21)Altered Mental Status
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21)Altered Mental Status

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21)Altered Mental Status 21)Altered Mental Status Presentation Transcript

  • Altered Mental Status
  • Altered Mental Status
    • What is AMS?
      • Any change from the normal of a pt’s mental status
    • Example
      • Mild confusion/abnormal behavior
      • Coma
    • Indications
      • Problem in the brain -(CVA/Stroke)
      • Problem affecting the brain -(Hypoxia)
  • Prehospital Goals of Treatment
    • Ensure adequate ventilation/circulation
    • Administer supplemental O2/glucose
    • Assess and treat underlying cause(s)
    • Assess and treat other problems
    • Consider possibility of trauma
    • PT may start at one LOC and degrade to another less stable one…
  • The Nervous System
    • Function
      • Controls voluntary/involuntary activity
    • Components
      • Central Nervous System (Computer)
        • Brain
        • Brainstem
        • Spinal Cord
      • Peripheral Nervous System (Communicator)
        • Associated nerves
        • Sensory- Carry info from body to brain
        • Motor – Carry info from the brain to the body
        • Divided into
          • Somatic NS = voluntary
          • Autonomic NS= Involuntary
  •  
  • Divisions of the Autonomic Nervous System
    • Sympathetic
      • “Fight or flight”
    • Parasympathetic
      • “Feed or breed”
    OR
  •  
  • The Nervous System The Brain
    • Cerebrum
      • Largest most superior portion of the brain
      • Divided into R & L hemispheres
      • Hemispheres divided into specialized lobes
        • Frontal = Intellect and motor function
        • Occipital = Eyesight
        • Temporal = Smell/Hearing
        • Parietal = Sensory information
    • Brainstem
      • Lower part of the brain
      • Circulation, Respiration, BP
    • Cerebellum
      • Outpocketing of brain, posterior to brainstem
      • Coordination and movement
  •  
  • The Nervous System The Brain: Blood Supply
    • Cerebral Blood Supply
      • 15% of Cardiac output
      • 80% of blood is supplied by the carotid arteries
      • Vertebral arteries supply the rest
        • Circle of Willis
      • Each area of the brain has its own blood supply
    • Sensitivity to Deprivation of glucose and O2
      • Cannot store glucose itself
        • Deprivation = AMS
      • Interruption in O2 supply
        • Unconsciousness 5-10 seconds
      • Blockage of O2 supply
        • Neural death 4-6 minutes
  • Structural Causes of AMS
    • Structural
      • Stroke/CVA
        • Blockage/disruption of blood flow in an artery feeding the brain
        • Only part of the brain is damaged
        • Asymmetry is noted in S/S
        • CVA pt may also have AMS
      • Asymmetric motor and sensory findings in the medical pt with AMS = Structural Condition
  • Metabolic Causes of AMS
    • Usually originates outside of the CNS
    • Tend to effect both sides of the body
      • Diffuse S/S
    • External & Internal Sources
      • External
        • -Poisoning - OD – Infection – Hypo/Hyperthermia
      • Internal
        • - Hypoxia – Hypotension – Diabetes/Endocine Emergencies – Organ failure
  • Endocrine Emergencies
    • Endocrine Glands
      • Secrete hormones directly into blood without aid of ducts
      • Pineal gland, Pituitary gland, Hypothalamus, Thyroid gland, Parathyroid glands, Adrenals, Pancreas, Ovaries, Testes
    • Hormones
      • Chemical produced by an organ/tissue
      • Controls/regulates activities of other organs
      • Rarely cause emergency disorders
        • Pancreas
  • The Pancreas
    • Pancreas
      • Retroperitoneal space, in folds of small intestine
    • Islets of Langerhans
      • 3 Different Cell types & Hormones
      • α cells – Glucagon
        • Causes stored carbohydrates/glycogen to break down to glucose
      • β cells – Insulin
        • Mediates passage of glucose into cells
      • Δ cells – Somatostatin
        • Inhibits release of Glucagon/Insulin
  • Diabetic Emergencies
    • What is it?
      • A disease of the pancreas in which insufficient amounts of insulin is produced or receptors become refractory to insulin
    • Glucose
      • C6H12O6
      • Carbohydrate energy source for cells.
    • Insulin
      • Hormone secreted by the pancreas that is essential for glucose metabolism.
    • Glucagon
      • Hormone secreted by the pancreas that causes stored forms of glucose to be released and glucose to be made from other molecules.
  • Glucose Metabolism
    • Glucose Metabolism
      • After a meal what glucose is needed is used
      • Excess glucose is stored as glycogen in:
        • Liver
        • Skeletal Muscles
        • Fat cells
      • Insulin
        • Binds to cells and through a cascade of events glucose it allowed into the cell through its receptor.
      • Glucagon
        • Secreted when blood sugar is low
        • Causes glycogen to convert to glucose
      • Epinephrine
        • Glucagon like effect
        • Further release from the liver
        • Pale, cool, diaphoretic skin
        • Rapid pulse, elevated bp
      • Effects of insulin/glucagon maintain constant level of glucose in blood
  •  
  • Diabetes Mellitus Hyperglycemia Type 1 Diabetes
    • Type I –Insulin Dependent DM (IDDM)
      • Destruction of Insulin producing β cells
        • Inadequate production of insulin by pancreas
      • Unsure as to cause
        • Viral infection? Autoimmune response? Heredity?
      • Frequent in children
      • Medicate with daily insulin injections
        • LIFELONG DEPENDENCEY
      • Diabetic Ketoacidosis (DKA)
  • Diabetes Mellitus Hyperglycemia Type II Diabetes
    • Type II – Non-Insulin Dependent DM (NIDDM)
      • Insulin resistance and relative insulin deficiency
        • Decreased insulin production, resistance by receptors, relative reduction in receptors
      • Associated with obesity
      • Weight loss, Oral diabetic medications
      • Does not usually cause DKA
      • Hyperosmolar Hyperglycemic Nonketonic Syndrome
  •  
  •  
  • Diabetic Ketoacidosis
      • What
        • Relatively prolonged insulin deficiency in which the blood glucose level rises and fatty acids are used as a fuel source
        • Slow onset, lasts 12-24 hrs
      • Why
        • Insulin levels are low and the liver reacts as if the body is starving
        • In spite of potentially high levels of plasma glucose
      • How
        • The liver produces glucose from fatty acids
        • Ketones are made as intermediate stages and used as fuel
        • Ketones are acidic
        • The p H of the body changes to an acid state
        • The brain switches from glucose to ketones for energy
        • Massive amounts of unusable glucose build up in the blood
      • S/S
        • Fruity acetone smell on pt breath
        • Kussmaul Respirations = (Deep rapid breath (compensation for acidic metabolic state)
        • Excessive urination/Osmotic Diuresis = (Glucose spills into urine, takes H2O with it)
          • Dehydration
          • Thirst
        • Unresponsiveness
        • Death
  •  
  •  
  • Hyperosmolar Hyperglycemic Nonketonic Syndrome
    • High serum glucose without ketoacidosis
      • Blood glucose > 600 mg/dL (33.3 mmol/L)
    • Body still produces enough Insulin to avoid entering starvation
      • No ketones produced
      • pH of blood not affected
    • Effects
      • Cellular dehydration
        • Fluid shift from intracellular to intravascular space
          • Hypotonic to hypertonic
      • Osmotic diuresis
        • Glucose dumps into urine, water follows = polyuria
        • Decreases blood volume
  • Hypoglycemia
    • Hypoglycemia
      • What
        • Excessively high insulin level
        • Abnormally low blood glucose level
        • TRUE MEDICAL EMERGENCY
      • Why
        • Too much insulin or not enough food intake
      • S/S
        • AMS
          • Combative, hostile, anxious, excited, agitated, uneasiness
          • Intoxicated appearance
        • S/S of epi release
          • Pale, cool, clammy, diaphoretic skin, increased pulse/bp, dilated pupils
        • Seizure/coma
        • Hunger, nausea, weakness, increased salivation
  • Blood glucose testing
    • Use BSI
    • Obtain:
      • Glucometer
      • Lancets
      • Alcohol prep pad
      • Bandaid/gauze
    • Take one of the pt fingers
    • Clean the tip and side of the finger with the alcohol prep pad
    • Allow alcohol to evaporate
    • Insert test strip into glucometer
    • Blanch side of pt finger
    • Uncap lancet and puncture pt finger
    • Squeeze a sample of blood from the finger and wipe it clean with gauze
    • Squeeze a second sample of blood from the finger and apply it to test strip
    • Wipe finger clean and apply bandage
    • Treat accordingly per findings of blood glucose level
  • Oral Glucose Pharmacology
    • Indication
      • AMS with suspected low blood glucose level
    • Contraindication
      • Unresponsive – Unable to swallow – No gag
    • Form
      • Gel
    • Dose
      • 1 tube = 1 unit = 15 g
    • Route
      • Oral
      • Placed between the cheek and gum
    • Action
      • Raises blood glucose level
    • Generic Name
      • Oral Glucose
    • Trade Name
      • Glucose, Insta-glucose
  • Administration
    • Obtain SAMPLE Hx and vitals
    • Ensure pt is AO and has a gag reflex
    • Allow pt to squeeze some of the glucose between cheek and gum
      • OR
    • Place glucose on a tongue blade and administer accordingly
    • Allow glucose to dissolve and continue with administration until tube is empty
    • Reassess glucose level shortly after giving glucose
    • DOCUMENT time given
  • Seizures
    • What
      • Temporary alteration in behavior caused by abnormal electrical activity in the brain
    • Causes
      • AMS
      • Trauma
      • Drug/alcohol withdrawal
      • Eclamspia
      • Infection
      • Fever
      • Poisoning
      • Hypoglycemia
      • Hypoxia
    • S/S
      • Depend on which section of the brain is affected
  • Gran Mal Seizures
    • Grand Mal
      • The type most people think of when they think of seizures
    • Three phases
      • Tonic
        • Sustained contraction of all voluntary muscles
        • Lasts approximately 30 seconds
      • Clonic
        • Intermittent contraction/relaxation of muscles
        • Rapid Jerking
        • Few seconds to several minutes
      • Postictal
        • Depressed LOC/confusion
  • Other Seizures Types
    • Focal Seizures
      • Do not generalize/involve entire brain
      • Seizure movement with 1 side of the body
    • Status Epilepticus
      • Rapid succession of seizures without an intervening period of consciousness
      • Threat to life b/c of sustained respiratory compromise
    • Febrile Seizures
      • In children 6 months-6 years that is precipitated by a rapid raise in temperature in the setting of an infection
    • Petit mal Seizures
      • Brief lapses of attention and awareness
      • 10-20 seconds
      • May suddenly stare with eyes turned upward or to the side with fluttering
      • Always brief and pt can resume normal activities as if nothing happened
  • Seizure Management
    • Airway
      • Pt may need assistance maintaining an airway
      • NPA/OPA
      • High flow O2
      • Suction
      • ALS?
    • Do not restrain pt or put anything in pt mouth
    • Remove objects in immediate area of pt
    • Be ready to take control of airway/breathing
  • Cerebrovascular Attacks (CVA) Strokes
    • Statistics
      • 3 rd leading cause of death in U.S.
      • 1 CVA every 40 seconds in U.S.
      • Approx. 795,000 CVA/yr (¼ die)
      • Aprrox 143,579 deaths/yr
      • Approx. ¼ of these die
      • Almost ¾ occur in people > 65 yo
      • Window for fibrinolytic drugs
        • 3 hours
    • Causes
        • Arteriosclerosis
          • Thrombus & Embolisms
        • Hemorrhages/Aneurysm
  •  
  • CVA Types Transient Ischemic Attacks (TIA)
    • Transient Ischemic Attacks
      • What
        • Temporary loss of brain function
        • Precursor to a CVA 50% of the time
        • AKA: “Mini Stroke”
      • Pathophysiology
        • Temporary diminished blood flow to the brain
      • S/S
        • Presents like typical CVA
        • Resolves completely in 24 hours
  • CVA Types Acute CVA
    • Acute CVA
      • What
        • Permanent neurological impairment
      • Why
        • Disruption of blood flow to the brain
        • Hemorrhage (10%), Ischemic (87%)
      • How
        • Clots form in cerebral arteries
        • Clots elsewhere in the body break off and travel to brain
        • Cerebral vessels rupture and bleed into the brain
  • CVA S/S
    • Alteration in consciousness
    • Decreased LOC
    • Facial Weakness, Asymmetry
    • Incoherent/slurred Speech
    • Headache
    • Uncoordination, weakness, paralysis
    • Sensory loss in limbs
    • Poor balance
    • Visual loss
    • Vertigo
    • Double vision
    • Hearing loss
    • Nausea/vomiting
  • CVA Assessment
    • Initial Assessment
      • ABC’s
        • Possible airway obstructions??
      • Supplemental O2
      • AVPU
    • Focused Hx and Px
      • Suspect CVA in pt with sudden loss of neurologic function/ALOC
      • TIME CRITICAL!!!!!!!
      • Focuses Hx
        • Focus on S/S
        • Interview conscious pt
        • Interview pt family, bystanders if pt ALOC
        • Time “0” = Symptom onset
        • Baseline Vitals
  • Cincinnati Prehospital Stroke Scale
    • Focused Hx and Px
      • Px Exam
        • Cincinnati Prehospital Stroke Scale
          • Facial Droop
            • Have pt show teeth/smile
            • Normal= Both sides are symmetric
            • Abnormal = Facial drooping/asymmetry noted on one side
          • Arm Drift
            • Have pt close their eyes and extend their arms and hold them out 8 -10 sec.
            • Normal= Both arms remain stable and equal
            • Abnormal= One arm either doesn’t move or slowly falls back to body
          • Abnormal Speech
            • Have pt repeat “You cant teach an old dog new tricks”
            • Normal= Correct words without slurring
            • Abnormal= Slurred words, wrong words, unable to speak
    • Interpretation
      • If ANY 1 of the above is + there is 75% chance the pt has a CVA
  • Glasgow Coma Scale
    • Px Exam
      • Glasgow coma scale- GCS scale
        • Numerical values assigned to responses of:
          • Eye
          • Verbal
          • Motor
        • Values range 1-4, 1-5, 1-6 respectively
        • 15 = Normal
        • 3 = Dead
  •  
  • CVA Assessment
    • Prehospital Management
      • Maintain patent airway
        • Airway
        • Breathing
        • Oxygenation
        • Suction
        • Adjuncts
      • Supportive therapy
      • Rapid transport
      • ALS intercept?
      • Cincinnati Stroke Scale and GCS score
      • Vitals
  • Altered Mental Status: Overall Management
    • Initial Assessment
      • Life threats
      • Ensure patent airway
      • Ventilation support if needed
      • Consider trauma
      • Hypo/hyperglycemia
    • Focuses Hx & Px
      • Provides rationale for transport
      • Focused Hx
        • Hx important as pt S/S may be minimal
        • Assoc complaints/chronology/hx of similar past episodes
          • i.e. Deterioration of LOC with hx of head trauma/Diabetes/Epilepsy
      • Px exam
        • Baseline vitals
        • Skin color, moisture, temperature
        • Fruity odor? (DKA)
        • PMS for motor deficit
        • Medic alert tags?
        • Cincinnati Stoke Scale & GSS score
  • Altered Mental Status: Overall Management
    • Management
      • Airway Compromise
        • Tongue & Inability to clear secretions
        • Manual airway techniques
        • Mechanical airways
        • Suction
      • Ventilation Support
        • ALL AMS pt should be assumed to have inadequate oxygenation
        • Supplemental O2 indicated
        • If in doubt err for BVM
      • Tx decision
        • Load and Go
        • Stay and play
      • On going assessment
        • Note any changes in pt condition
        • Repeat Vitals, AVPU, GCS score, Stroke Scale, etc.
  • TWINS???