2. Introduction
•Consciousness is being awake, alert, and aware of your
surroundings.
• Stupor (Latin – to be stunned) – deep sleep/unresponsiveness
from which patient can be arouse only with vigorous/continuous
stimulation.
• Coma (Latin – deep sleep or trance) – state of unresponsiveness in
which patient lies with eyes closed and cannot be aroused even
with vigorous stimulation.
3. 4 things you need to
conscious
• Sugar
• Oxygen
• Intact neural pathways
• Intact reticular activating system (RAS)
Anything that disturbs or disrupts these
can cause alterations in mental status.
A sudden lack of blood flow to the brain
or lack of oxygen will shut the brain
down in 5 to 10 seconds.
4. Neural
pathway
• Groups of nerves that run through the brain
• Carry signals from the brainstem to various destinations in the brain
• These pathways can be disturbed by trauma, tumors, chemicals (drugs) or
electrical interference (that which cause seizures).
• Stroke, epilepsy, and trauma are different events that affect these
pathways resulting in altered mental states.
5. Intact RAS
• reticular activating system (RAS) — An area of nerves inthe
brainstem, thalamus and hypothalamus that controls
consciousness.
AMS is a strong
indication of insult to
the central nervous
system.
7. Acidosis
Acidosis is the increase in the acid level in the body. Its causes
include:
•diabetes
•shock
•poisoning
•overdose
•kidney failure
•impaired breathing
8. Alcohol
• A depressant that inhibits the brain
• As the blood alcohol level rises, reason and judgment are impaired.
• Intoxicated patients may progress from stupor to coma to death primarily
from respiratory depression and arrest.
• These people cannot maintain their airway and
are in danger of aspirating their saliva or vomitus.
9. Epilepsy/Seizures
•occurs when the neural pathways become disturbed
by excessive discharge of electricity in the brain
•can affect either part of the brain or the whole brain
itself
•Alcohol withdrawal in addicts may cause seizures
due to disruptions in the neural pathways.
10. Infection
•Usually causes high temperatures and inflammation
that affect the brain’s neural pathways, the brainstem
and supplies of sugar and oxygen
•Infection of the central nervous system, such as
meningitis or encephalitis, may cause an altered mental
status.
11. Overdose
•Barbiturates and narcotics (for example, heroin) are drugs
that can suppress brainstem function.
•Narcotics can slow the respiratory centers of the brain
resulting in a lack of oxygen.
•Cocaine can produce extremeCNS stimulation resulting in
seizures and strokes.
12. Underdose/Uremia
•Some medical conditions may cause altered mental status
when the patient does not take adequate amounts their
prescribed medication.
•Diabetic coma may occur in diabetics who do not take
adequate amounts of insulin.
•COPD patients can develop an altered mental status from
retaining too much carbon dioxide when they do not use
medicines delivered by their metered-dose inhaler.
13. Trauma/Tumors/Temperature
•Trauma to the head can cause damage to vessels and brain
tissue.
•Tumors can affect neural pathways and the brainstem,
neural pathways, oxygen and sugar.
•Temperature extremes have a dramatic impact on all four
elements of consciousness.
14. Insulin
•The insulin-dependent diabetic produces an insufficient amount of
insulin and must inject insulin into the body.
•If the diabetic forgets to eat, overexerts, or takes too much insulin,
there is a serious shortage of glucose (hypoglycemia).
•The brain, which is very sensitive to sugar supplies, begins to shut
itself down.
•Another condition called hyperglycemia may occur when there is
not enough insulin in the blood.
15. Psychosis
•A mental illness that commonly affects personality, for
example, schizophrenia and manic depression.
•Delirium and acute brain syndrome are specific types of
psychoses where the patient displays disorientation,
memory-loss, and lapses in
consciousness.
16. Poisoning
•Mechanism that causes unconsciousness varies greatly depending
on the substance.
•Carbon monoxide prevents oxygen from reaching the brain.
•An overdose of tricyclic antidepressants can cause hypotension,
cardiac dysrhythmias and a lack of oxygen and sugar.
Poisoning can occur through inhalation,
injection, absorption and ingestion.
17. Stroke
•A stroke occurs when a portion of the brain is damaged due to
interruption of blood flow (lack of sugar and oxygen).
•Strokes affecting one side of the brain may cause alteredmental
status.
•Massive strokes involving the brainstem will causecoma.
•Transient ischemic attacks (TIAs) can be thought of as "mini-
strokes"—symptoms of these events subside completely within 24
hours.
22. Generalized seizures (whole brain
involve)
• Tonic seizure — A brief seizures (usually < 60 seconds)
consisting of the sudden onset of increased tone in the
extensor muscles
• Clonic seizure —A sudden onset of alternate involuntary
muscular contraction and relaxation in rapid succession
• Tonic-clonic seizure — A type of seizure involving the entire
body, usually characterized by violent rhythmic muscle
contractions and loss of consciousness.
23. Generalized seizures (whole brain involve)
•Atonic seizure — A type of seizure that consist of a
sudden loss in muscle tone (usually <15 seconds)
•Myoclonic seizure — Tonic type of seizure in very short
duration (milliseconds) that may involve the whole body
or part of the body
•Absence seizure — brief seizure, usually <15 seconds,
causes loss of awareness associated with automatisms
24. Simple Partial Seizure
Signs/symptoms
• Tingling starts with fingers and moves proximally (epileptic
march)
• Twitching of muscles or extremities
• Head turning
• Visual changes
• Dizziness
• Aura
•Sensation of smelling odors, seeing lights or colors, feeling of
butterflies in the stomach
25. Complex Partial Seizure
Focal seizure with associated loss of consciousness &
automatisms
Signs and symptoms
•Confusion and no memory of the episode
•Abnormal behavior, possibly not noticed by others
•Staring, sense of déjà vu, visual hallucinations
•Aimless moving, fidgeting, repetitive motion
•Smacking, chewing lips
27. Causes of Seizure
By age group:
6 months to 3 years
• Common: high fever (febrile seizures)
• Metabolic abnormalities
•High/low sugar or sodium levels
•Low calcium or magnesium levels
•Vitamin B6 deficiency
2 to 14 years
• Often the cause is unknown
• May be the result of measles, mumps, other childhood diseases
28. Causes of Seizure
By age group
After age 25
• Head injury (trauma)
• Stroke
• Tumor
• Alcohol withdrawal
•Seizure and altered mental state are two signs ofdelirium
tremens, a sign of alcohol withdrawal
•May result in death (35% if untreated; 5% if recognizedand
treated early
29. Approach to Altered
Mental Status
•Danger
•Respond
•Airway
•Breathing
•Circulation
•Disability (neurologic)
•Exposure
30. Danger
•Observe the surroundings, the patient’s body
position, bystanders and other clues that may
indicate danger to you, your crew or the patient.
•Decide if it safe to enter the scene and if you need
additional resources.
31. Respond - Mental Status
•AVPU mnemonic
•Alert
• Responds to Verbal stimuli
• Responds to Pain
•Unresponsive
32. Approach
•Airway, breathing and circulation (ABC) must
be monitored closely.
•An altered mental status & seizure especially
requires that you attend to the airway,
breathing & oxygen therapy to meet patient
needs and proper positioning.
•Consider the use of an airway adjunct if the
airway cannot be maintained.
33. • If patient is still seizing:
• Position on side (no spinal
injury) for oral drainage
• Do not force anything into
mouth
• Do not restrain
• Loosen restrictive clothing
• Protect from injury
• Consider cause of seizure
Approach
34. Airway
• How do you assess?
Open the airway
Check pulse-oxymetry.
• What do you look for?
Check to see that the airway is
patent
Are there secretions or vomit that
needs to be suctioned?
Any foreign body?
• What interventions can you
make?
Provide supplemental oxygen if
needed
Intubate if GCS <8 comesmostly
from trauma literature
Maintain C-spine collarif
history unknown
35. Airway
• Head tilt/ chin lift
• Jaw thrust for
trauma patients
with suspected
cervical spine injury
36. Airway
• Note abnormal sounds.
• Snoring
• Denotes obstruction by the tongue
• Oropharyngeal or nasopharyngeal airway to maintain patency
• Gurgling
• Suction may be needed to clear fluids.
37. Airway
•Stridor or inability to speak
• May denote airway
obstruction
• Heimlich or other maneuvers may
be needed.
• Patient may be having severe
allergic reaction.
• Positive-pressure ventilation,
epinephrine, and rapid transport
may be needed.
38. Airway
•In unresponsive patients
• Maintain an open airway.
• Oropharyngeal or
nasopharyngeal airway may be
needed for continued airway
control.
• Suction may be
needed to clear
airway
39. Breathing
•How do you assess?
• Rate
• Depth
• Pattern
• Auscultation (bilateral and equal?)
• Pulse oximetry
• EndTidalCO2
• What options are there for
interventions?
• SupplementalO2
• Positive pressure support (CPAP,
BiPAP)
• Intubation
• Decompression
40. Breathing
•Look, listen, and feel
method
• Look for chest and abdominal
movements, accessory muscle
use, and retractions.
• Listen for air movement and
abnormal sounds of breathing.
• Feel for warm air from the lips
and mouth.
42. Circulation
•How do you assess?
• Distal pulses
• Blood Pressure
• Cardiac rhythm
• Distal perfusion
•What options are there for
interventions?
• IV fluids
• Blood products
• Cardioversion
• Cardiac pacing
• Inotropes/vasopressors
43. Circulation
•Pulse check
• Radial pulse in childrenand
adults
• Brachial pulse in infants
• Carotid pulse in unresponsive
adults and children when
unable to feel a pulse in the
arm
44. Circulation
• Observe for obvious bleeding.
• Assess for color, temperature, and condition (moisture).
• Skin
• Nail bed
• Conjunctivae and mucous membranes
• Note cyanosis.
• Signs of hypoperfusion — pale, cool, clammy skin.
45. Disability (neurologic
catastrophe)
•How do you assess?
GCS/IVPU
Pupillary exam
Look for seizure activity
Evaluate extremity
movement
Signs of elevated ICP
•What interventions can
you make?
Anti-epileptics
Elevate head of bed
Hypertonic agents
46.
47. Exposure
•What does this mean?
• Fully undress patient
• Head to toe rapid exam
•What are you looking for?
• Trauma
• Patches
• Lines, tubes, fistulas
• Rashes, wounds/decubitus
ulcers
49. Personal history
Seizure
Preictal
• Any warning? Abdominal pain, fear, unpleasant
sensation, any fever?
• What was patient doing? Asleep or awake?
• Precipitating events (head injury, source of
infections – CNS/middleears/sinus/abdo/respi/cvs)
50. History
Ictal
impaired
• Did child remember spell
• Repetitive behaviors during spell – lip
smacking, etc
• Body movements – part or all, gaze
deviation, eye rolling
• Cyanosis, Incontinence
• How long, how many, how often
Post ictal
• Responding during spell vs consciousness • How did they feel after (Drowsy?
Confused?Tired?)
• How long until return to baseline?
• Sustained any injuries?
• Previous history of seizures, febrile
seizures
51. Altered Mental Status (AMS)
• Baseline – be specific, what is the “change” they observed?
• How often do they see the patient?
• Changes in sleep-awake cycle
• Onset, location, evidence of trauma, information about home environment,
medications in home
• Family/friends: focal signs prior to LOC
Personal history
52. • Chronic illnesses (hepatic or renal failure, endocrinopathies, COPD,
DM,CCF)
• Medication - Immunosuppression/ recent cancer treatment
• Drugs that lower seizure threshold: Β lactam antibiotics,
Quinolones, INH, Acyclovir, Theophylline
• Previous history of alcoholism orWernicke'sencephalopathy
• Physical, emotional, mental disabilities
• Recent hospitalizations
• Recent dialysis
Past Medical history
53. Social history
•Home environment and social support systems
•Nutritional status (thiamine deficiency,Vit B12 and
folate deficiency)
•Any recent life-altering social or emotional events
•Any recent scuba diving (? air embolism) or foreign
travel (malaria)
54. Physical Examination
• Complete physical exam:
Check vital signs
Check pupils for size, symmetry and reactivity to light
Abnormal pupillary response may indicate depressed brain function or
brain injury.
Occular movements and oculovestibular response
DXT
Pulse oximetry
Neurology – signs of increased ICP,cranial nerves, motor power, sensory,
cerebellar, reflexes
57. Investigations
ECG / cardiac monitoring
Venous blood
FBC, electrolytes, LFT,TFT,CRP,blood
cultures, viral titer, glucose
Arterial blood
pH, pO2, pCO2, HCO3, lactate
Urine drugs ofAbuse? (ifsuspected)
Urinalysis, UPT
Imaging
CXR, CT Brain
Lumbar puncture
Indicated if there is suspicion of
meningitis or encephalitis
– Cells
– Gram stain
– Glucose / protein
– Cultures
Other test
Urine
EEG
58. •After seizure stops
•Identify and treat injuries
•Suction airway if necessary
•If cyanotic, provide oxygen (12-15 lpm NRB or 2-6 lpm nasal
cannula—adults and peds)
•Monitor vital signs and respirations
•Treat fever – tepid sponging and medication
•Consider antibiotics if high suspicion of infection
Treatment: Care for adult and pediatric
patients
59. Treat seizure
• Correct any reversible causes :
- Electrolytes/Glucose
• Specific drugs :
1) BezodiazepamGroup
- IV Lorazepam 0.1 mg/kg
- IV Diazepam 0.15 mg/kg
2) IV Phenytoin 20mg/kg at <50mg/min + BP monitoring & arrythmias
If still fitting, give :
- IV Phenobarbital 20mg/kg at 50 mg/minute
- IV Propofol 2mg/kg bolus then infuse 2mg/kg/hr
60. Treatment
•minimize sensory overload by limiting the number of care-
givers and ensuring a quiet enviroment
•allow family members to remain in constant/frequent
attendance
•do not leave patients unattended in the hallway and
ensure that the bed side-rails are up
