Transcript Altered Mental Status

Altered Mental Status
Coma and Reduced GCS Emergencies
Franko Haller, Medical English VI
[email protected]
December 2010
Mentor: A. Žmegač Horvat
Imagine yourself...
- A1 highway
- early August
- foreign tourists
- high-traffic season
A 112-call
- 65 year old female
- LOC
- bus tour
- exit Brinje, direction
South
- English speaking tour
with Croatian guide
*
What can you expect?
- 65 year old female
- LOC
- bus tour
- exit Brinje
- English speaking tour with Croatian
guide
ALMOST anything!
How to approach the patient?
DANGER
How to approach the patient?
RESPONSE
AVPU assessment
A - ALERT
V - responds to VOICE
P - responds to PAIN
U - UNRESPONSIVE
How to approach to a patient?
DANGER, RESPONSE,
AIRWAY, BREATHING,
CIRCULATION
What can you see?
- 65 year old female
- group of 15 Canadians
D - no danger to provider/emergency team
R - reduced LOC; not alert, does not respond to voice stimuli,
responds to pain stimulus on sternum AVPU
A - open, patent
B - normal breathing, RR 18/min
C - strong, 98 bpm, BP 120/80
SAMPLE history
S - signs & symptoms
A - allergies
M - medications
P - past medical history
L - last oral intake
E - events preceding this acute emergency
SAMPLE
history
S - signs & symptoms: tired and cranky, complained of
lightheadedness
A - allergies: no known allergies
M - medications: metformin and other drugs for her diabetes
P - past medical history: known diabetic, history of a stroke 5
years ago
L - last oral intake: breakfast 3 hours ago
E - events preceding this acute emergency: severe and sudden
headache minutes before she lost consciousness
What should you do next?
Check blood glucose
Establish an i.v. access (50 ml of 50% glucose/dextrose flushed with
NS)
Check pupils
Check reflexes
Reevaluate ABCs (consider oropharyngeal airway)
Determine GCS
What should you do next?
Blood Glucose 1.1 mmol/L on glucometer
Establish an i.v. access (50 ml of 50% glucose/dextrose flushed with NS)
Check pupils - fixed and dilated, symmetric
Check reflexes - diminished, symmetric
Reevaluate ABCs - unchanged
Coma and decreased GCS
THINK ABOUT
* no focal neurology:
low O2, high CO2, hypotension, metabolic (glucose, Na+, Ca++, K+,
acidosis, alkalosis, renal, liver failure), hypothermia, pyrexia, malignant
hypertension
overdose: opiates, benzos, alcohol, insulin, some oral hypoglycemics
* focal neuro findings:
CVA, tumor, hematoma, trauma, hypoglycemia
* meningism:
meningitis, encephalitis, SAH
Glasgow Coma Scale (GCS)
= or < 8
requires intubation
E2 V3 M5
total GCS 10
Acute confusion
Confusion
acute deficit in thinking, memory, orientation or awareness
Off-legs
medical slang for acute inability to walk in the elderly
Acopia
medical slang for elderly patients no longer coping at home
Dementia
chronic deficit in thinking, memory and/or personality
Delirium
acute onset confusion with hallucinations or illusions
Psychosis
hallucinations or illusions without confusion
Acute confusion
THINK ABOUT
EMERGENCIES
low O2, high CO2, MI, sepsis, intracranial bleed,
acute
meningitis, encephalitis, raised ICP, CVA, arrhythmia;
common: infection, metabolic, head injury, alcohol
withdrawal/intoxication,
post-ictal, Korsakoff’s
chronic
dementia
ASK ABOUT
history from family, relatives, friends, nurses
PMH: lung, hear, liver, kidney, epi, dementia, psych
DH: benzos, opiods, steroids, NSAIDs, B-blockers, psych
drugs, alcohol, recreational drugs
Acute confusion
THINK ABOUT
EMERGENCIES
cyanosis, pulse (HR and rhythm), bronchial breathing,
Look for
creps, abdo pain, signs of head injury, neck stiffness,
photophobia, focal neurology, pupils, papilloedema, tone
and reflexes
Obs
GCS, temp, HR, BP, RR, O2 sats
Investigations
urine dipstick, middle stream, culture, swab
blds FBC, U+E, LFTs, CRP, glucose, Ca++, cardiac
markers, blood cultures, amylase, TFT, B12 level, ABG
ECG, CXR, CT, LP if CT normal
Acute confusion
Abbreviated MiniMental
(10-point test)
8 or more is
normal in an
elderly patient
Thank you for your attention
Literature:
1. Oxford Handbook for The Foundation Programme; Hurley, Dawson,
Sanders, 2nd E, Oxford University Press, 2008
2. Oxford Cases in Medicine and Surgery; Guiding Your Through
Diagnosis; Farne, Norris, Smith, Oxford University Press, 2010