Altered Mental Status

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Altered Mental Status
Chapter 19
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Case History

• The police are requesting your response for a
  semiconscious patient in the subway. On arrival,
  the police tell you that they found this
  40-year-old male stumbling around the platform
  about 15 minutes ago. The patient is now lying
  down on the ground. While doing your initial
  assessment, you find a medical alert tag that
  says Diabetic.

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Central and Peripheral Nervous System
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Brain
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Blood Supply to the Brain
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Altered Mental Status

• Structural problems
• Injury or damage to an area of the brain
• OR
• Metabolic problems
• Affect the entire brain

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Structural

• Stroke
• Head injury
• Characterized by one-sided signs
• Paralysis
• Facial droop
• Weakness on one side of the body
• Unequal pupils

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Metabolic

• External
• Poisoning
• Overdose
• Hypo- or hyperthermia
• Infections
• Internal
• Diabetes
• Hypoxia
• Hypotension
• Organ failure
• Affects both sides of the brain equally
• Primarily recognized on the basis of altered
  mental status and history

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Causes of Altered Mental Status

• Hypoglycemia, diabetic ketoacidosis
• Poisoning
• After seizure
• Infection
• Head trauma
• Decreased oxygen levels (hypoxia)

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Diabetes

• Disease of the pancreas
• Caused by a partial or total lack of insulin
  production
• Symptoms of diabetes
• Increased urination
• Increased thirst
• Increased hunger

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Diabetes Insulin

• Insulin escorts glucose into cells.
• Glucose provides fuel for basic energy needs.
• Excess glucose is stored as fat.
• Brain depends almost exclusively on glucose.
• When glucose level is low, brain function is
  altered.
• Unconsciousness, seizures, brain cell death

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Diabetes

• Two major diabetic emergencies
• Hypoglycemia
• Abnormally low blood glucose level
• Diabetic ketoacidosis
• Blood glucose level too high and insulin level
  too low

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Hypoglycemia Signs and Symptoms

• Alteration of mental status (rapid onset)
• Anxiety, confusion, intoxicated behavior,
  combativeness, bizarre behavior, or coma
• Hunger
• Rapid pulse
• Pale, cool, and clammy skin
• Dilated pupils
• Seizures

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Hypoglycemia Signs and Symptoms

• Took prescribed insulin
• After missing a meal
• Vomiting after a meal
• After unusual exercise or physical work
• Insulin in refrigerator
• Medications found at scene
• Diabinese
• Orinase
• Micronase

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Hypoglycemia - Signs and Symptoms

• Can also occur in patients who do not have
  diabetes
• Infants with poor glycogen supplies
• Malnourished individuals
• Alcoholics

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Diabetic Ketoacidosis

• Blood glucose level is too high and insulin level
  is too low.
• When insulin level is low, body burns fat for
  fuel.
• Acetone breath from fatty acids
• Excess glucose spills into urine, pulling water
  with it.
• Increased urination, dehydration, hunger, thirst

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Diabetic Ketoacidosis

• Increased acidity in blood
• Body tries to compensate by breathing deeply and
  rapidly.
• Slow onset

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Emergency Medical Care - History of Diabetes

• Initial assessment
• Focused history and physical exam
• Vital signs
• SAMPLE history

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Focused History and Physical Examination

• Description of episode
• Onset
• Duration
• Associated symptoms
• Evidence of trauma
• Interruptions
• Seizures
• Fever

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Vital Signs and SAMPLE History

• History of diabetes
• Medical identification tags, etc.
• Last meal
• Last medication dose
• Related illness
• Determine if patient can swallow.

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Management Diabetic Emergencies

• Ensure patent airway.
• Supplemental oxygen consider positive-pressure
  ventilation
• Consider oral glucose administration.
• Per local protocol
• Reassess patient en route to hospital.

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Glucose Administration

• Administer if patient has altered mental status
  when hypoglycemia is suspected.
• Will save hypoglycemic patient from brain cell
  death
• Will not harm patient in diabetic ketoacidosis
• Never administer oral glucose to patients who are
  unconsciousness or have no gag reflex.

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Side Effects and Reassessment

• Side effects
• No side effects when given properly
• Glucose gel may be aspirated by the patient
  without a gag reflex.
• Reassessment strategies
• If patient loses consciousness or has a seizure

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Seizures

• May be brief or prolonged
• Causes
• Fever
• Infections
• Poisoning
• Hypoglycemia
• Trauma
• Drug or alcohol withdrawal
• Hypoxia
• Idiopathic

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Seizures Infants and Children

• Chronic seizures in children are rarely life
  threatening.
• Febrile seizures should be considered
  life-threatening.

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Types of Seizures

• Grand mal
• Focal
• Status epilepticus
• Febrile
• Petit mal

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Grand Mal Seizures

• Three phases
• Tonic
• Clonic
• Postictal

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Grand Mal Seizures Tonic Phase

• All voluntary muscles in sustained contraction
• Body and extremities are usually extended.
• Lasts for up to 30 seconds
• All respiratory muscles in contraction
• Ventilation can be compromised.

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Grand Mal Seizures Clonic Phase

• Skeletal muscles intermittently contract and
  relax.
• Rapid, jerking movements
• Patient may be injured by striking surrounding
  objects.
• Clonic phase lasts a few seconds to a few
  minutes.
• Spasms may interfere with respirations.
• Patient may become cyanotic.
• Spasms may be followed by short periods of
  flaccid paralysis.
• Patient may urinate or bite tongue.

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Grand Mal Seizures Postictal Phase

• Decreased LOC and confusion
• Slow awakening
• Patient may fall asleep for short period.
• Afterward, may complain of headache

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Focal Seizures

• May affect only a portion of the body
• OR
• May present as altered mental status with bizarre
  behavior

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Status Epilepticus

• Rapid succession of seizures without an
  intervening period of consciousness
• Prolonged seizure
• Life-threatening because of sustained respiratory
  compromise

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Febrile Seizures

• Caused by fever
• Children 6 months to 6 years of age
• Occur in up to 5 of children

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Petit Mal Seizures

• Brief lapse of attention and awareness
• Staring
• Fluttering eyelids
• Eyes turned upward
• Last from 10 to 20 seconds
• More common in children

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Seizures Emergency Medical Care

• Protect patient from harm.
• Position patient on side, if no possibility of
  cervical spine trauma.
• Ensure patent airway suction as needed
  administer high-concentration oxygen.
• Transport immediately.
• Obtain vital signs en route.
• Rule out trauma.

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Stroke

• Permanent neurologic impairment caused by a
  disruption in blood supply to a region of the
  brain
• Two causes
• Related to arteriosclerosis
• Ischemic
• Weakened artery in brain ruptures
• Hemorrhagic

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Stroke

• Third leading cause of death in the U.S.
• 500,000 Americans are affected annually.
• Nearly 25 die.

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Transient Ischemic Attack (TIA)

• Symptoms are the same as for stroke.
• Lasts few minutes to a few hours
• Resolves within 24 hours
• Approximately 25 of patients presenting with
  stroke had a TIA.
• Approximately 5 of patients with TIA will have
  stroke within 1 month, if untreated.

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Acute Stroke

• Ischemic
• Approximately 75 of strokes
• May be eligible for treatment if in ED within 3
  hours of onset
• Hemorrhagic
• Can be fatal at onset

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Stroke Initial Assessment

• Ensure patent airway.
• Support ventilations, as necessary.

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Stroke Signs and Symptoms

• Altered level of consciousness
• Confusion, stupor, delirium, coma, seizures
• Severe headache
• Worst headache of my life
• Aphasia
• Facial weakness or asymmetry
• Incoordination, weakness, paralysis, sensory loss
  of one or more limbs
• Ataxia
• Visual loss
• Dysarthria
• Intense vertigo, diplopia

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Stroke Focused History and Physical Exam

• Focused history
• Chief complaint
• Time of onset, if known
• Accurate time of onset is crucial
• If onset unknown, ask what time patient was last
  seen or went to bed.
• Gather SAMPLE history.

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Stroke Focused History and Physical Exam

• Physical examination
• If stroke is suspected, examine rapidly.
• Cincinnati Prehospital Stroke Scale
• Los Angeles Prehospital Stroke Screen
• Glasgow Coma Scale
• Consider transport to appropriate facility
  without delay.
• Notify receiving facility.
• Monitor vital signs en route.

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Stroke Cincinnati Prehospital Stroke Scale
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Stroke Los Angeles Prehospital Stroke Screen
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Glasgow Coma Scale
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Altered Mental Status Emergency Medical Care

• Initial assessment
• Ensure patent airway.
• Consider potential for head trauma provide
  spinal immobilization.
• Consider hypoxia
• Provide appropriate ventilatory support.
• Consider hypoglycemia.
• Administer oral glucose, if appropriate.

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Altered Mental Status Emergency Medical Care

• Focused history
• Patients last normal level of function
• Associated complaints
• Chronology of events
• History of similar past experiences
• SAMPLE history

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Altered Mental Status Emergency Medical Care

• Physical examination
• Vital signs
• Abnormal smells
• Pupillary status
• Motor and sensory function
• Asymmetry
• Check for medical alert tag.