AMS - Psychological Emergencies CME 2007

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AMS - Psychological Emergencies CME 2007

  1. 1. AMS and Psychological Emergencies Brown University EMS March 4, 2007
  2. 2. What is AMS? <ul><li>Altered mental status: a condition in which the patient displays a change in his/her normal mental state ranging from disorientation to complete unresponsiveness </li></ul>
  3. 3. What Causes AMS? <ul><li>Traumatic head injury </li></ul><ul><li>Poisoning or drug overdose </li></ul><ul><ul><li>Intoxication </li></ul></ul><ul><li>Post-seizure </li></ul><ul><li>Infection </li></ul><ul><li>Shock </li></ul><ul><li>Hypoxia </li></ul><ul><li>Stroke </li></ul><ul><li>Diabetes </li></ul>
  4. 4. Signs and Symptoms: Trauma <ul><li>Obvious trauma (DCAP-BTLS) </li></ul><ul><li>Abnormal respirations </li></ul><ul><li>Abnormal heart rate </li></ul><ul><li>Unequal or sluggish pupils </li></ul><ul><li>Hypo/hypertension </li></ul><ul><li>Pale, cool, moist skin </li></ul><ul><li>Posturing </li></ul><ul><li>Raccoon eyes (late sign) </li></ul><ul><li>Battle’s signs (late sign) </li></ul>
  5. 5. Signs and Symptoms: Medical <ul><li>Abnormal respirations </li></ul><ul><li>Abnormal heart rate </li></ul><ul><li>Abnormal skin condition </li></ul><ul><li>Unequal or sluggish pupils </li></ul><ul><li>Stiff neck </li></ul><ul><li>Seizure activity </li></ul><ul><li>Hypertension and bradycardia </li></ul><ul><li>Bowel/bladder incontinence </li></ul><ul><li>Irregular blood glucose level </li></ul>
  6. 6. Signs and Symptoms: Diabetes <ul><li>Irregular blood glucose level: </li></ul><ul><ul><li>Hypoglycemia (<60mg/dl w.signs; <50mg/dl w/o signs) </li></ul></ul><ul><ul><li>Hyperglycemia (>120mg/dl) </li></ul></ul><ul><li>Seizure activity </li></ul><ul><li>Stroke-like symptoms </li></ul><ul><li>Combativeness or bizarre behavior </li></ul><ul><li>Anxiousness/restlessness </li></ul><ul><li>Rapid AMS onset </li></ul><ul><li>Intoxicated appearance </li></ul><ul><li>Tachycardia </li></ul><ul><li>Cool, moist skin </li></ul><ul><li>Hunger </li></ul>
  7. 7. Signs and Symptoms: Intoxication <ul><li>25% of calls at Brown! </li></ul><ul><li>Symptoms depend on class of drugs </li></ul><ul><ul><li>CNS Stimulants </li></ul></ul><ul><ul><li>CNS Depressants </li></ul></ul><ul><ul><li>Narcotics </li></ul></ul><ul><ul><li>Hallucinogens </li></ul></ul><ul><ul><li>Volatile Inhalants </li></ul></ul>
  8. 8. Assessment <ul><li>Initial assessment: </li></ul><ul><ul><li>Stabilize c-spine if trauma cannot be ruled out </li></ul></ul><ul><ul><li>ABCs </li></ul></ul><ul><li>SAMPLE history </li></ul><ul><li>Baseline vital signs </li></ul><ul><ul><li>Include blood glucose </li></ul></ul><ul><li>Physical exam: </li></ul><ul><ul><li>Head and pupils </li></ul></ul><ul><ul><li>Mouth and oral mucosa </li></ul></ul><ul><ul><li>Chest and breath sounds </li></ul></ul><ul><ul><li>Abdomen, extremities, posterior </li></ul></ul>
  9. 9. Assessment (cont’d) <ul><li>Check the scene for evidence of: </li></ul><ul><ul><li>Rx or OTC medication (including insulin) </li></ul></ul><ul><ul><li>Drug or alcohol abuse </li></ul></ul><ul><ul><li>Oxygen tanks </li></ul></ul><ul><ul><li>Unusual odors (gas, poisons) </li></ul></ul><ul><li>Transport decision: </li></ul><ul><ul><li>Patients with AMS fall under implied consent and must be transported </li></ul></ul>
  10. 11. Behavioral Emergency <ul><li>A situation in which a person may exhibit panic, agitation, or bizarre thinking or actions </li></ul><ul><li>Examples of psychological emergencies: </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Phobias </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Bipolar disorder </li></ul></ul><ul><ul><li>Paranoia </li></ul></ul><ul><ul><li>Schizophrenia </li></ul></ul><ul><ul><li>Suicidal ideations </li></ul></ul>
  11. 12. Causes of Behavioral Changes <ul><li>Abuse/traumatic event </li></ul><ul><li>Traumatic head injury </li></ul><ul><li>Poisoning or drug overdose </li></ul><ul><li>Infection </li></ul><ul><li>Shock </li></ul><ul><li>Hypoxia </li></ul><ul><li>Stroke </li></ul><ul><li>Diabetes </li></ul><ul><li>Excessive heat/cold </li></ul>
  12. 13. Psych vs. AMS <ul><li>AMS </li></ul><ul><li>Sudden onset </li></ul><ul><li>Visual hallucinations </li></ul><ul><li>CAOx<3 </li></ul><ul><li>Abnormal pupils </li></ul><ul><li>Excessive salivation </li></ul><ul><li>Incontinence </li></ul><ul><li>Psych </li></ul><ul><li>Gradual onset </li></ul><ul><li>Auditory/visual hallucinations </li></ul><ul><li>CAOx3 </li></ul><ul><li>PEARRL </li></ul>
  13. 14. Assessment <ul><li>Initial assessment </li></ul><ul><li>SAMPLE history </li></ul><ul><li>Baseline vital signs </li></ul><ul><li>Physical exam </li></ul><ul><li>Be sure to rule out a physical emergency! </li></ul>
  14. 15. Keep In Mind… <ul><li>Emotional injury is just as real as physical injury </li></ul><ul><li>Speak calmly and be reassuring </li></ul><ul><li>Maintain a comfortable distance </li></ul><ul><li>Maintain eye contact </li></ul><ul><li>Respond honestly </li></ul><ul><li>Never threaten or challenge the patient </li></ul><ul><li>Do not play into hallucinations </li></ul><ul><li>Do not touch the patient without his/her consent </li></ul><ul><li>Never leave the patient alone </li></ul>
  15. 17. Emergency Care Algorithm: Altered Mental Status Adapted from Fig. 17.9 of Brady, 7th ed. Ongoing assessment Head tilt-chin lift or jaw thrust Suction if necessary Airway adjunct PPV with O 2 Mechanism of injury present? Yes No Consider manual in-line stabilization Assess mental status Focused history and physical exam Assess circulation Transport Airway open? NRB 15 lpm History of diabetes and on medication to control diabetes? Able to swallow? Administer oral glucose Assess breathing Assess circulation NRB 15 lpm Rapid medical assessment Unable to obey commands, responsive only to painful stimuli or unresponsive Altered but responds to verbal stimuli and obeys commands No No Yes Yes Yes No Adequate Inadequate
  16. 18. Emergency Care Algorithm: Behavioral Emergency Adapted from Fig. 26.4 of Brady, 7th ed. Ongoing assessment Head tilt-chin lift or jaw thrust Suction if necessary Airway adjunct PPV with O 2 Mechanism of injury present? Yes No Consider manual in-line stabilization Assess mental status Attempted suicide? Assess circulation Transport Airway open? NRB 15 lpm Patient violent? Restrain Assess breathing Assess circulation NRB 15 lpm Rapid medical assessment Altered or unresponsive Alert and able to obey commands No No Yes Yes Yes No Adequate Inadequate Recovery position (no trauma) Position of comfort Focused history and physical exam

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