Altered Mental States …or everything you need to know about coma, stroke, seizures, syncope, diabetic emergencies, etc... Altered Mental States Defined as when a patient is not thinking clearly or is incapable of being aroused. Consciousness/unconsciousness Responsiveness/unresponsiveness Coma Nervous System Anatomy Brain Anatomy & Function Major Functions: Brain Stem Cerebellum Cerebrum Brain Function Altered Mental States Hypoglycemia Hypoxemia Intoxication Drug overdose Head injury Brain tumors Glandular abnormalities Poisoning Hypo/hyperthermia Brain infection Differential Diagnosis A – Alcohol E – Electrolyte imbalance I – Insulin (diabetic emergencies) O – Opiates U – Uremia T – Trauma I – Infection (sepsis) P – Psychogenic causes S – Stroke, seizure, syncope Stroke Third leading cause of death in industrialized countries after heart disease and cancer. Risk factors include hypertension, age, smoking, lack of exercise, obesity, stress, with prevalence in certain racial/ethnic groups. High rate of successful recovery if recognized and treated quickly! Stroke (CVA) Cerebral vascular accident (CVA) is the interruption of blood flow to the brain. Stroke is the loss of brain function that results from CVA when blood flow is interrupted. Hemorrhagic Ischemic TIA Hemorrhagic Stroke Results from vessel rupture on the surface or within the brain. Subarachnoid Intracerebral 10% of all strokes with a 50 % mortality rate. Typically sudden onset of signs/symptoms. Ischemic Stroke Ischemic stroke results from arterial blockage, either: Thrombus Embolis Greater chances of survivability if treatment initiated within 3 hours. Transient Ischemic Attack Temporary disruption of brain function due to insufficient oxygenation. (“Mini-stroke”) Stroke-like symptoms usually rapid in onset with complete resolution within 24 hours. Often proceeds a stroke. Hard to distinguish from a stroke at onset. Stroke: Signs & Symptoms One-sided weakness or paralysis (hemiparesis) Facial droop on one side. Altered level of consciousness (confusion to coma). Change in personality or mood Headache or dizziness Impaired speech, blurred vision, poor coordination. Stroke: Signs & Symptoms Left Hemisphere Problems: Aphasia Receptive aphasia Expressive aphasia Right Hemisphere Problems: Dysarthria Neglect Stroke Mimics Hypoglycemia (Insulin reaction) Postictal state after a seizure Head injury: Epidural bleed (rapid onset) Subdural bleed (slower onset) Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan Stroke ALS Indicators Unconsciousness Decreased level of consciousness Severe hypertension (systolic > 200 mmHg or diastolic > 110 mmHg with neurologic signs) Hypotension and severe bradycardia Seizures Severe headache/vomiting Airway problems Progression of stroke symptoms Physical Exam Baseline vitals signs Blood glucometry Neurological function (Cincinnati Prehospital Stroke Scale: Facial droop Arm drift Speech Check for stroke mimics! Cincinnati Stroke Scale Patient History Chief complaint and time of onset are key in the assessment of stroke. Signs/symptoms (hypertension, HA, numbness or weakness, difficulty with speech/movement) Allergies Medications (blood thinners or anticoagulants) Past medical history ( previous stroke or TIA, AVM, cerebral aneurysm) Last oral intake Events leading to call Treatment and Plan Revascularization by clot dissolving medication must be initiated within 3 hours of a stroke. If a stroke is of recent onset, very short scene and transport times are CRITICAL! Determine time of onset of symptoms and notify hospital as soon as possible. Arrival at hospital is critical within first two hours of onset of symptoms. Patient Care ABCS! Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Rapid transport Seizure Defined as generalized, uncoordinated muscular activity associated with a loss of consciousness; a convulsion. Catergorized as: Generalized (grand mal) Absence (petite mal) Simple partial (focal motor) Complex partial (psychomotor) Generalized Seizure Usually presents with an aura. May be unifocal with progression to convulsion Loss of consciousness Tonic phase Clonic phase Postictal phase Be concern with status epilecticus Absence Seizure Also known as petit mal seizures Most common in children No loss of consciousness No loss of postural tone “Spacing out” Simple Partial Seizure Focal motor seizure or “Jacksonian” seizure. Characterized by a rhythmic jerking of limb or one side of the body. No loss of consciousness Complex Partial Seizure Also known as pyschomotor seizures Involve loss of consciousness Characterized by stereotyped movements (automatisms) Movements may look purposeful but they are not Lip smacking, movement of hands Typically present as intoxication, drug OD, or “psych patient” Febrile Seizures Common in children under age of 2 years Caused by spike in fever, usually patient has had cold or flu-like signs/symptoms. Presents similar to grand mal seizure with accompanying postictal phase. Causes Congenital defects (epilepsy) Febrile or high fever Brain structural problems (trauma) Metabolic disorders Chemical disorders (poisons/overdoses) Seizure: Signs & Symptoms Cyanosis Abnormal breathing Obvious head injury Loss of bowel control/incontinence Severe muscle twitching/motion Bite marks on tongue Postictal state with unresponsiveness/labored breathing Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan Seizure ALS Indicators Status seizures Seizure lasting longer than 5 minutes or postictal stage > 15 minutes without change in LOC Seizures in pregnant female Seizures due to: Hypogylcemia (Insulin reaction) Hypoxia Head trauma Drugs or alcohol Physical Exam Look for signs of trauma, overdose Baseline vital signs Blood glucometry Patient History Chief complaint, description and length of seizure are key to seizure assessment Signs/symptoms (witnessed event?) Allergies Medications (anticonvulsants) Past medical history (previous seizure history?) Last oral intake Events leading to call (historians?) Treatment & Plan If patient is in active seizure, allow seizure to run it’s course. Protect patient from further harm. Airway management (most common cause of seizure deaths are postictal airway loss!) Treat trauma. Know when to call for medics! Do not assume that all seizures are epilepsy. Patient Care ABCS! Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Transport Diabetes Diabetes affects over 20 million people in the US alone, 7% of the total population! Condition in which the body does not produce or use insulin properly. Complications can include kidney failure, blindness, heart disease, stroke, and lower extremity amputations. Risk factors include: genetics, obesity, lack of exercise, and certain racial/ethnic groups. Diabetes Type I: Juvenile diabetes No insulin production Controlled with insulin injections Type II: Adult onset diabetes Inadequate insulin production with increased tissue resistance to insulin effects Controlled with diet, exercise, oral medications Diabetic Emergencies Hypergylcemia (high blood glucose level) Diabetic Ketoacidosis (DKA) Hyperosmolar coma (HHNC) Hypogylcemia (low blood glucose level) Insulin shock Diabetic Ketoacidosis (DKA) Pancreas not producing enough or effectively insulin. Slow onset over several days Cells metabolizing fat for energy Result of: Too little insulin Not enough exercise Too much food Stress, fever, infection DKA: Signs & Symptoms Kussmaul respirations Weak, rapid pulse (possibly irregular) Warm, dry skin Normal to profoundly decreased blood pressure Fruity odor on breath (ketones) Nausea, vomiting, abdominal pain Altered level of consciousness Polyuria, polydipsia, polyphagia Hyperosmolar Coma State of unconsciousness resulting from: Hypergylcemia Ketoacidosis (no fruity breath) Profound dehydration Signs & symptoms: 3 – P’s Dry skin, mucous membranes Tachycardia, hypotension Insulin Shock Insufficient glucose stores necessary for blood oxygenation Sudden onset, life threatening Occurs as a result of: Too much insulin – accidental or intentional Low food intake Too much exercise Insulin Shock: Signs & Symptoms Cold, clammy, pale skin Abnormal, bizarre, or hostile behavior Shaking, trembling, weakness Full, rapid pulse Normal or elevated blood pressure Normal or elevated respirations Dizziness, headache, blurred vision Extreme hunger Slurred speech Seizures, loss of consciousness Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan Diabetic ALS Indicators Altered level of consciousness Patient unable to protect airway (absent gag) Unstable vital signs Rapid respirations Shock signs and symptoms Failure to respond to oral glucose Suspected DKA Seizures Physical Exam Mental status/level of consciousness Airway management (ability to swallow?) Baseline vital signs Blood glucometry Patient History Chief complaint, think about other possibilities. Signs/symptoms: DKA vs. Insulin shock Allergies Medications (Using insulin/meds? Last used?) Past medical history (Diabetic?) Last oral intake (Last meal or food) Events leading to call (Changes in health, stress level, exercise routine) Treatment & Plan Perform glucose check Position patient upright and give oral glucose if able to swallow (intact gag) Document times and blood glucose levels, patient responses to oral glucose Patient Care ABCS! Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Transport King County Guidelines Patients on insulin may be safely left at home: Blood glucose level is > 60 Able to eat and drink normally Someone is able to stay with them After care instructions left with repeat blood glucose level check and proper documentation Overdose Overdose is an excessive exposure, either accidental or intentional, to a chemical substance. Majority of calls will involve habitual drug users and attempted suicide with prescription medications. Observations at the scene and accurate history are critical in assessment of these patients. Overdose: Signs & Symptoms Altered Mental Status: Paranoia Agitation Nonsensical conversation Aggression Lethargy Coma Hallucinations Rapid speech Skin Signs: Diaphoretic Pale Flushed Cyanotic Look for needle track marks and/or abcesses Overdose: Signs & Symptoms Pupil Reaction: Normal Dilated Constricted Cardiovascular: Respiratory: Tachypnea Bradypnea Apnea Hyper/hypotension Tachycardia Bradycardia Arrhythmias Cardiac Arrest Temperature: Hyperthermia Hypothermia Overdose: Signs & Symptoms CNS depressants, sedatives, tranquilizers SSRI’s Stimulants Antidepressants Acetaminophen Pyschedlic drugs (LSD) Alcohol Intoxication Opiates/narcotics Cannabis Inhalants GHB ASA Poisoning 2.2 million poison exposures reported in the U.S. in 2000, that’s 1 every 15 seconds. 90% occur at home with > 50% under the age of 6 years. Poisoning occurs through the following routes: Ingestion Inhalation Injection Absorption Common Toxidromes: Carbon Monoxide Poisoning: Headache Tachypnea Nausea and vomiting Altered level of consciousness Pink, flushed membranes Coma Inaccurate SpO2 readings Common Toxidromes Organophosphate Poisoning: Decreased level of consciousness Bradycardia/hypotension Vomiting/excessive salivation Miosis Diaphoresis Bronchospasm Common Toxidromes Cyanide Poisoning: Headache Burning sensation in mouth or throat Confusion Decreased level of consciousness Agitation or combative behavior Shortness of breath Bitter smell of almonds Assessment Scene Safety/BSI Initial Assessment (Sick/Not Sick) Focused Exam Detailed Exam Assessment Treatment and Plan Altered LOC ALS Indicators Decreased LOC Respiratory distress or compromise Signs/symptoms of shock Signs of inadequate perfussion Sustained tachycardia Hypotension Unstable vital signs Cyanosis Scene Safety Protection of yourself and crew are your first priority! Do not become part of the problem! Scene secure? Police back-up needed? Contamination/exposure issues? Watch for needles! Stay alert! Restrain a patient whenever there are safety concerns! Focused Exam Airway! (check gag reflex) Chief complaint Baseline vital signs (pupil check, lung sounds) Blood glucometry Neurological exam (GCS) Ask pertinent SAMPLE/OPQRST questions Look for ALL possible clues…do a thorough exam! Pupillary Reaction Dilated = Reactive: Dilated = Non-reactive: Anoxia, profound ETOH, SZ, drugs (LSD) Dilated/Unequal/Non-reactive: Hypoxia, alcohol, stimulants (cocaine, meth) CVA (hemorrhagic), head injury Constricted = Non-reactive: Opiate/barbituate OD, brainstem injury Patient Care ABCS! Medics? Position of comfort Oxygen Maintain body temperature Monitor vitals signs Calm and reassure Minimize patient movement Transport Syncope Fainting Sudden loss of consciousness Usually caused by lack of blood flow to the brain Syncope Causes Stress, fright, pain (vasovagal syncope) Orthostatic hypotension (standing BP drop) Decreased blood volume Increased size of vascular space Decreased cardiac output Prolonged, forceful coughing Syncope Fainting or passing out is a sign that something is not working right. Look for the underlying cause, be a good detective. All syncope should be evaluated in the ER, although 60% of all syncope is undiagnosed. ALS indicators? Remember… …it’s okay if you do not diagnose the patient’s problem. It’s not okay if you fail to take care of what you are trained to take care of.