Transcript a01648-19-ppt 1582KB Jan 14 2015 08:21:44 AM

Copyright © 2004, Mosby Inc. All rights reserved.
Chapter 19
Altered Mental Status
Slide 1
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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.”
Slide 2
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Central and Peripheral
Nervous System
Slide 3
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Brain
Slide 4
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Blood Supply to the Brain
Slide 5
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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
Slide 6
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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
Slide 7
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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
Slide 8
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Causes of
Altered Mental Status
•
•
•
•
•
•
Hypoglycemia, diabetic ketoacidosis
Poisoning
After seizure
Infection
Head trauma
Decreased oxygen levels (hypoxia)
Slide 9
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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
Slide 10
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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.
o Unconsciousness, seizures, brain cell death
Slide 11
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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
Slide 12
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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
Slide 13
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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™
Slide 14
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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
Slide 15
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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
Slide 16
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Diabetic Ketoacidosis
•
Increased acidity in blood
 Body tries to compensate by breathing
deeply and rapidly.
•
Slow onset
Slide 17
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Emergency Medical Care History of Diabetes
•
Initial assessment
•
Focused history and physical exam
•
Vital signs
•
SAMPLE history
Slide 18
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Focused History and
Physical Examination
•
•
•
•
•
•
•
•
Description of episode
Onset
Duration
Associated symptoms
Evidence of trauma
Interruptions
Seizures
Fever
Slide 19
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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.
Slide 20
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Management –
Diabetic Emergencies
•
Ensure patent airway.
•
Supplemental oxygen; consider positivepressure ventilation
•
Consider oral glucose administration.
 Per local protocol
•
Reassess patient en route to hospital.
Slide 21
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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.
Slide 22
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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
Slide 23
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Seizures
•
•
May be brief or prolonged
Causes
 Fever
 Infections
 Poisoning
 Hypoglycemia
 Trauma
 Drug or alcohol withdrawal
 Hypoxia
 Idiopathic
Slide 24
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Seizures –
Infants and Children
•
Chronic seizures in children are rarely life
threatening.
•
Febrile seizures should be considered
life-threatening.
Slide 25
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Types of Seizures
•
Grand mal
•
Focal
•
Status epilepticus
•
Febrile
•
Petit mal
Slide 26
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Grand Mal Seizures
•
Three phases
 Tonic
 Clonic
 Postictal
Slide 27
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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.
Slide 28
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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.
Slide 29
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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
Slide 30
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Focal Seizures
•
May affect only a portion of the body
OR
•
May present as altered mental status
with bizarre behavior
Slide 31
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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
Slide 32
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Febrile Seizures
•
Caused by fever
•
Children – 6 months to 6 years of age
•
Occur in up to 5% of children
Slide 33
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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
Slide 34
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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.
Slide 35
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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
Slide 36
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Stroke
•
Third leading cause of death in the U.S.
 500,000 Americans are affected annually.
» Nearly 25% die.
Slide 37
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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.
Slide 38
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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
Slide 39
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Stroke – Initial Assessment
•
Ensure patent airway.
•
Support ventilations, as necessary.
Slide 40
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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
Slide 41
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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.
Slide 42
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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.
Slide 43
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Stroke –
Cincinnati Prehospital Stroke Scale
Slide 44
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Stroke –
Los Angeles Prehospital Stroke Screen
Slide 45
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Glasgow Coma Scale
Slide 46
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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.
Slide 47
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Altered Mental Status –
Emergency Medical Care
•
Focused history
 Patient’s last normal level of function
 Associated complaints
 Chronology of events
 History of similar past experiences
 SAMPLE history
Slide 48
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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.
Slide 49
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