21)Altered Mental Status

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21)Altered Mental Status

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

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