Transcript Altered Mental Status - Hatzalah of Miami-Dade

Altered Mental Status
Strokes, Seizures, & Syncopy
Southside Regional Fire Academy EMT-Basic
Navy Regional Fire-Rescue Hampton Roads
EMS Training (757)433-2065
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Altered Mental Status
Many calls are dispatched as…
– “patient unconscious”
– “active seizure”
– “possible stroke”
Or a family member may describe the patient
as “not acting right”.
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Possible Causes of AMS
•
•
•
•
•
•
•
Stroke
Seizure
Cardiac-related
Syncopal episode (fainting spell)
Diabetic emergency
Drug or alcohol problem
Accidental poisoning
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Presentation
Any or all of the following…
– Seems drowsy or sleepy; not alert
– Awake and cooperative, but seems confused
– Awake, but used inappropriate words
– reported unconscious, but is now awake, with
or without impaired memory
-continued4
Presentation
– Awake, but not oriented to self, time, place, or
events
– Unconscious, but responds to verbal or painful
stimuli
– Unresponsive
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General Treatment Pathway
ALL PATIENTS WITH AMS
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
Sample History
•Trauma Mechanism?
•Does scene indicate
drug/alcohol use?
•Did patient fall?
•C-spine precautions if
indicated
•Rule-out hypoxia…
•Fire, drowning, toxic
exposure…
•Appearance, color
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General Treatment Pathway
ALL PATIENTS WITH AMS
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
If unconscious, how
unconscious are they?
•AVPU
•A & O x 4
Person, Place
Time, Events
•Can patient follow
basic commands?
Sample History
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General Treatment Pathway
ALL PATIENTS WITH AMS
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
Many AMS patients
will require
vigorous airway
maintenance…
•Assistance vomiting
•Suctioning
•Placing in recovery
position
•Oral or nasal airways
Sample History
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General Treatment Pathway
ALL PATIENTS WITH AMS
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
Adequate
respirations, but
altered mentation
= High-flow
oxygen via NRM
Respirations too fast
or too slow
=BVM attached to
oxygen, oral or
nasal airway
Sample History
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General Treatment Pathway
ALL PATIENTS WITH AMS
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
Sample History
Pulse is:
•Very weak, or very slow…
= Rapid transport
•Very fast
= Rapid transport
Hypotension, pale,
diaphoretic…
= Treat for shock
Rapid Transport
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General Treatment Pathway
ALL PATIENTS WITH AMS
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
•S.A.M.P.L.E
•Any similar episodes in
the past?
•History of trauma in
the past 2-3 days? (head
injury)
•Medic-alert jewelry,
wallet cards
•Inspect scene for clues,
medications
Sample History
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Cardiac-Related
BRADYCARDIA
• Heart beats too slow, low blood pressure
results.
– Poor tissue perfusion (e.g. the brain)
• Will usually have other symptoms
– Feeling faint
– Low blood pressure
– Chest pain possible
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Cardiac-Related
BRADYCARDIA-Treatment
• Position of comfort
– Consider elevating feet if hypotensive
• Oxygen
• ALS
• Rapid transport
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Cardiac-Related
TACHYCARDIA
• If heart pumps too fast…
– Ventricles don’t fill completely
– Pumping is ineffective
– Diminished volume of blood pumped from heart
• May complain of “palpitations” or “my heart
is racing”
• May have chest pain, be anxious
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Cardiac-Related
TACHYCARDIA-Treatment
Position of comfort
High concentration oxygen
ALS
Rapid Transport
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Cardiac-Related
LOW VOLUME
• Blood loss
• Spinal injury
• Dehydration
– Heat exhaustion
– Illness
– Infection
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Cerebrovascular Accident (CVA)
Stroke
Two types…
• Ischemic—caused by a blood clot that developed
in a brain vessel, or developed somewhere else
(like the heart) and traveled to the brain. (85% of
strokes are ischemic)
• Hemorrhagic—brain vessel ruptures, causing
bleeding into the brain tissue or cranial vault. (15%
of strokes are hemorrhagic)
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Stroke
Transient Ischemic Attack
• Often called a “mini-stroke”
• Clot affects a minor vessel, or collateral
circulation compensates for blockage
“A TIA is a period of stroke-like symptoms
that self-resolve within 24 hours”
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Stroke
Transient Ischemic Attacks…
• Very often predict future strokes
– Person who has had a TIA is 30 times more
likely to have a full stroke
• Impossible to differentiate between TIA and
Stroke in the field: treat the same.
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Stroke-Risk Factors
That can be changed or modified…
• Hypertension single, most important risk
factor that can be changed in strokes
• Previous TIA’s or strokes:
– future strokes may be prevented with lifestyle
modifications and treatment with bloodthinning medications
• Heart disease
• Cigarette smoking
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Stroke-Risk Factors
That can be changed or modified…
• Combined risk factors:
– Lower level risk factors become more
significant when combined…
– For example, oral contraceptive use and
cigarette smoking…
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Stroke-Risk Factors
That CANNOT be changed or modified…
• Increasing age
– Most important non-modifiable risk factor
• Sex—men at higher risk
• Race—death and disability is twice as high in
blacks than in caucasians
• Diabetes
– Higher liklihood of vascular disease
– More often have high blood pressure
• Heredity—family history of stroke
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Stroke-Presentation
• Altered mental status or memory loss
• Slurred speech or difficulty speaking or
understanding speech
• Difficulty swallowing
• Confusion
• Patient appears awake, but cannot speak,
move, or follow commands
• Headache
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Stroke-Presentation
• Facial droop (usually
unilateral)
•
•
•
•
Partial paralysis or weakness
Hypertension
Rapid, full pulse
Impaired vision, unequal
pupils
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Stroke-Presentation
In more severe cases…
• Difficulty in mainatining airway
• Seizures
• Unresponsive to voice or pain
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Stroke-Presentation
In milder cases…
• Test for arm drop
• Test for slurred
speech…
“You can’t teach an old
dog new tricks”
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Stroke—Treatment
• Until recently, stroke care was largely supportive
only.
• Now ischemic strokes are treated with clot-busting
drugs that can limit future disability, and in some
cases restore full function.
• 3-hour time window for safe administration of
clot-busting drugs…
Time is brain!
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Stroke—Treatment
• Use of new drugs requires
that a hemorrhagic stroke be
ruled out first.
• After managing the airway,
breathing, and circulation, the
EMT’s priority should be
rapid transport to a facility
with a CAT-scanner
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Stroke—Treatment
• ABC’s: carefull attention to airway
management
• High-flow oxygen with non-rebreather
mask
• Rule-out trauma: take C-spine precautions if
necessary
• Place in recovery position
• Contact or intercept with ALS
• Rapid transport & early notification of E.R.
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Stroke—Treatment
• Reassure patient and explain all of your
actions…
The patient may be unable to verbalize or
respond, but may still be aware of the
surroundings and able to hear
everything that you say.
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Seizures
• Irregularity in electrical neuron conduction
patterns in the brain causes a temporary
“short circuit” in brain function.
• Lay people may refer to a seizure as a “fit”
or “spell”
• A seizure is not a disease, but a symptom of
an underlying problem
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Seizures
• May present as…
– “Absence seizure” (petite mal)…momentary
loss of awareness, staring into space.
to…
– General Motor Seizure…body spasms and
convulsions lasting up to a few minutes.
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Seizures—Causes
• Epilepsy (most
common cause in
adolescents and
adults)
• Toxic/Drug effects
• Drug/alcohol
withdrawal
• Infection (e.g.
meningitis)
• Tumors, brain defects
• Febrile (due to fever)
• Head injury/traumatic
spinal cord injury
• Stroke
• Hypoxia
• Heat stress
• Pregnancy Induced
Hypertension
• Ideopathic (unknown
cause)
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Seizures—Causes
Epilepsy—Most frequent cause of adolescent and
adult seizures
• Perhaps the best-known cause of seizures
• Some patients are born with the condition,
others develop it after a head injury or brain
surgery
• Compliance with medications can lead to
normal life and function
Non-compliance with meds is biggest cause
of serious seizures due to epilepsy.
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Seizures—Causes
Febrile Seizures—most common cause of
seizures in children aged 6 months to 3 years.
High fever—by itself is a common and frequent
reason for 9-1-1 calls involving children.
• Caused by metabolic irregularities in
patient’s chemistry due to sustained, high
fever.
• Often due to childhood diseases like mumps
and measles, or common flu.
• The body’s thermostat “resets” itself.
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Seizures-Types
Complex Partial (Psychomotor)
– Hallmark is bizarre behavior, which varies
widely person-to-person
– Glassy stare, confusion
– Aimless moving about
– Repetitive motions
• Lip smacking, pacing
• Chewing, grinding teeth
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Seizures-Types
Simple Partial
• Starts or affects a single part of the body
• Usually presents with jerking, tingling, or
numbness in a single extremity
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Seizures-Types
General Motor Seizure
• Convulsive muscle spasms
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–
–
–
–
–
Breathing may be irregular, or stop temporarily
Diaphragm may be paralyzed
Throat and jaw muscles clenched
Excessive salivation
May lose bowel or bladder control
May bite tongue
• Patient is unresponsive
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Seizures
Postictal Phase
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•
•
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Body & brain’s “rest period” after a seisure
Headache is common
Patient may remain unconscious, or…
May regain consciousness but be very
drowsy and confused
• May last several minutes to many hours
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Seizures
• Normally last only a minute or two.
• Rarely, it may last 30 minutes or longer
– Known as a status seizure, or status epilepticus
– This is a true emergency
– May require rapid transport while patient is still
seizing
– Requires ALS provider to administer drugs to
stop the seizure
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Seizures
• Seizures in children and adults with a
history of a seizure disorder are rarely lifethreatening.
Any seizure that results in a 9-1-1 call
should be transported to the
emergency department for evaluation.
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Seizures-Treatment
1. Do NOT restrain patient
•
•
•
Move furniture out of the way
Place pillow under head or cradle head in your lap
DO NOT try to insert anything into the mouth
2. After seizure, suctioning of secretions may be
required
3. Place in recovery position
4. Transport to E.R.
5. Consider trauma if patient fell down, or if
seizure was particularly violent
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Seizures-Treatment
Status Seizure
• ALS is required
• Administer high-flow oxygen
• Place patient on side to help in draining
secretions during the seizure
• Protect the patient’s head
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Syncopal Episodes
(fainting spell)
May result from…
Patient stands up too quickly after being
dehydrated, illness, heat stress.
Severe emotional challenge.
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Syncopal Episode
• When patient stands up, momentary
decrease in perfusion to the brain.
• Patient faints.
• Once flat on ground, circulation is restored
to the brain, and patient wakes up.
Often seen in old movies…Treated by slapping the
face, rubbing the wrists, using smelling salts
(Slapping is NOT recommended for EMT’s!)
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Syncopal Episode-Treatment
1. Rule out trauma during the fall (consider
C-spine precautions)
2. Open airway & assess breathing
3. Elevate feet if patient’s face is pale and
cool
4. Do not allow the patient to stand
immediately.
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Syncopal Episode-Treatment
If patient does not immediately regain
consciousness…
•
•
•
•
Consider other causes…
Request ALS
Apply oxygen
Frequently reassess the ABC’s of
unconscious patients
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Altered Mental Status
The most important symptom of
brain injuries is the patient’s
mental status (level of
consciousness)
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Altered Mental Status
Assessing Mental Status
A.V.P.U.
A- Alert
V- Responds, open eyes to VOICE
P- Responds, opens eyes, moves, moans to PAIN
U- Completely UNRESPONSIVE
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Altered Mental Status
Assessing Mental Status
A & O (Alert & Oriented) x 4
Person—knows who he/she is
Place—knows where he/she is
Time—knows approximate calendar date, can
identify president, current events, etc.
Events—knows what happened
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Altered Mental Status
During Focused History & Physical Exam…
Assess the Pupils (PERRL)
P- Pupils are
E- Equal,
R- Round,
R- Reactive to
L- Light
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Review
General Treatment Pathway for All AMS Patients
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
Sample History
•Trauma Mechanism?
•Does scene indicate
drug/alcohol use?
•Did patient fall?
•C-spine precautions if
indicated
•Rule-out hypoxia…
•Fire, drowning, toxic
exposure…
•Appearance, color
52
Review
General Treatment Pathway for All AMS Patients
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
If unconscious, how
unconscious are they?
•AVPU
•A & O x 4
Person, Place
Time, Events
•Can patient follow
basic commands?
Sample History
53
Review
General Treatment Pathway for All AMS Patients
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
Many AMS patients
will require
vigorous airway
maintenance…
•Assistance vomiting
•Suctioning
•Placing in recovery
position
•Oral or nasal airways
Sample History
54
Review
General Treatment Pathway for All AMS Patients
General Impression
Level of
Consciousness
Adequate
respirations, but
altered mentation
= High-flow
oxygen via NRM
Airway
Breathing
Circulation
Respirations too fast
or too slow
=BVM attached to
oxygen, oral or
nasal airway
Sample History
55
Review
General Treatment Pathway for All AMS Patients
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
Sample History
Pulse is:
•Very weak, or very slow…
= Rapid transport
•Very fast
= Rapid transport
Hypotension, pale,
diaphoretic…
= Treat for shock
Rapid Transport
56
Review
General Treatment Pathway for All AMS Patients
General Impression
Level of
Consciousness
Airway
Breathing
Circulation
•S.A.M.P.L.E
•Any similar episodes in
the past?
•History of trauma in
the past 2-3 days? (head
injury)
•Medic-alert jewelry,
wallet cards
•Inspect scene for clues,
medications
Sample History
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• Drug & Alcohol Emergencies
• Poisonings & Accidental Overdoses
Will be covered in later chapters.
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Questions?
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installations and surrounding communities of Southside
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To provide comments or suggestions for this slide program, contact EMS Training
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