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Chapter 19. Altered Mental Status. Case History.

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Altered mental status

Chapter 19

Altered Mental Status


Case history

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

Central and Peripheral Nervous System


Brain

Brain


Blood supply to the brain

Blood Supply to the Brain


Altered mental status1

Altered Mental Status

  • Structural problems

    • Injury or damage to an area of the brain

      OR

  • Metabolic problems

    • Affect the entire brain


Structural

Structural

  • Stroke

  • Head injury

  • Characterized by “one-sided” signs

    • Paralysis

    • Facial droop

    • Weakness on one side of the body

    • Unequal pupils


Metabolic

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

Causes of Altered Mental Status

  • Hypoglycemia, diabetic ketoacidosis

  • Poisoning

  • After seizure

  • Infection

  • Head trauma

  • Decreased oxygen levels (hypoxia)


Diabetes

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

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


Diabetes1

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

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 symptoms1

    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 symptoms2

    Hypoglycemia - Signs and Symptoms

    • Can also occur in patients who do not have diabetes

      • Infants with poor glycogen supplies

      • Malnourished individuals

        • Alcoholics


    Diabetic ketoacidosis

    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 ketoacidosis1

    Diabetic Ketoacidosis

    • Increased acidity in blood

      • Body tries to compensate by breathing deeply and rapidly.

    • Slow onset


    Emergency medical care history of diabetes

    Emergency Medical Care - History of Diabetes

    • Initial assessment

    • Focused history and physical exam

    • Vital signs

    • SAMPLE history


    Focused history and physical examination

    Focused History and Physical Examination

    • Description of episode

    • Onset

    • Duration

    • Associated symptoms

    • Evidence of trauma

    • Interruptions

    • Seizures

    • Fever


    Vital signs and sample history

    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

    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

    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 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

    Seizures

    • May be brief or prolonged

    • Causes

      • Fever

      • Infections

      • Poisoning

      • Hypoglycemia

      • Trauma

      • Drug or alcohol withdrawal

      • Hypoxia

      • Idiopathic


    Seizures infants and children

    Seizures – Infants and Children

    • Chronic seizures in children are rarely life threatening.

    • Febrile seizures should be considered life-threatening.


    Types of seizures

    Types of Seizures

    • Grand mal

    • Focal

    • Status epilepticus

    • Febrile

    • Petit mal


    Grand mal seizures

    Grand Mal Seizures

    • Three phases

      • Tonic

      • Clonic

      • Postictal


    Grand mal seizures tonic phase

    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

    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

    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

    Focal Seizures

    • May affect only a portion of the body

      OR

    • May present as altered mental status with bizarre behavior


    Status epilepticus

    Status Epilepticus

    • Rapid succession of seizures without an intervening period of consciousness

    • Prolonged seizure

    • Life-threatening because of sustained respiratory compromise


    Febrile seizures

    Febrile Seizures

    • Caused by fever

    • Children – 6 months to 6 years of age

    • Occur in up to 5% of children


    Petit mal seizures

    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

    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

    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


    Stroke1

    Stroke

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

      • 500,000 Americans are affected annually.

        • Nearly 25% die.


    Transient ischemic attack tia

    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

    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

    Stroke – Initial Assessment

    • Ensure patent airway.

    • Support ventilations, as necessary.


    Stroke signs and symptoms

    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

    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 exam1

    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 – Cincinnati Prehospital Stroke Scale


    Stroke los angeles prehospital stroke screen

    Stroke – Los Angeles Prehospital Stroke Screen


    Glasgow coma scale

    Glasgow Coma Scale


    Altered mental status emergency medical care

    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 care1

    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 care2

    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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