1. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter 11 Altered Mental Status

2. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 11.1 Define altered mental status. 11.2 List nine causes of altered mental status using the mnemonic AEIOU-TIPS. 11.3 List and compare the four major types of diabetes. continued

3. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 11.4 List the signs and symptoms and demonstrate the treatment of the following medical conditions: a.hypoglycemia b.hyperglycemia c.partial seizure d.generalized seizure continued

4. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 11.5 Compare and contrast the three types of stroke: a.ischemic stroke b.hemorrhagic stroke c.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. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Topics Anatomy and Physiology Altered Mental Status (AMS) Violent Behavior and Altered Mental Status Chapter Summary

6. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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.

7. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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.

8. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

9. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Anatomy and Physiology continued

10. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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.

11. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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.

12. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

13. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

14. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

15. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Causes of Altered Mental Status I: insulin ◦ Any condition that adversely affects production or use of insulin or regulation of blood glucose level. continued

16. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Causes of Altered Mental Status O: oxygen and overdose ◦ Oxygen – any decrease in cerebral O 2 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. continued

17. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Causes of Altered Mental Status U: uremia ◦ Poor kidney function results in toxic build-up of waste products, lethargy, coma, and death. continued

18. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

19. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Causes of Altered Mental Status MOIs that can cause AMS continued

20. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Causes of Altered Mental Status continued

21. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

22. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Causes of Altered Mental Status I: infection ◦ Meningitis Inflammation of meninges of the brain/spinal cord caused by infection. continued

23. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

24. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

25. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

26. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Conditions Associated with AMS continued Copyright Edward McNamara

27. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Conditions Associated with AMS Medic Alert Tags may help identify the cause continued

28. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

29. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

30. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

31. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

32. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Conditions Associated With AMS Status epilepticus: ◦ Seizure lasting longer than 10 minutes, or ◦ 3 or more seizures without regaining responsiveness. ◦ True medical emergency. continued

33. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

34. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

35. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

36. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

37. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

38. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

39. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

40. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

41. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Conditions Associated With AMS Hyperglycemia- Effects of Diabetes ◦ Unusual to encounter hyperglycemia in the outdoor recreational environment. continued

42. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

43. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

44. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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!”

46. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Assessment Patient assessment with AMS: continued

47. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Assessment continued Copyright Edward McNamara

48. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Assessment Scene size-up – gather family/friends or bystanders to help with history; traumatic or medical origin? continued

49. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

50. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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 continued

51. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Management Deal with deficits in ABCDs. Provide high-flow O 2. Provide sugar to an awake diabetic. Consider spinal precautions. Activate EMS and provide rapid transport. continued

52. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

53. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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 O 2, rapid transport. ◦ U – Uremia: maintain ABCDs and transport. continued

54. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Management Symptom-based management in AMS: ◦ T – Trauma and tumors: maintain ABCDs, high-flow O 2, treat to prevent shock, rapid transport. ◦ I – Infection: maintain ABCDs, if remote – clean wound, cool fever, suggest NSAID. continued

55. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Management Symptom-based management in AMS: ◦ P – Poisoning and psychiatric causes: maintain ABCDs, high-flow O 2, contact poison center, for psychosis – support and prevent from harming self. ◦ S – Seizures, stroke, and syncope: prevent further injury, maintain ABCDs, high-flow O 2, activate EMS, rapid transport.

56. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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.

57. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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. continued

60. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY 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.