated with anti-convulsant medications.
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26. Conditions Associated with AMS
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Copyright Edward McNamara

27. Conditions Associated with AMS
Medic Alert Tags may help identify the cause
Discussion Point: Many, many illnesses are not readily obvious. Mention that students should not make assumptions and much check for Medic Alert Tags that will give clues to the persons AMS.
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28. Conditions Associated With AMS
Seizures: electrical disturbance in the brain, causes altered awareness, attentiveness, responsiveness, behavior, or body movement; lasts seconds to hours, average is1-3 minutes.
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29. Conditions Associated With AMS
Seizures
Partial seizure – focal point in a group of muscles or on abnormal sensations.
Generalized seizure – affects both sides of body equally and usually causes a decreased level of responsiveness.
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30. Conditions Associated With AMS
Grand mal seizure – most common type of generalized seizure.
Tonic activity – muscle tensing an contraction.
Clonic activity – muscle groups spasm violently in a jerking fashion.
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31. Conditions Associated With AMS
Generalized seizure – three phases:
Pre-ictal – occurs before seizure; aura or premonition of seizure.
Ictal – tonic-clonic phase; unconscious.
Post-ictal – minimally responsive.
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32. Conditions Associated With AMS
Status epilepticus:
Seizure lasting longer than 10 minutes, or
3 or more seizures without regaining responsiveness.
True medical emergency.
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33. Conditions Associated With AMS
Diabetes – inability to regulate blood sugar level; glucose level to high
Chronic disease.
Pancreas cannot produce enough insulin, or cells do not respond to insulin, or both.
Glucose does not enter the cells and builds up in blood stream.
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34. Conditions Associated With AMS
Diabetes – inability to regulate blood sugar level; glucose level to high
Symptoms – polyuria, polydipsia, increased appetite, change in weight, fatigue, dry mouth, cellular damage.
Discussion Point: Return to the discussion of those who know someone who has diabetes. Expand upon their statements with this detailed information.
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35. Conditions Associated With AMS
Diabetes mellitus– 4 Types:
Type 1
Caused by autoimmune disease in the young.
Destroys pancreatic cells that produce insulin.
Controlled by injectable insulin or insulin pump.
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36. Conditions Associated With AMS
Diabetes mellitus– 4 Types:
Type 2
Unknown cause; increased incidence in the obese; also may be genetically predisposed.
Cells are resistant to action of insulin.
Controlled by weight loss, exercise, and oral hypoglycemic medication.
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37. Conditions Associated With AMS
Diabetes mellitus– 4 Types:
Gestational diabetes mellitus
Develops only during pregnancy.
Other
Genetic defect in insulin-producing cells.
Genetic defect in the action of insulin.
Drug or chemical affect on insulin.
Hormone-related disorders.
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38. Conditions Associated With AMS
Hypoglycemia – Effects of Diabetes:
 Blood sugar – less than 70 mg/dL.
Patient took too much diabetic medication or took medication and did not eat adequately.
Early signs and symptoms – anxiety, dizziness, tachycardia, diaphoresis, tremor, headache, mild confusion, conscious ,and able to swallow.
Will resolve quickly after receiving glucose.
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39. Conditions Associated With AMS
Hypoglycemia – Effects of Diabetes:
Severe signs and symptoms – marked confusion, disorientation, lethargy, slurred speech, seizures, unilateral extremity weakness or unresponsiveness; irrational or combative behavior is common.
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40. Conditions Associated With AMS
Hyperglycemia- Effects of Diabetes
 Blood sugar – greater than 180 mg/dL.
Patient forgot to take diabetic medication
Early signs and symptoms – polyuria, polydipsia, dry mouth, and fatigue.
Late signs and symptoms – nausea, vomiting, abdominal pain, AMS, coma, brain injury, death.
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41. Conditions Associated With AMS
Hyperglycemia- Effects of Diabetes
Unusual to encounter hyperglycemia in the outdoor recreational environment.
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42. Conditions Associated With AMS
Stroke: neurological impairment due to low or no blood flow to areas of the brain.
Three types of stroke –
Ischemic:
Most common – 80%
Embolism – disrupted blood flow due to foreign material in the blood vessel, e.g. blood clot, fat from fractures or cholesterol plaque migration.
Discussion Point: Once students learn its signs and symptoms, stroke may be more obvious than some other causes of AMS.
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43. Conditions Associated With AMS
Three types of stroke –
Hemorrhagic:
Blood vessel ruptures in the brain.
Hematoma forms, placing pressure on brain.
Caused by structural weakness in vessel.
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44. Conditions Associated With AMS
Three types of stroke –
Transient ischemic attack (TIA):
Temporary interruption of blood flow to an area in the brain.
No permanent brain damage.
Signs and symptoms resolve within 24 hours after embolism moves on.
Early warning sign of a more serious stroke.

45. Case Update
You tell the manager to hold the man’s head. You ask patient’s permission to help. While doing a secondary survey, the man’s eyes roll back. He groans, stiffens, and begins to shake violently. The manager grabs the patient’s wallet, and directs you to, “Put it in the patient’s mouth before he dies!”
Discussion Points:
What should you do now?
Take wallet from manager, but set aside.
Instruct manager to protect patient’s head from banging on the floor.
Clear away nearby objects.
Time the seizure (45 seconds).
After seizure, place patient on left side and assure airway is clear.
Check patient’s wallet for medical card  he is diabetic.
If conscious and able to swallow, administer sugar or glucose.
Monitor ABCDs.

46. Patient Assessment Patient assessment with AMS: continued
Discussion Points:
What would you do when encountering this man?
What does the scene size-up tell you?
Can you rule out a traumatic injury as the cause of AMS?
ABCDs, primary survey, AVPU and/or Glasgow.
Look for clues. Hypoxia and hypoglycemia are the two most common causes of AMS.
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47. Patient Assessment
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Copyright Edward McNamara

48. Patient Assessment
Scene size-up – gather family/friends or bystanders to help with history; traumatic or medical origin?
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49. Patient Assessment Scene size-up Primary survey: ABCDs
AVPU and/or Glasgow (monitor for changes).
Look for clues – hypoxia and hypoglycemia are the two most common causes of AMS.
Activate EMS.
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50. Patient Assessment Scene size-up Secondary survey:
SAMPLE history and vital signs.
OPQRST
DCAP-BTLS
Gather history from others when necessary
Ask about taking medications as prescribed
Look for medical information tags
Pupillary exam
Motor-sensory exam
Higher cortical function exam
Vocal/speech exam
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51. Patient Management Deal with deficits in ABCDs. Provide high-flow O2.
Provide sugar to an awake diabetic.
Consider spinal precautions.
Activate EMS and provide rapid transport.
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52. Patient Management Symptom-based management in AMS:
A – Alcohol and acidosis: protect airway, support respirations, rapid transport.
E – Epilepsy, environment & electrolytes: protect from injury, protect airway, take steps to restore a normal body temperature, rapid transport.
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53. Patient Management Symptom-based management in AMS:
I – Insulin: give sugar (if fully conscious), activate EMS, monitor, transport.
O – Oxygen and overdose: maintain ABCDs, high-flow O2, rapid transport.
U – Uremia: maintain ABCDs and transport.
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54. Patient Management Symptom-based management in AMS:
T – Trauma and tumors: maintain ABCDs, high-flow O2, treat to prevent shock, rapid transport.
I – Infection: maintain ABCDs, if remote – clean wound, cool fever, suggest NSAID.
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55. Patient Management Symptom-based management in AMS:
P – Poisoning and psychiatric causes: maintain ABCDs, high-flow O2, contact poison center, for psychosis – support and prevent from harming self.
S – Seizures, stroke, and syncope: prevent further injury, maintain ABCDs, high-flow O2, activate EMS, rapid transport.

56. Violent Behavior and AMS
Uncooperative, can be dangerous:
Patients usually unaware that actions are inappropriate.
Cannot reason with patient.
Remain calm and reassure patient.
Avoid use of force, when possible. May cause more harm.
Discussion Points:
OEC Technicians help by:
Assisting in research projects, disaster relief, identifying outdoor safety issues, promoting safety
Completing EMS incident reports

57. Case Disposition
You set aside the wallet. You instruct the manager to protect patient’s head, clear away nearby objects, and time seizure (45 seconds). You place man on his left side and monitor ABCDs and check the patient’s wallet for medical card and find he is diabetic. He becomes responsive and tells you his name. You offer water, which he takes and does well. You stir in 5 packs of sugar, ask him to drink, and monitor closely.

58. Case Disposition
He is fully oriented in a few minutes. He reports that he was in a hurry and did not eat. Ambulance arrives, patient is handed off and thanks you.

59. Chapter Summary AMS describes an abnormality in brain function.
Causes of AMS are numerous and may result in global or focal changes.
AEIOU-TIPS helpful to discover cause.
Patients with AMS are “load and go”.
High-flow O2 for all AMS patients.
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60. Chapter Summary
Diabetics with AMS need sugar, but only if able to follow commands and have intact gag reflex.
Must treat for spinal injury with any unwitnessed onset of AMS, until proven otherwise.
Seizures are usually self-limiting; treatment focus is preventing harm.