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7/31/2019 Altered Mental States
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2010 Seattle / King County EMS
CBT443: Altered Mental States 2010
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Introduction
It is important for the EMS provider toaccurately assess and recognize changes
in a patients level of consciousness.
Consciousness is being awake, alert, andaware of your surroundings.
A healthy person is aware of thoughts,
ideas and emotions when conscious. There are varying degrees of consciousness
ranging from conscious and alert tolethargic to obtunded.
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Terms
brainstem Area of the brain between the spinal cordand cerebellum. The brain stem controls basic functionsthat do not require conscious attention such asbreathing, digestion and heart activity.
central nervous system (CNS) The main part of thenervous system that includes the cerebrum,cerebellum, brain stem and spinal cord.
cerebrum Largest part of the brain. It controlsthought, movement, hearing, vision, speech, emotionsand personality.
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Terms, continued
cerebellum A division of the brain also called thelittle brain. It is located below the cerebrum andcoordinates involuntary and primitive functions suchas balance.
coma A state of deep, often prolongedunconsciousness, usually the result of injury, disease orpoison, in which a person cannot sense or respond to
external stimuli and internal needs.
neuron A specialized type of cell whose main role isto process and transmit information.
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Terms, continued
peripheral nervous system This division of thenervous system includes sensory and motor nervescoming from the spinal cord and brain stem that run tothe bodys organs, skin and muscles.
postical state The period following a seizure orconvulsion characterized by motor weakness, lethargy,confusion and nausea.
tonic-clonic seizure A type of seizure involving theentire body, usually characterized by violent rhythmicmuscle contractions and loss of consciousness.
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Terms, continued
acidosis Excessive acid in the blood.
lethargy Pertaining to or resembling drowsiness.
miosis Constriction of the pupil of the eye, resultingfrom a normal response to an increase in light orcaused by certain drugs or pathological conditions.
obtunded Dulled or deadened, responds to pain.
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Terms, continued
reticular activating system (RAS) An area of nervesin the brainstem, thalamus and hypothalamus thatcontrols consciousness.
toxidrome A listing of specific signs and symptomscaused by exposure to specific types of poisons ortoxins.
uremia A condition resulting from advanced stagesof kidney failure in which urea and other wasteproducts are found in the blood in high concentration.
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Central Nervous System (CNS)
Includes the brain and spinal cord Helps control all of the body systems
and organs
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Peripheral Nervous System
Made of all the nerves that project outof the brain and spinal cord
Provides direct input to the central
nervous system from sensors in thebody
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Peripheral Nervous System
Motor nerves extend from the spinalcord and control the muscles of thebody
Sensory nerves allow sensations offeeling, hot or cold and travel back tothe spinal cord and up to the brain
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The Brain
thought personality memory
motor skills tactile (touch) speech vision
cerebrum
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The Brain, continued
coordination balance basic movement
muscle tone
cerebellum
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The Brain, continued
heart function respiration autonomic nervous
system digestion glandular secretions
brain stem
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4 Things You Need to Conscious
Sugar
Oxygen
Intact neural pathways
Intact reticular activating system (RAS)
Anything that disturbs or disrupts thesecan cause alterations in mental status.
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Sugar
Sugar (in the form of glucose) is the fuel onwhich the brain runs.
Oxygen is needed by brain cells to carry out
metabolism.
A sudden lack of blood flow to the brainor lack of oxygen will shut the brain
down in 5 to 10 seconds.
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Neural Pathways
Groups of nerves that run through the brain
Carry signals from the brainstem to variousdestinations in the brain
These pathways can be disturbed by trauma,tumors, chemicals (drugs) or electricalinterference (that which cause seizures).
Stroke, epilepsy, and trauma are differentevents that affect these pathways resultingin altered mental states.
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Intact RAS
Consciousness center of the brain thatmaintains wakefulness
Small area of nerves in the brainstem that
controls consciousness
Altered LOC is a strong indication of
insult to the central nervous system.
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AEIOU-TIPS
A commonly used mnemonic to helpremember the causes of altered mentalstates.
BLS providers are not expected to knowand recognize all these causes, but it ishelpful to be familiar with them in orderto know what types of questions to ask
when assessing a patient.
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Acidosis
Acidosis is the increase in the acid level inthe body. Its causes include:
diabetes
shock
poisoning
overdose
kidney failure
impaired breathing
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Alcohol
A depressant that inhibits the brain
As the blood alcohol level rises, reasonand judgment are impaired.
Intoxicated patients may progress fromstupor to coma to death primarily fromrespiratory depression and arrest.
These people cannot maintain their airwayand are in danger of aspirating their salivaor vomitus.
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Epilepsy/Seizures
occurs when the neural pathways becomedisturbed by excessive discharge of electricityin the brain
can affect either part of the brain or thewhole brain itself
Alcohol withdrawal in addicts may causeseizures due to disruptions in the neuralpathways.
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Infection
Usually causes high temperatures andinflammation that affect the brainsneural pathways, the brainstem and
supplies of sugar and oxygen Infection of the central nervous system,
such as meningitis or encephalitis, maycause an altered LOC.
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Overdose
Barbiturates and narcotics (for example,heroin) are drugs that can suppressbrainstem function.
Narcotics can slow the respiratory centersof the brain resulting in a lack of oxygen.
Cocaine can produce extreme CNSstimulation resulting in seizures andstrokes.
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Underdose/Uremia
Some medical conditions may causealtered LOC when the patient does nottake adequate amounts of his or her
prescribed medication. Diabetic coma may occur in diabetics
who do not take adequate amounts ofinsulin.
COPD patients can develop an alteredLOC from retaining too much carbondioxide when they do not use medicinesdelivered by their metered-dose inhaler.
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Trauma/Tumors/Temp
Trauma to the head can cause damage tovessels and brain tissue.
Tumors can affect neural pathways and the
brainstem, neural pathways, oxygen andsugar.
Temperature extremes have a dramaticimpact on all four elements of consciousness.
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Insulin
The insulin-dependent diabetic produces aninsufficient amount of insulin and mustinject insulin into the body.
If the diabetic forgets to eat, overexerts, ortakes too much insulin, there is a seriousshortage of glucose (hypoglycemia).
The brain, which is very sensitive to sugar
supplies, begins to shut itself down. Another condition called hyperglycemia
may occur when there is not enough
insulin in the blood.
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Psychosis
A mental illness that commonly affectspersonality, for example, schizophrenia andmanic depression.
Delirium and acute brain syndrome arespecific types of psychoses where the patientdisplays disorientation, memory-loss, andlapses in consciousness.
Common medications for these patientsinclude lithium (Lithobid, Eskolith),risperidone (Rusoerdak) and olanzapine
(Zyprexa).
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Poisoning
Mechanism that causes unconsciousnessvaries greatly depending on the substance.
Carbon monoxide prevents oxygen from
reaching the brain. An overdose of tricyclic antidepressants can
cause hypotension, cardiac dysrhythmias anda lack of oxygen and sugar.
Poisoning can occur through ingestion,inhalation, injection, absorption and ingestion.
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Stroke
A stroke occurs when a portion of the brain isdamaged due to interruption of blood flow(lack of sugar and oxygen).
Strokes affecting one side of the brain maycause altered LOC.
Massive strokes involving the brainstem willcause coma.
Transient ischemic attacks (TIAs) can bethought of as "mini-strokes"symptoms ofthese events subside completely within 24
hours.
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Scene Size-up
Observe the surroundings, the patientsbody position, bystanders and other cluesthat may indicate danger to you, your
crew or the patient. Decide if it safe to enter the scene and if
you need additional resources.
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Baseline LOC
LOC is the single most important element inthe assessment of a patient with altered LOC.
Establish a baseline LOC using AVPU early.
Document the baseline LOC and subsequentchanges.
Be specific about what you observe.
Repeat LOC checks every few minutes todetect changes and trends.
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Noxious Stimuli
A noxious stimulus is a test of centralnervous system function.
Document the reaction to the stimulus:
Appropriate response (e.g. attemptsto push away the stimulus)
Inappropriate response (e.g.decerebrate posturing)
No response
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Focused History
The key to a good assessment of an alteredlevel of consciousness is taking a thoroughhistory and examining the surroundings for
clues about what happened. Remember to look for medic-alert
information on necklaces or bracelets.
You may need to check refrigerators,medicine cabinets and bedside tables.
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Physical Exam
A complete physical exam for a patient withan altered level of consciousness shouldinclude:
Assess LOC Check vital signs
Check pupils for size, symmetry and
reactivity to light Auscultate breath sounds
Glucometry
Pulse oximetry
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AVPU
Alert means the patient is awake and awareof his surroundings. The oriented patientremembers person, place, time, and event.
Verbal means that the patient awakens orresponds to verbal stimulus. Use a simplecommand such as "stick out your tongue."
Pain means the patient awakens or respondsto painful stimulus.
Unresponsive means the patient does notrespond to verbal or painful stimuli.
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Pupil Response
Pupils should respond briskly and equallyto a penlight.
Abnormal pupil response may indicate
depressed brain function or centralnervous system depression or injury.
Record the results of this checkeven ifit is negative.
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ABCs
Airway, breathing and circulation (ABCs)must be monitored closely.
An altered mental status especially requires
that you attend to the airway and breathing. You may need to manually hold the airway
open, remove obstructions, or breathe for apatient using a BVM and high-flow oxygen.
Consider the use of an airway adjunct if theairway cannot be maintained.
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Oxygen
Oxygen is vital to sustaining the brain andmaintaining consciousness.
Remember that unresponsive patients can
lose their gag and cough reflexes. Keep the airway clear and open and monitor
the airway closely.
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Patient Position
Position the patient according to thesuspected illness or injury.
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Summary
The central nervous system includes thebrain and spinal cord.
The peripheral nervous system is made of all
the nerves that project out of the brain andspinal cord
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Summary, continued
The four things the brain needs to beconscious and alert:
Sugar
Oxygen
Intact neural pathways
Intact reticular activating system (RAS)
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Summary, continued
Major causes of altered mentation areAEIOU-TIPS:
Acidosis, Alcohol
Trauma, Tumors,Temperature
Epilepsy/Seizures
Insulin
Infection
Psychosis, Poisoning
Overdose
Stroke
Underdose, Uremia
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Summary, continued
The major safety concern associated withoverdose patients is protecting you and yourcrew.
The first step in the assessment of a patientwith altered mentation is determiningbaseline LOC.
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Summary, continued
The essential components of a physicalexam for a patient with an altered LOC:
Assess LOC
Check vital signs
Check pupils for size, symmetry andreactivity to light
Auscultate breath sounds
Glucometry
Pulse oximetry
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Summary, continued
Abnormal pupillary response may indicatedepressed brain function or brain injury.
Proper emergency care for a patient with an
altered mental status includes theABCs,oxygen therapy to meet patient needs andproper positioning.
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Resources
The recertification exam for this module isbased on a variety of resources. Werecommend that you review the following:
Chapter 13: Neurologic Emergencies inEmergency Care and Transportation of theSick and Injured, 9th edition (AAOS).
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Questions
Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp
EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp
Tracey White
Training Division ManagerEmail support:[email protected]
http://www.emsonline.net/doc.asphttp://www.emsonline.net/downloads.asphttp://www.emsonline.net/downloads.asphttp://www.emsonline.net/http://www.emsonline.net/http://www.emsonline.net/downloads.asphttp://www.emsonline.net/downloads.asphttp://www.emsonline.net/doc.asp