Transcript File - Huff Hills Ski Patrol

Chapter 11
Altered Mental Status
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Objectives
11.1 Define altered mental status.
11.2 List nine causes of altered mental status
using the mnemonic AEIOU-TIPS.
11.3 List and compare the four major types of
diabetes.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Objectives
11.4 List the signs and symptoms and
demonstrate the treatment of the
following medical conditions:
a.
b.
c.
d.
hypoglycemia
hyperglycemia
partial seizure
generalized seizure
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Objectives
11.5 Compare and contrast the three types of
stroke:
a.
b.
c.
ischemic stroke
hemorrhagic stroke
transient ischemic attack
11.6 Describe how to assess a patient with
altered mental status.
11.7 Describe and demonstrate the treatment
of a patient with altered mental status.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Topics
 Anatomy
and Physiology
 Altered Mental Status (AMS)
 Violent Behavior and Altered Mental
Status
 Chapter Summary
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Case Presentation
In a convenience store, you hear the manager call for
help and state that a customer is “really out of it” in
the bathroom.
You identify yourself as an OEC technician and offer
to help as you suspect this might be a case of AMS.
You find a middle-aged man lying on the floor. He is
confused and responds only to loud verbal stimuli.
His radial pulse is fast and strong. His skin is pale,
cool to the touch, and diaphoretic.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Anatomy and Physiology
 CNS:
Brain and spinal cord
◦ Brain: three main parts protected by
skull and CSF:
• Brain stem – controls life functions, (i.e.,
breathing, swallowing, responsiveness, and
cardiovascular system)
• Cerebellum – controls balance and
coordination
• Cerebrum – controls emotion, thought,
speech, integration, memory, sensation and
motor function.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Anatomy and Physiology
 Spinal
Cord:
◦ Connects the peripheral nervous system
to the brain, transmitting information to
and from the brain.
◦ Part of the Central Nervous System
 Peripheral
nervous system: All other
neural elements not included in the
CNS.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Anatomy and Physiology
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Anatomy and Physiology
 Endocrine
system regulates level of
glucose available to nervous system.
◦ Endocrine organs produce and secrete
hormones.
◦ Pancreas secretes insulin and glucagon
to regulate levels of circulating glucose.
◦ Too high or too low blood glucose
affects level of awareness or
responsiveness.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Altered Mental Status
 AMS
malfunction can be:
◦ Global – affecting all parts of the central
nervous system equally.
• Decreased levels of responsiveness or
abnormally stimulated states.
◦ Localized or focal – affecting a portion of
the body.
• Motor weakness, balance problems, vision
loss, or speech abnormalities.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 Causes
of AMS: AEIOU-TIPS
◦ A: alcohol and acidosis
• Alcohol – most commonly abused drug in
US; CNS depressant.
• Acidosis – decrease in body pH, affecting
homeostasis; numerous causes, e.g.
decreased respiratory or cardiac function,
renal disease, severe hyperglycemia, and
various gastrointestinal disorders.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 Causes
of AMS: AEIOU-TIPS
◦ E: epilepsy, environment, and
electrolytes
• Epilepsy –disorder resulting in sudden,
recurrent seizures.
• Environment – extreme variation from
normal body temperature; results in changes
in level of responsiveness; also toxic
bites/stings.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 Causes
of AMS: AEIOU-TIPS
◦ E: epilepsy, environment, and
electrolytes
• Electrolytes – imbalance disrupts
homeostasis; levels affected by diet,
exercise, medications, ill health, sweating,
vomiting, or diarrhea.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 I:
insulin
◦ Any condition that adversely affects
production or use of insulin or regulation
of blood glucose level.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 O:
oxygen and overdose
◦ Oxygen – any decrease in cerebral O2
level will result in decrease of global
CNS function and responsiveness; most
common cause of AMS.
◦ Overdose – due to overuse or abuse of
prescription or illicit drug; depressants
may negatively affect both CNS and
respiratory function.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 U:
uremia
◦ Poor kidney function results in toxic
build-up of waste products, lethargy,
coma, and death.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 T:
trauma and tumors
◦ Trauma – traumatic brain injury causes
brain swelling and increased intra-cranial
pressure; results in focal or global AMS.
◦ Tumors – abnormal growth of cells in
brain: malignant or benign; focal or
global AMS.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 MOIs
that can cause AMS
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 I:
infection
◦ Presence of foreign microorganisms that
cause tissue damage.
◦ When spread throughout the body by
blood it is called sepsis.
◦ AMS associated with infection is a grave
sign.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 I:
infection
◦ Meningitis
• Inflammation of meninges of the brain/spinal
cord caused by infection.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 P:
poisoning and psychiatric causes
◦ Poisoning – poison is a substance that,
when taken into the body, can cause
AMS, injury, or death.
◦ Psychiatric causes – examples are
schizophrenia, manic-depressive
disorder, depression, and dementia.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Causes of
Altered Mental Status
 S:
seizure, stroke, and syncope
◦ Seizure – electrical disturbance in the
brain; focal or global.
◦ Stroke – loss of blood supply to part of
brain, resulting in neurological
impairment.
◦ Syncope (fainting) – temporary loss of
responsiveness due to disrupted blood
flow to the brain.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
– chronic condition causing
recurrent seizures.
 Epilepsy
◦ Factors associated with epilepsy – head
injury, brain trauma, brain tumors,
genetic conditions, and chemical
imbalance.
◦ Chronic epileptics treated with anticonvulsant medications.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated with
AMS
continued
Copyright Edward McNamara
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated with
AMS
 Medic
Alert Tags may help identify
the cause
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Seizures:
electrical disturbance in the
brain, causes altered awareness,
attentiveness, responsiveness,
behavior, or body movement; lasts
seconds to hours, average is1-3
minutes.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Seizures
◦ Partial seizure – focal point in a group of
muscles or on abnormal sensations.
◦ Generalized seizure – affects both sides
of body equally and usually causes a
decreased level of responsiveness.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
mal seizure – most common
type of generalized seizure.
 Grand
◦ Tonic activity – muscle tensing an
contraction.
◦ Clonic activity – muscle groups spasm
violently in a jerking fashion.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Generalized
seizure – three phases:
◦ Pre-ictal – occurs before seizure; aura or
premonition of seizure.
◦ Ictal – tonic-clonic phase; unconscious.
◦ Post-ictal – minimally responsive.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Status
epilepticus:
◦ Seizure lasting longer than 10 minutes,
or
◦ 3 or more seizures without regaining
responsiveness.
◦ True medical emergency.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
– inability to regulate blood
sugar level; glucose level to high
 Diabetes
◦ Chronic disease.
◦ Pancreas cannot produce enough
insulin, or cells do not respond to insulin,
or both.
◦ Glucose does not enter the cells and
builds up in blood stream.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
– inability to regulate blood
sugar level; glucose level to high
 Diabetes
◦ Symptoms – polyuria, polydipsia,
increased appetite, change in weight,
fatigue, dry mouth, cellular damage.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Diabetes
mellitus– 4 Types:
◦ Type 1
• Caused by autoimmune disease in the
young.
• Destroys pancreatic cells that produce
insulin.
• Controlled by injectable insulin or insulin
pump.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Diabetes
mellitus– 4 Types:
◦ Type 2
• Unknown cause; increased incidence in the
obese; also may be genetically predisposed.
• Cells are resistant to action of insulin.
• Controlled by weight loss, exercise, and oral
hypoglycemic medication.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Diabetes
mellitus– 4 Types:
◦ Gestational diabetes mellitus
• Develops only during pregnancy.
◦ Other
•
•
•
•
Genetic defect in insulin-producing cells.
Genetic defect in the action of insulin.
Drug or chemical affect on insulin.
Hormone-related disorders.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Hypoglycemia
BRADY
– Effects of Diabetes:
◦  Blood sugar – less than 70 mg/dL.
◦ Patient took too much diabetic
medication or took medication and did
not eat adequately.
◦ Early signs and symptoms – anxiety,
dizziness, tachycardia, diaphoresis,
tremor, headache, mild confusion,
conscious ,and able to swallow.
continued
◦ Will resolve quickly after receiving
glucose.
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Hypoglycemia
– Effects of Diabetes:
◦ Severe signs and symptoms – marked
confusion, disorientation, lethargy,
slurred speech, seizures, unilateral
extremity weakness or
unresponsiveness; irrational or
combative behavior is common.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Hyperglycemia-
Effects of Diabetes
◦  Blood sugar – greater than 180
mg/dL.
◦ Patient forgot to take diabetic medication
◦ Early signs and symptoms – polyuria,
polydipsia, dry mouth, and fatigue.
◦ Late signs and symptoms – nausea,
vomiting, abdominal pain, AMS, coma,
continued
brain injury, death.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Hyperglycemia-
Effects of Diabetes
◦ Unusual to encounter hyperglycemia in
the outdoor recreational environment.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Stroke:
neurological impairment
due to low or no blood flow to areas
of the brain.
 Three types of stroke –
◦ Ischemic:
• Most common – 80%
• Embolism – disrupted blood flow due to
foreign material in the blood vessel, e.g.
blood clot, fat from fractures or
cholesterol plaque migration.
BRADY
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Three
types of stroke –
◦ Hemorrhagic:
• Blood vessel ruptures in the brain.
• Hematoma forms, placing pressure on brain.
• Caused by structural weakness in vessel.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Conditions Associated
With AMS
 Three
types of stroke –
◦ Transient ischemic attack (TIA):
• Temporary interruption of blood flow to an
area in the brain.
• No permanent brain damage.
• Signs and symptoms resolve within 24 hours
after embolism moves on.
• Early warning sign of a more serious stroke.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Case Update
You tell the manager to hold the man’s head.
You ask patient’s permission to help. While doing a
secondary survey, the man’s eyes roll back. He
groans, stiffens, and begins to shake violently.
The manager grabs the patient’s wallet, and directs
you to, “Put it in the patient’s mouth before he dies!”
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Assessment
 Patient
assessment with AMS:
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Assessment
continued
Copyright Edward McNamara
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Assessment
size-up – gather family/friends
or bystanders to help with history;
traumatic or medical origin?
 Scene
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Assessment
 Scene
size-up
◦ Primary survey:
• ABCDs
• AVPU and/or Glasgow (monitor for
changes).
• Look for clues – hypoxia and hypoglycemia
are the two most common causes of AMS.
• Activate EMS.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Assessment
 Scene
size-up
◦ Secondary survey:
• SAMPLE history and vital signs.
•
•
•
•
BRADY
•
•
•
•
•
OPQRST
DCAP-BTLS
Gather history from others when necessary
Ask about taking medications as prescribed
Look for medical information tags
Pupillary exam
continued
Motor-sensory exam
Higher cortical function exam
Vocal/speech exam
National Ski Patrol, Outdoor Emergency Care, 5 Ed.
th
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Management
 Deal
with deficits in ABCDs.
 Provide high-flow O2.
 Provide sugar to an awake diabetic.
 Consider spinal precautions.
 Activate EMS and provide rapid
transport.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Management
 Symptom-based
management in
AMS:
◦ A – Alcohol and acidosis: protect airway,
support respirations, rapid transport.
◦ E – Epilepsy, environment &
electrolytes: protect from injury, protect
airway, take steps to restore a normal
body temperature, rapid transport.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Management
 Symptom-based
management in
AMS:
◦ I – Insulin: give sugar (if fully conscious),
activate EMS, monitor, transport.
◦ O – Oxygen and overdose: maintain
ABCDs, high-flow O2, rapid transport.
◦ U – Uremia: maintain ABCDs and
transport.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Management
 Symptom-based
management in
AMS:
◦ T – Trauma and tumors: maintain
ABCDs, high-flow O2, treat to prevent
shock, rapid transport.
◦ I – Infection: maintain ABCDs, if remote
– clean wound, cool fever, suggest
NSAID.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Management
 Symptom-based
management in
AMS:
◦ P – Poisoning and psychiatric causes:
maintain ABCDs, high-flow O2, contact
poison center, for psychosis – support
and prevent from harming self.
◦ S – Seizures, stroke, and syncope:
prevent further injury, maintain ABCDs,
high-flow O2, activate EMS, rapid
transport.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Violent Behavior and AMS
 Uncooperative,
can be dangerous:
◦ Patients usually unaware that actions
are inappropriate.
◦ Cannot reason with patient.
◦ Remain calm and reassure patient.
◦ Avoid use of force, when possible. May
cause more harm.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Case Disposition
You set aside the wallet. You instruct the manager to
protect patient’s head, clear away nearby objects,
and time seizure (45 seconds).
You place man on his left side and monitor ABCDs
and check the patient’s wallet for medical card and
find he is diabetic.
He becomes responsive and tells you his name. You
offer water, which he takes and does well. You stir in
5 packs of sugar, ask him to drink, and monitor
closely.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Case Disposition
He is fully oriented in a few minutes. He reports that
he was in a hurry and did not eat. Ambulance arrives,
patient is handed off and thanks you.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Chapter Summary
 AMS
describes an abnormality in
brain function.
 Causes of AMS are numerous and
may result in global or focal changes.
 AEIOU-TIPS helpful to discover
cause.
 Patients with AMS are “load and go”.
 High-flow O2 for all AMS patients. continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Chapter Summary
 Diabetics
with AMS need sugar, but
only if able to follow commands and
have intact gag reflex.
 Must treat for spinal injury with any
unwitnessed onset of AMS, until
proven otherwise.
 Seizures are usually self-limiting;
treatment focus is preventing harm.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ