May 2012 CE

Site code # 107200E-1212

Altered Mental Status Revision - Region X Multiple

Patient Plan

Objectives by Reviewed/revised by Sharon Hopkins, RN, BSN, EMT-P

To view on the Advocate Condell website visit: www.advocatehealth.com/condell/body.cfm?id=422

Date of CE presentation: May 2012 Topic: Altered Mental Status – Revision of Region X Multiple Patient Plan Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to:

1. Identify varying levels of consciousness following the AVPU scale 2. List potential causes of altered mental status. 3. List components of a field neurological examination. 4. Define transient ischemic attack (TIA). 5. Differentiate between an ischemic stroke and hemorrhagic stroke. 6. Demonstrate obtaining the Cincinnati Stroke Scale. 7. Given a scenario, demonstrate assigning a Glasgow Coma Scale (GCS) score to a patient. 8. Given a situation, utilize the SOP resources to determine appropriate interventions. 9. Given equipment, prepare medication for administration in a variety of methods. 10.Review changes to the Region X Multiple Patient Policy 11. Successfully complete the post quiz with a score of 80% or better. Bibliography

Region X Advanced Life Support Standard Operating Procedures February 1, 2012

American Heart Association. STEMI Professional Provider Manual. 2008. Beasley, B. Understanding EKGs – A Practical Approach 3rd Edition.

Brady. 2012. Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices

Third Edition. Brady. 2009. Limmer, D., O’Keefe, M. Emergency Care 12th Edition. Brady. 2012. dying.about.com/od/glossary/g/LOC.htm En.wikiopedia.org/wiki/Karen_Ann_Quinlan

Level of consciousness Definition

LOC is a measurement of a person’s awareness of their surroundings or arousability and responsiveness to their environment

AVPU as a general mental status assessment A – alert and awake V – responds to verbal stimuli

P – responds to painful stimuli U – unresponsive AEIOU –TIPS A – alcohol E – endocrine, electrolytes, encephalopathy I- insulin O – opiates U – uremia T- trauma, head injury, blood loss I- intracranial, infection P- poisoning, psychiatric S - seizures, syncope

Field neurological exam Level of consciousness A V P U Pupillary response Ability to identify person, place, and time GCS

GCS scoring Eye opening

4 – spontaneous 3 – to voice 2 – to pain/tactile stimulation 1 – no response

Verbal response

5 – Oriented (coos, babbles) 4 – Confused (irritable cry) 3 – Inappropriate words (cries to pain) 2 – Incomprehensible sounds (responds to pain) 1 – no response

Motor response

6 – Obeys commands 5 – Purposeful movement (withdraws to touch) 4 – Withdraws to pain (withdraws to pain) 3 – Abnormal flexion 2 – Abnormal extension 1 – No response

GCS Practice #1

45 year-old patient was pedestrian vs car Upon arrival they are crying out in pain and looking around with a

frightened look They do not answer your direct questions; they are very worried about

picking up dry cleaning & talking about grocery shopping The patient is pulling at your hands trying to stop you from your care; they

are attempting to pull off the collar

Eye – Verbal – Motor – Total – GCS Practice #2

88 year-old from home. Fell 1/2 hour ago with possible fractured hip Upon arrival patient sitting on the floor watching you come into the room Answers most questions appropriately, thinks you are the nephew coming

to visit Extends her arm for the blood pressure cuff when requested; follows all

commands Eye – Verbal – Motor – Total -

GCS Practice #3

You are on the scene for a 1 year-old who rolled off the changing table

and fell to the floor The patient is found on the ground with eyes closed. The eyelids flutter

when the patient is touched The patient moans when IV established One arm flexes to the chest with wrists curling inward, 1 extends as you

are delivering care; the legs extend

Eye – Verbal – Motor – Total –

GCS Practice #4

14 year-old patient found unresponsive behind the school They are laying on their side, there is evidence of vomitus at the scene As you call their name, their eyelids flutter The are talking nonsense They are tugging and pulling at any equipment you have placed

Eye – Verbal – Motor – Total –

GCS Practice #5

You have a 3 year-old who is found unresponsive next to grandma’s purse Their eyelids flutter but never open after begin touched They are whimpering and moaning when stimulated They slowly bend their arms into their chest with wrists curling (decorticate

posturing) when you are trying to deliver care

Eye – Verbal – Motor – Total –

FAST Exam F – facial droop

A – arm drift S – speech problem T – time of onset

Cincinnati Stroke Scale

Facial droop Ask the patient to smile big enough to show all their teeth Record as right droop, left droop, or no droop

Arm drift

Have patient hold arms outstretched, palms up, for 10 seconds with eyes closed

Record as a right drift, left drift or no drift Speech

Can have the patient repeat after you any words or a sentence you give them

“You can’t teach an old dog new tricks” Record as speech clear or not

Most important question – time last known to be normal

Rhythm Review

#1

#2

#3

#4

Endocrine Problems Diabetic Ketoacidosis Takes days/weeks to develop (slow process to occur, longer time to fix and straighten out)

3 P’s - Polyuria, polydipsia, polyphagia Warm, dry skin & mucous membranes Nausea/vomiting Abdominal pain Tachycardia Deep, rapid respirations (Kussmaul’s) Fruity odor on breath Fever (if associated infection) Decreased mental status

Insulin shock Rapid onset, rapid fix. Brain extremely reliant on appropriate/adequate levels of glucose to function. First presentation often a rapid change in level of consciousness.

Weak, rapid pulse Cold, clammy skin Weakness and uncoordinated Headache Irritability, agitated behavior Seizure at critically low levels of glucose Coma – severe

Documentation of medications Use mg/mcg/gm (use ml to draw up and prepare a syringe) Document a “0” in front of a decimal point (prevents losing the decimal point and making an error in dosing) Case Scenario #2 - 12 lead EKG

Case Scenario #3 - 12 lead EKG

Case Scenario #5 Rhythm Strip

Pre-Quiz Paramedic And Basic Level

From May 2012 CE Material

Altered Mental Status Name_____________________________Date__________ 1. Describe how you assess/what you are looking for with the components of the AVPU scale: A – V – P – U – 2. List as many items that are triggered for an altered level of consciousness when you use the AEIOU-TIPS mnemonic: A – T - E – I - I - P - O – U - 3. Calculate the GCS: The patient is watching you approach. They respond to all your questions. They are able to walk to the cot on their own with minimal assistance. Eye opening _____ Verbal response _____ Motor response_____Total ____ 4. The patient opens their eyes when you yell at them. The patient is mumbling and moaning. The patient tries to grab at your hands and pull off equipment. Eye opening _____ Verbal response _____ Motor response_____Total ____

5. The patient flutters their eyelids when stimulated. They are moaning and groaning. The patient draws one arm into the chest and extends one arm when stimulated. Eye opening _____ Verbal response _____ Motor response_____Total ____ 6. What is the difference between a TIA and CVA? What is the significance to the patient of a TIA (i.e.: why do they need to be evaluated)?

May 2012 pre-quiz

7. What is the treatment for a patient with symptomatic bradycardia? 8. List at least 4 signs or symptoms of diabetic ketoacidosis. What is the field treatment? 9. List at least 4 signs or symptoms of insulin shock. What is the field treatment? 10. List at least 4 signs or symptoms of opiate use/overuse.

File: CE, EMS; CE Packets; 2012; May altered Mental Status