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Slide 1Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Altered Mental StatusAltered Mental StatusChapter 19Chapter 19
Slide 2Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Case HistoryCase History
The police are requesting your response for a The police are requesting your response for a semiconscious patient in the subway. On arrival, the semiconscious patient in the subway. On arrival, the police tell you that they found this 40-year-old male police tell you that they found this 40-year-old male stumbling around the platform about 15 minutes ago. stumbling around the platform about 15 minutes ago. The patient is now lying down on the ground. While The patient is now lying down on the ground. While doing your initial assessment, you find a medical alert doing your initial assessment, you find a medical alert tag that says “Diabetic.”tag that says “Diabetic.”
Slide 3Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Central and Peripheral Central and Peripheral Nervous SystemNervous System
Slide 4Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
BrainBrain
Slide 5Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Blood Supply to the BrainBlood Supply to the Brain
Slide 6Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Altered Mental StatusAltered Mental Status
Structural problems Structural problems Injury or damage to an area of the brainInjury or damage to an area of the brain
OROR
Metabolic problems Metabolic problems Affect the entire brainAffect the entire brain
Slide 7Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
StructuralStructural
StrokeStroke Head injuryHead injury Characterized by “one-sided” signsCharacterized by “one-sided” signs
ParalysisParalysis Facial droopFacial droop Weakness on one side of the bodyWeakness on one side of the body Unequal pupilsUnequal pupils
Slide 8Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
MetabolicMetabolic
ExternalExternal PoisoningPoisoning OverdoseOverdose Hypo- or hyperthermiaHypo- or hyperthermia InfectionsInfections
Internal Internal DiabetesDiabetes HypoxiaHypoxia HypotensionHypotension Organ failureOrgan failure
Affects both sides of the brain equallyAffects both sides of the brain equally
Primarily recognized on the basis of altered mental status and historyPrimarily recognized on the basis of altered mental status and history
Slide 9Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Causes of Causes of Altered Mental StatusAltered Mental Status
Hypoglycemia, diabetic ketoacidosisHypoglycemia, diabetic ketoacidosis PoisoningPoisoning After seizureAfter seizure InfectionInfection Head traumaHead trauma Decreased oxygen levels (hypoxia)Decreased oxygen levels (hypoxia)
Slide 10Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
DiabetesDiabetes
Disease of the pancreas Disease of the pancreas Caused by a partial or total lack of insulin Caused by a partial or total lack of insulin
productionproduction Symptoms of diabetesSymptoms of diabetes
Increased urinationIncreased urination Increased thirstIncreased thirst Increased hungerIncreased hunger
Slide 11Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Diabetes – InsulinDiabetes – Insulin
Insulin “escorts” glucose into cells.Insulin “escorts” glucose into cells.
Glucose provides fuel for basic energy needs.Glucose provides fuel for basic energy needs. Excess glucose is stored as fat.Excess glucose is stored as fat. Brain depends almost exclusively on glucose.Brain depends almost exclusively on glucose.
• When glucose level is low, brain function is altered.When glucose level is low, brain function is altered. Unconsciousness, seizures, brain cell deathUnconsciousness, seizures, brain cell death
Slide 12Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
DiabetesDiabetes
Two major diabetic emergenciesTwo major diabetic emergencies HypoglycemiaHypoglycemia
• Abnormally low blood glucose levelAbnormally low blood glucose level
Diabetic ketoacidosisDiabetic ketoacidosis• Blood glucose level too high and insulin level too lowBlood glucose level too high and insulin level too low
Slide 13Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Hypoglycemia – Hypoglycemia – Signs and SymptomsSigns and Symptoms
Alteration of mental status (rapid onset)Alteration of mental status (rapid onset)• Anxiety, confusion, intoxicated behavior, combativeness, Anxiety, confusion, intoxicated behavior, combativeness,
bizarre behavior, or comabizarre behavior, or coma
HungerHunger Rapid pulseRapid pulse Pale, cool, and clammy skinPale, cool, and clammy skin Dilated pupilsDilated pupils SeizuresSeizures
Slide 14Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Hypoglycemia – Hypoglycemia – Signs and SymptomsSigns and Symptoms
Took prescribed insulinTook prescribed insulin After missing a mealAfter missing a meal Vomiting after a mealVomiting after a meal After unusual exercise or physical workAfter unusual exercise or physical work
Insulin in refrigeratorInsulin in refrigerator
Medications found at sceneMedications found at scene Diabinese™Diabinese™ Orinase™Orinase™ Micronase™Micronase™
Slide 15Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Hypoglycemia - Hypoglycemia - Signs and SymptomsSigns and Symptoms
Can also occur in patients who do not have Can also occur in patients who do not have diabetesdiabetes Infants with poor glycogen suppliesInfants with poor glycogen supplies Malnourished individualsMalnourished individuals
• AlcoholicsAlcoholics
Slide 16Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Diabetic KetoacidosisDiabetic Ketoacidosis
Blood glucose level is too high and insulin Blood glucose level is too high and insulin level is too low.level is too low. When insulin level is low, body burns fat for fuel.When insulin level is low, body burns fat for fuel.
• Acetone breath from fatty acidsAcetone breath from fatty acids
Excess glucose spills into urine, pulling water with Excess glucose spills into urine, pulling water with it.it.• Increased urination, dehydration, hunger, thirstIncreased urination, dehydration, hunger, thirst
Slide 17Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Diabetic KetoacidosisDiabetic Ketoacidosis
Increased acidity in bloodIncreased acidity in blood Body tries to compensate by breathing deeply and Body tries to compensate by breathing deeply and
rapidly.rapidly.
Slow onsetSlow onset
Slide 18Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Emergency Medical Care - Emergency Medical Care - History of Diabetes History of Diabetes
Initial assessmentInitial assessment
Focused history and physical examFocused history and physical exam
Vital signsVital signs
SAMPLE historySAMPLE history
Slide 19Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Focused History and Focused History and Physical ExaminationPhysical Examination
Description of episodeDescription of episode OnsetOnset DurationDuration Associated symptomsAssociated symptoms Evidence of traumaEvidence of trauma InterruptionsInterruptions SeizuresSeizures FeverFever
Slide 20Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Vital Signs and SAMPLE HistoryVital Signs and SAMPLE History
History of diabetes History of diabetes Medical identification tags, etc.Medical identification tags, etc.
Last mealLast meal Last medication doseLast medication dose Related illnessRelated illness Determine if patient can swallow.Determine if patient can swallow.
Slide 21Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Management – Management – Diabetic EmergenciesDiabetic Emergencies
Ensure patent airway.Ensure patent airway.
Supplemental oxygen; consider positive-pressure Supplemental oxygen; consider positive-pressure ventilationventilation
Consider oral glucose administration.Consider oral glucose administration. Per local protocolPer local protocol
Reassess patient en route to hospital.Reassess patient en route to hospital.
Slide 22Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Glucose AdministrationGlucose Administration
Administer if patient has altered mental status when Administer if patient has altered mental status when hypoglycemia is suspected.hypoglycemia is suspected. Will save hypoglycemic patient from brain cell deathWill save hypoglycemic patient from brain cell death Will not harm patient in diabetic ketoacidosisWill not harm patient in diabetic ketoacidosis
NeverNever administer oral glucose to patients who are administer oral glucose to patients who are unconsciousness or have no gag reflex.unconsciousness or have no gag reflex.
Slide 23Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Side Effects and Side Effects and ReassessmentReassessment
Side effectsSide effects No side effects when given properlyNo side effects when given properly Glucose gel may be aspirated by the patient Glucose gel may be aspirated by the patient
without a gag reflex.without a gag reflex.
Reassessment strategiesReassessment strategies If patient loses consciousness or has a seizureIf patient loses consciousness or has a seizure
Slide 24Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
SeizuresSeizures
May be brief or prolongedMay be brief or prolonged CausesCauses
FeverFever InfectionsInfections PoisoningPoisoning HypoglycemiaHypoglycemia Trauma Trauma Drug or alcohol withdrawalDrug or alcohol withdrawal HypoxiaHypoxia IdiopathicIdiopathic
Slide 25Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Seizures – Seizures – Infants and ChildrenInfants and Children
Chronic seizures in children are rarely life Chronic seizures in children are rarely life threatening.threatening.
Febrile seizures should be considered Febrile seizures should be considered life-threatening.life-threatening.
Slide 26Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Types of SeizuresTypes of Seizures
Grand malGrand mal
FocalFocal
Status epilepticusStatus epilepticus
FebrileFebrile
Petit malPetit mal
Slide 27Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Grand Mal SeizuresGrand Mal Seizures
Three phasesThree phases
TonicTonic
ClonicClonic
PostictalPostictal
Slide 28Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Grand Mal Seizures – Grand Mal Seizures – Tonic PhaseTonic Phase
All voluntary muscles in sustained contractionAll voluntary muscles in sustained contraction Body and extremities are usually extended.Body and extremities are usually extended.
Lasts for up to 30 secondsLasts for up to 30 seconds
All respiratory muscles in contractionAll respiratory muscles in contraction Ventilation can be compromised.Ventilation can be compromised.
Slide 29Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Grand Mal Seizures –Grand Mal Seizures –Clonic PhaseClonic Phase
Skeletal muscles intermittently contract and relax.Skeletal muscles intermittently contract and relax. Rapid, jerking movementsRapid, jerking movements
Patient may be injured by striking surrounding objects.Patient may be injured by striking surrounding objects. Clonic phase lasts a few seconds to a few minutes.Clonic phase lasts a few seconds to a few minutes. Spasms may interfere with respirations.Spasms may interfere with respirations.
Patient may become cyanotic.Patient may become cyanotic. Spasms may be followed by short periods of flaccid paralysis.Spasms may be followed by short periods of flaccid paralysis. Patient may urinate or bite tongue.Patient may urinate or bite tongue.
Slide 30Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Grand Mal Seizures – Grand Mal Seizures – Postictal PhasePostictal Phase
Decreased LOC and confusionDecreased LOC and confusion
Slow awakeningSlow awakening Patient may fall asleep for short period.Patient may fall asleep for short period.
Afterward, may complain of headacheAfterward, may complain of headache
Slide 31Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Focal SeizuresFocal Seizures
May affect only a portion of the bodyMay affect only a portion of the body
OROR
May present as altered mental status with May present as altered mental status with bizarre behavior bizarre behavior
Slide 32Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Status EpilepticusStatus Epilepticus
Rapid succession of seizures without an Rapid succession of seizures without an intervening period of consciousnessintervening period of consciousness
Prolonged seizureProlonged seizure
Life-threatening because of sustained Life-threatening because of sustained respiratory compromiserespiratory compromise
Slide 33Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Febrile SeizuresFebrile Seizures
Caused by feverCaused by fever
Children – 6 months to 6 years of ageChildren – 6 months to 6 years of age
Occur in up to 5% of childrenOccur in up to 5% of children
Slide 34Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Petit Mal SeizuresPetit Mal Seizures
Brief lapse of attention and awarenessBrief lapse of attention and awareness StaringStaring Fluttering eyelidsFluttering eyelids Eyes turned upwardEyes turned upward
Last from 10 to 20 secondsLast from 10 to 20 seconds
More common in childrenMore common in children
Slide 35Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Seizures – Seizures – Emergency Medical Care Emergency Medical Care
Protect patient from harm.Protect patient from harm. Position patient on side, if no possibility of cervical Position patient on side, if no possibility of cervical
spine trauma.spine trauma. Ensure patent airway; suction as needed; administer Ensure patent airway; suction as needed; administer
high-concentration oxygen.high-concentration oxygen. Transport immediately.Transport immediately. Obtain vital signs en route.Obtain vital signs en route. Rule out trauma.Rule out trauma.
Slide 36Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
StrokeStroke
Permanent neurologic impairment caused by a Permanent neurologic impairment caused by a disruption in blood supply to a region of the braindisruption in blood supply to a region of the brain
Two causesTwo causes Related to arteriosclerosis Related to arteriosclerosis
• IschemicIschemic Weakened artery in brain ruptures Weakened artery in brain ruptures
• HemorrhagicHemorrhagic
Slide 37Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
StrokeStroke
Third leading cause of death in the U.S.Third leading cause of death in the U.S. 500,000 Americans are affected annually.500,000 Americans are affected annually.
• Nearly 25% die.Nearly 25% die.
Slide 38Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Transient Ischemic Attack Transient Ischemic Attack (TIA)(TIA)
Symptoms are the same as for stroke.Symptoms are the same as for stroke. Lasts few minutes to a few hoursLasts few minutes to a few hours
• Resolves within 24 hoursResolves within 24 hours
Approximately 25% of patients presenting with stroke Approximately 25% of patients presenting with stroke had a TIA.had a TIA.
Approximately 5% of patients with TIA will have Approximately 5% of patients with TIA will have stroke within 1 month, if untreated.stroke within 1 month, if untreated.
Slide 39Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Acute StrokeAcute Stroke
IschemicIschemic Approximately 75% of strokesApproximately 75% of strokes May be eligible for treatment if in ED within 3 May be eligible for treatment if in ED within 3
hours of onsethours of onset
HemorrhagicHemorrhagic Can be fatal at onsetCan be fatal at onset
Slide 40Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Stroke – Initial AssessmentStroke – Initial Assessment
Ensure patent airway.Ensure patent airway.
Support ventilations, as necessary.Support ventilations, as necessary.
Slide 41Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Stroke – Stroke – Signs and Symptoms Signs and Symptoms
Altered level of consciousnessAltered level of consciousness• Confusion, stupor, delirium, coma, seizuresConfusion, stupor, delirium, coma, seizures
Severe headacheSevere headache• ““Worst headache of my life”Worst headache of my life”
AphasiaAphasia Facial weakness or asymmetryFacial weakness or asymmetry Incoordination, weakness, paralysis, sensory loss of one or Incoordination, weakness, paralysis, sensory loss of one or
more limbsmore limbs AtaxiaAtaxia Visual lossVisual loss DysarthriaDysarthria Intense vertigo, diplopiaIntense vertigo, diplopia
Slide 42Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Stroke –Stroke –Focused History and Physical ExamFocused History and Physical Exam
Focused historyFocused history Chief complaintChief complaint Time of onset, if knownTime of onset, if known
• Accurate time of onset is crucialAccurate time of onset is crucial
• If onset unknown, ask what time patient was last seen or If onset unknown, ask what time patient was last seen or went to bed.went to bed.
Gather SAMPLE history.Gather SAMPLE history.
Slide 43Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Stroke –Stroke –Focused History and Physical ExamFocused History and Physical Exam
Physical examinationPhysical examination If stroke is suspected, examine rapidly.If stroke is suspected, examine rapidly.
• Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale
• Los Angeles Prehospital Stroke ScreenLos Angeles Prehospital Stroke Screen
• Glasgow Coma ScaleGlasgow Coma Scale
Consider transport to appropriate facility without delay.Consider transport to appropriate facility without delay.• Notify receiving facility.Notify receiving facility.
• Monitor vital signs en route.Monitor vital signs en route.
Slide 44Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Stroke – Stroke – Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale
Slide 45Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Stroke – Stroke – Los Angeles Prehospital Stroke ScreenLos Angeles Prehospital Stroke Screen
Slide 46Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Glasgow Coma ScaleGlasgow Coma Scale
Slide 47Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Altered Mental Status – Altered Mental Status – Emergency Medical CareEmergency Medical Care
Initial assessmentInitial assessment Ensure patent airway.Ensure patent airway.
• Consider potential for head trauma; provide spinal Consider potential for head trauma; provide spinal immobilization.immobilization.
Consider hypoxiaConsider hypoxia• Provide appropriate ventilatory support.Provide appropriate ventilatory support.
Consider hypoglycemia.Consider hypoglycemia.• Administer oral glucose, if appropriate.Administer oral glucose, if appropriate.
Slide 48Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Altered Mental Status – Altered Mental Status – Emergency Medical CareEmergency Medical Care
Focused historyFocused history Patient’s last normal level of functionPatient’s last normal level of function Associated complaintsAssociated complaints Chronology of eventsChronology of events History of similar past experiencesHistory of similar past experiences SAMPLE historySAMPLE history
Slide 49Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Altered Mental Status – Altered Mental Status – Emergency Medical CareEmergency Medical Care
Physical examinationPhysical examination Vital signsVital signs Abnormal smellsAbnormal smells Pupillary statusPupillary status Motor and sensory functionMotor and sensory function
• AsymmetryAsymmetry
Check for medical alert tag.Check for medical alert tag.