Altered mental status
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Chapter 19. Altered Mental Status. Case History.

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Altered Mental Status

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Chapter 19

Altered Mental Status


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.”


Central and Peripheral Nervous System


Brain


Blood Supply to the Brain


Altered Mental Status

  • Structural problems

    • Injury or damage to an area of the brain

      OR

  • Metabolic problems

    • Affect the entire brain


Structural

  • Stroke

  • Head injury

  • Characterized by “one-sided” signs

    • Paralysis

    • Facial droop

    • Weakness on one side of the body

    • Unequal pupils


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


Causes of Altered Mental Status

  • Hypoglycemia, diabetic ketoacidosis

  • Poisoning

  • After seizure

  • Infection

  • Head trauma

  • Decreased oxygen levels (hypoxia)


Diabetes

  • Disease of the pancreas

  • Caused by a partial or total lack of insulin production

  • Symptoms of diabetes

    • Increased urination

    • Increased thirst

    • Increased hunger


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


Diabetes

  • Two major diabetic emergencies

    • Hypoglycemia

      • Abnormally low blood glucose level

    • Diabetic ketoacidosis

      • Blood glucose level too high and insulin level too low


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


  • 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™


    Hypoglycemia - Signs and Symptoms

    • Can also occur in patients who do not have diabetes

      • Infants with poor glycogen supplies

      • Malnourished individuals

        • Alcoholics


    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


    Diabetic Ketoacidosis

    • Increased acidity in blood

      • Body tries to compensate by breathing deeply and rapidly.

    • Slow onset


    Emergency Medical Care - History of Diabetes

    • Initial assessment

    • Focused history and physical exam

    • Vital signs

    • SAMPLE history


    Focused History and Physical Examination

    • Description of episode

    • Onset

    • Duration

    • Associated symptoms

    • Evidence of trauma

    • Interruptions

    • Seizures

    • Fever


    Vital Signs and SAMPLE History

    • History of diabetes

      • Medical identification tags, etc.

    • Last meal

    • Last medication dose

    • Related illness

    • Determine if patient can swallow.


    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.


    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.


    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


    Seizures

    • May be brief or prolonged

    • Causes

      • Fever

      • Infections

      • Poisoning

      • Hypoglycemia

      • Trauma

      • Drug or alcohol withdrawal

      • Hypoxia

      • Idiopathic


    Seizures – Infants and Children

    • Chronic seizures in children are rarely life threatening.

    • Febrile seizures should be considered life-threatening.


    Types of Seizures

    • Grand mal

    • Focal

    • Status epilepticus

    • Febrile

    • Petit mal


    Grand Mal Seizures

    • Three phases

      • Tonic

      • Clonic

      • Postictal


    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.


    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.


    Grand Mal Seizures – Postictal Phase

    • Decreased LOC and confusion

    • Slow awakening

      • Patient may fall asleep for short period.

    • Afterward, may complain of headache


    Focal Seizures

    • May affect only a portion of the body

      OR

    • May present as altered mental status with bizarre behavior


    Status Epilepticus

    • Rapid succession of seizures without an intervening period of consciousness

    • Prolonged seizure

    • Life-threatening because of sustained respiratory compromise


    Febrile Seizures

    • Caused by fever

    • Children – 6 months to 6 years of age

    • Occur in up to 5% of children


    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


    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.


    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


    Stroke

    • Third leading cause of death in the U.S.

      • 500,000 Americans are affected annually.

        • Nearly 25% die.


    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.


    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


    Stroke – Initial Assessment

    • Ensure patent airway.

    • Support ventilations, as necessary.


    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


  • 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.


    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.


    Stroke – Cincinnati Prehospital Stroke Scale


    Stroke – Los Angeles Prehospital Stroke Screen


    Glasgow Coma Scale


    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.


    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


    Altered Mental Status – Emergency Medical Care

    • Physical examination

      • Vital signs

      • Abnormal smells

      • Pupillary status

      • Motor and sensory function

        • Asymmetry

      • Check for medical alert tag.


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