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Will/Grundy EMS

Will/Grundy EMS. 2 nd Trimester July 2010 ALTERED MENTAL STATUS and OVERDOSE. Altered Mental Status. Many calls are dispatched as… “patient unconscious” “active seizure” “possible stroke” “unknown illness” Or a family member may describe the patient as “not acting right”.

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Will/Grundy EMS

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  1. Will/Grundy EMS 2nd Trimester July 2010 ALTERED MENTAL STATUS and OVERDOSE

  2. Altered Mental Status Many calls are dispatched as… • “patient unconscious” • “active seizure” • “possible stroke” • “unknown illness” • Or a family member may describe the patient as “not acting right”.

  3. Some Possible Causes of AMS • Stroke • Seizure • Cardiac-related • Syncopal episode (fainting spell) • Diabetic Emergencies • Sepsis • Drug or alcohol problem/overdose

  4. Presentation Any or all of the following… • Seems drowsy or sleepy; not alert • Awake and cooperative, but seems confused • Awake, but using inappropriate words • Reported unconscious, but is now awake, with or without impaired memory

  5. Cardiac-Related BRADYCARDIA • Heart beats too slow, low blood pressure results. • Poor tissue perfusion (e.g. the brain) • Will usually have other symptoms • Altered mental status: may faint or feel “loopy” from low oxygen • Low blood pressure • Pale • Chest pain possible

  6. Cardiac-Related BRADYCARDIA-Treatment Position of comfort High concentration oxygen ALS – pacing, atropine, dopamine Rapid Transport

  7. Cardiac-Related HYPOVOLEMIA – Low Blood Volume • May faint or have altered mental status from low oxygen levels in body • Blood loss • Spinal injury • Dehydration • Heat exhaustion • Illness • Infection

  8. Cerebrovascular Accident (CVA or Stroke) Two types… • Ischemic—caused by a blood clot that developed in a brain vessel, or developed somewhere else (like the heart) and traveled to the brain. (85% of strokes are ischemic) • Hemorrhagic—brain vessel ruptures, causing bleeding into the brain tissue or cranial vault. (15% of strokes are hemorrhagic)

  9. Stroke Transient Ischemic Attack • Often called a “mini-stroke” • Clot affects a minor vessel, or collateral circulation compensates for blockage “A TIA is a period of stroke-like symptoms that self-resolve within 24 hours”

  10. Stroke-Presentation • Altered mental status or memory loss • Slurred speech or difficulty speaking or understanding speech • Difficulty swallowing • Confusion • Patient appears awake, but cannot speak, move, or follow commands

  11. Stroke-Presentation (cont.) • Facial droop (usually unilateral) • Partial paralysis or weakness • Hypertension • Rapid, full pulse • Impaired vision, unequal pupils

  12. Stroke-Presentation • New stroke SMO – Cincinnati Stroke Scale • Test for arm drop • Test for slurred speech…“You can’t teach an old dog new tricks” • Test for facial droop (even smile) • Document findings in narrative or report

  13. Stroke—Treatment • Until recently, stroke care was largely supportive only. • Now ischemic strokes are treated with clot-busting drugs that can limit future disability, and in some cases restore full function. • 3-hour time window for safe administration of clot-busting drugs… Time is brain!

  14. Stroke—Treatment • ABC’s: careful attention to airway management • High-flow oxygen with non-rebreather mask • Rule-out trauma: take C-spine precautions if necessary • Place in recovery position • Always check blood sugar • Contact or intercept with ALS • Rapid transport & early notification of E.R.

  15. Seizures • Irregularity in electrical neuron conduction patterns in the brain causes a temporary “short circuit” in brain function. • Lay people may refer to a seizure as a “fit” or “spell” • A seizure is not a disease, but a symptom of an underlying problem

  16. Seizures—Causes • Some patients are born with the condition, others develop it after a head injury or brain surgery • Compliance with medications can lead to normal life and function Non-compliance with meds is biggest cause of serious seizures due to epilepsy.

  17. Seizures-Types Complex Partial (Psychomotor) • Hallmark is bizarre behavior, which varies widely person-to-person • Glassy stare, confusion • Aimless moving about • Repetitive motions • Lip smacking, pacing • Chewing, grinding teeth

  18. Seizures—Types • Febrile Seizures—most common cause of seizures in children aged 6 months to 3 years. • High fever—by itself is a common and frequentreason for 9-1-1 calls involving children. • Caused by metabolic irregularities in patient’s chemistry due to sustained, high fever. • Often due to childhood diseases like mumps and measles, or common flu. • The body’s thermostat “resets” itself.

  19. Seizures-Types Simple Partial • Starts in or affects a single part of the body • Usually presents with jerking, tingling, or numbness in a single extremity

  20. Seizures-Types General Motor Seizure – formerly “Grand Mal” seizure Convulsive muscle spasms involving entire body • Breathing may be irregular, or stop temporarily • Diaphragm may be paralyzed • Throat and jaw muscles clenched • Excessive salivation • May lose bowel or bladder control • May bite tongue • Patient is unresponsive

  21. Seizures Postictal Phase Body & brain’s “rest period” after a seizure – often accompanied by altered mental status • Headache is common • Patient may remain unconscious, or… • …may regain consciousness but be very drowsy and confused • May last several minutes to many hours

  22. Seizures • Normally last only a minute or two. • Rarely may last 30 minutes or longer • Known as a status seizure, or status epilepticus • This is a true emergency • May require rapid transport while patient is still seizing • Requires ALS provider to administer drugs to stop the seizure – Versed per SMO

  23. Seizures-Treatment Do NOT restrain patient • Move furniture out of the way • Place pillow under head or cradle head in your lap • DO NOT try to insert anything into the mouth After seizure, suctioning of secretions may be required Place in recovery position Transport to E.D. Consider trauma if patient fell down, or if seizure was particularly violent

  24. Seizures-Treatment Status Seizure • ALS is required, even with febrile seizures • Administer high-flow oxygen • Place patient on side to help in draining secretions during the seizure • Protect the patient’s head

  25. Syncopal Episodes(fainting spell) May result from… • Patient stands up too quickly after being dehydrated, illness, heat stress (“orthostatic hypotension”). • Severe emotional challenge. • Hypoglycemia • Medications that lower blood pressure • Sudden cardiac arrhythmias (new-onset atrial fibrillation, short burst of v-tach or torsades)

  26. Syncopal Episode • 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.

  27. Syncopal Episode-Treatment Rule out trauma during the fall (consider C-spine precautions) Open airway & assess breathing Elevate feet if patient’s face is pale and cool Do not allow the patient to stand immediately. ALS protocols – remember fainting (like all altered mental status) is a symptom, not an illness, and requires further detective work on your part

  28. “So what makes diabetes a medical emergency?” Hypo (low) glycemia (blood sugar) • Too much insulin in blood. • Not enough sugar for brain • Altered mental status results as brain is starved for nutrients Hyper (high) glycemia (blood sugar) • Too much sugar in blood. • Not enough insulin in system to let glucose into cells. • Altered mental status results from dehydration as urination increases (body tries to get rid of ketones)

  29. Diabetes - Treatment • Always check a blood sugar with altered mental status, just in case. • IMC • If blood sugar is low (under 60), and patient is awake/alert, give oral glucose • If low and patient is altered or unconscious, give Dextrose IVP or Glucagon IM • If blood sugar is high (above 180) and patient is showing signs of ketoacidosis, give an 200 ml bolus IV NS.

  30. Clinical Presentation Hypoglycemia (BG < Normal) • Normal or rapid respirations • Pale, moist skin • Diaphoresis • Dizziness, headache • Rapid pulse • Normal or low BP • Altered mental status • Anxious or combative • Seizure or fainting • Coma • Weakness simulating CVA

  31. Clinical Presentation • Hyperglycemia • (BG > 200 mg/dl) • Kussmaul respirations • Dehydration with dry, warm skin and sunken eyes • Polydipsia: excessive thirst • A sweet or fruity (acetone) odor to breath • Polyphagia: excessive hunger • Poor wound healing • Rapid and weak pulse • Polyuria: excessive urination • Blurred vision, fatigue • Normal or slightly low BP • Varying degrees of unresponsiveness (altered mental status), slower onset than in hypoglycemia

  32. Sepsis • The body's response to an 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, a car crash, or a bullet • Abusers of alcohol or drugs • Receiving IV’s, wound drainage, urinary catheters • Genetic factors

  33. Sepsis – signs, symptoms and treatment • 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 • Treatment in the field includes fluid resuscitation and supportive care. In the hospital, the patient will get more fluids, IV antibiotics, steroids, mechanical ventilation and inotropic meds. Even with this treatment, 50 percent of patients in septic shock will die.

  34. Altered Mental Status • The most important symptom of brain injuries is the patient’s mental status (level of consciousness)

  35. Altered Mental Status Assessing Mental Status A.V.P.U. A- Alert V- Responds, open eyes to VOICE P- Responds, opens eyes, moves, moans to PAIN U- Completely UNRESPONSIVE

  36. Altered Mental Status Assessing Mental Status A & O (Alert & Oriented) x 4 Person—knows who he/she is Place—knows where he/she is Time—knows approximate calendar date, can identify president, current events, etc. Events—knows what happened

  37. Altered Mental Status During Focused History & Physical Exam… Assess the Pupils (PERRL) P- Pupils are E- Equal, R- Round, R- Reactive to L- Light

  38. Substance Abuse and Overdose • Addiction • Habituation • Physiological dependence • Psychological dependence • Tolerance • Withdrawal • Drug Overdose

  39. Common Drugs of Abuse

  40. Common Drugs of Abuse

  41. Common Drugs of Abuse

  42. Common Drugs of Abuse

  43. Common Drugs of Abuse • Drugs Used for Sexual Purposes • Ecstasy (MDMA) • Signs and symptoms include anxiety, nausea, tachycardia, and hypertension, followed by relaxation and euphoria. • Provide supportive care. • Rohypnol (“Date Rape Drug”) • Potent benzodiazepine, illegal in the U.S. • Treat as a benzodiazepine overdose and sexual assault victim.

  44. Alcohol Abuse • Physiologic Effects • CNS depressant • Alcoholism • Susceptible to methanol or ethylene glycol ingestion • Peripheral vasodilation, diuresis • General Alcoholic Profile • Drinks early in the day, alone, or secretly • Binges, blackouts, GI problems, “green tongue syndrome,” chronic flushing of face and palms • Cigarette burns, tremulousness, and odor of alcohol

  45. Alcohol Abuse • Consequences of Chronic Alcohol Ingestion • Poor nutrition • Alcohol hepatitis • Liver cirrhosis, pancreatitis • Sensory loss in hands/feet • Loss of balance and coordination • Upper GI hemorrhage • Hypoglycemia • Falls (fractures and subdural hematoma)

  46. Alcohol Abuse • Withdrawal Syndrome • Delirium Tremens (DTs) • Signs and Symptoms • Coarse tremor of hands, tongue, eyelids • Nausea, vomiting, general weakness, anxiety • Tachycardia, sweating, hypertension, hallucinations, irritability or depressed mood, poor sleep • Increased sympathetic tone, orthostatic hypotension

  47. Alcohol Abuse • Withdrawal Syndrome • Treatment • Establish and maintain the airway. • Determine if other drugs are involved. • Establish IV access. • Consider saline bolus if dehydrated • Consider medications. • 50ml of D50 if hypoglycemic – many alcoholics also have diabetes • Narcan if suspected narcotic involvement • Transport, maintaining a sympathetic attitude, and reassure the patient.

  48. But Always First (no matter whether it’s AMS or overdose)!!!! • ABC’s • Vitals Signs • O2 Administration • SPO2 if available • Complete SAMPLE history • Good BLS Comes First………….

  49. BLS Pre-Hospital Care Scene Safety/Survey Perform initial assessment May require airway control, definitely oxygen Ensure cervical spine immobilization as indicated Activate ALS!

  50. BLS Pre-Hospital Care Perform focused history and physical exam SAMPLE history Signs/Symptoms (when did they start?; how long did they last?) Allergies Medications (When last taken?) Prior Medical History (diabetes?, seizure disorder?) Last oral intake (When did patient last eat)? Events leading to illness/injury

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