Altered Mental Status Presentation

Altered Mental Status (AMS)

Condition characterized by changes in a person's awareness, alertness, and cognitive functions.

Reticular Activating System (RAS)

Series of neurologic circuits responsible for staying awake, paying attention, and sleeping.

Three requirements for normal CNS function

Oxygen, glucose, and water.

Causes of altered mental status

Deficiencies in oxygen, glucose, or water; trauma; infection; toxins; stroke; mass effect; problems in other body systems causing hypoxia.

Primary assessment priorities for AMS

Identify life-threatening problems, assess airway and breathing, consider oxygen, positioning, suctioning, and determine baseline mental status.

Secondary assessment for AMS

Examine patient thoroughly, perform body systems exam, obtain complete history.

Sources of information during AMS assessment

Family members, bystanders, medications, Medic Alert bracelets, health-related items.

Pediatric assessment question for AMS

'Are they acting differently than normal?'

Insulin

Hormone produced by the pancreas that allows glucose to enter cells for energy.

Function of insulin

Binds to receptors on cells and allows glucose to pass into cells.

Type 1 Diabetes Mellitus

Pancreas produces little or no insulin; treated with synthetic insulin.

Type 2 Diabetes Mellitus

Body's cells do not use insulin properly; treated with diet, oral medications, and sometimes insulin.

Definition of hypoglycemia

Blood glucose less than 70 mg/dL.

Significant AMS is expected at what glucose level?

Less than 50 mg/dL.

Causes of hypoglycemia

Too much insulin, not eating enough, overexertion, vomiting, increased metabolic rate (fever or shivering).

Onset of hypoglycemia

Rapid.

Behavior associated with hypoglycemia

May mimic drunkenness.

Skin signs of hypoglycemia

Pale and diaphoretic.

Cardiovascular sign of hypoglycemia

Tachycardia.

Respiratory sign of hypoglycemia

Rapid breathing.

Neurologic complications of hypoglycemia

Seizures, altered mental status, unconsciousness, permanent brain damage.

Treatment for hypoglycemia

Safety first, airway management, support breathing, oral glucose if conscious, ALS/transport.

Definition of hyperglycemia

Blood glucose greater than 140 mg/dL.

High blood glucose level associated with severe symptoms

Greater than 300 mg/dL for prolonged periods.

'HI' reading on glucometer

Greater than 500 mg/dL.

Causes of hyperglycemia

Decreased insulin, stress, increased dietary intake.

Onset of hyperglycemia

Develops over days to weeks.

Signs of hyperglycemia

Chronic thirst, hunger, increased urination, nausea, warm flushed skin.

Results of hyperglycemia

Dehydration, excessive waste products, diabetic ketoacidosis (DKA).

Treatment for hyperglycemia

Safety first, airway management, support breathing, ALS/transport.

Diabetic ketoacidosis (DKA)

Severe hyperglycemia with profoundly altered mental status, dehydration, shock, Kussmaul respirations, and acetone odor on the breath.

Kussmaul respirations

Deep, rapid respirations associated with DKA.

Acetone odor on breath

Fruity odor characteristic of DKA.

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Severe hyperglycemia without Kussmaul respirations or acetone odor.

Normal blood glucose range

70–120 mg/dL.

Hypoglycemia

Less than 70 mg/dL.

Severe hypoglycemia

Less than 50 mg/dL.

LOW glucometer reading

Less than 15 mg/dL.

Hyperglycemia

Greater than 140 mg/dL.

Severe hyperglycemia

Greater than 300 mg/dL.

HI glucometer reading

Greater than 500 mg/dL.

History questions for diabetic patients

Onset, duration, associated symptoms, trauma, seizures, fever, medications, insulin use.

SAMPLE history

Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to illness.

Clues suggesting diabetes

Medical identification bracelet, insulin, medications, insulin pump.

Important diagnostic test in diabetic emergencies

Blood glucose monitoring.

Sepsis

Collection of problems caused by the body's response to infection.

Sepsis is similar to what condition?

Anaphylaxis.

Sepsis is what type of problem?

Systemic problem.

Severe sepsis causes what cardiovascular effects?

Systemic vasodilation and decreased cardiac output.

Septic shock results from

Severe infection causing circulatory collapse.

Stroke

Interruption of blood flow to part of the brain.

Two major types of stroke

Ischemic and hemorrhagic.

Ischemic stroke

Caused by blockage of blood flow to the brain.

Hemorrhagic stroke

Caused by bleeding within the brain.

Transient Ischemic Attack (TIA)

Temporary blockage of blood flow causing stroke-like symptoms that resolve completely.

TIA symptoms usually resolve within

Minutes, always within 24 hours.

Sudden stroke symptoms

Weakness, numbness, confusion, trouble speaking, trouble seeing, loss of balance, severe headache.

Facial droop test

Ask the patient to smile or grimace.

Pronator drift test

Ask patient to close eyes and extend both arms for 10 seconds.

Speech test phrase

'You can't teach an old dog new tricks.'

Abnormal findings on the Cincinnati Stroke Scale suggest

Stroke.

Important information to determine in stroke patients

Time of symptom onset or last known well.

If symptoms began less than 5 hours ago

Activate a Stroke Alert.

Head of stretcher should be elevated to

30 degrees.

Transport priority for stroke patients

Do not delay transport for ALS intercept.

Partial seizure

Involves one area of the brain; patient may remain conscious.

Generalized seizure

Involves the entire brain and affects consciousness.

Tonic-clonic seizure

Generalized seizure with muscle rigidity and rhythmic jerking.

Postictal phase

Period after seizure when consciousness gradually returns.

Aura

Smell, sound, or unusual sensation that may precede a seizure.

Status epilepticus

Seizure lasting longer than 10 minutes or two or more seizures without regaining consciousness.

Common causes of seizures

Hypoxia, stroke, traumatic brain injury, toxins, hypoglycemia, infection, brain tumors, metabolic disorders, epilepsy, eclampsia, heat stroke.

Complex partial seizure

Often preceded by an aura.

Generalized tonic-clonic seizure

Most commonly recognized seizure type.

Syncope

Brief loss of consciousness followed by spontaneous recovery.

Duration of most syncopal episodes

Seconds to a few minutes.

Patients often experience what before syncope?

Warning signs that the episode is coming.

Causes of syncope

Cardiovascular, environmental, toxicological, hypovolemic, metabolic, structural causes.

Common cardiovascular causes of syncope

Bradycardia, tachycardia, and vasovagal syncope.

Cause of syncope is never identified in approximately

Half of all cases.

Questions to ask a syncopal patient

Did you have nausea?, Did you experience strong emotions?, Did you injure yourself?, Did anyone witness seizure activity?

Patient management for syncope

Oxygen as needed, call ALS, loosen tight clothing, lay patient flat, treat injuries, assess blood glucose and stroke scale.

Signs of inhaled poison exposure

Difficulty breathing, Chest pain, Coughing, Hoarseness, Dizziness, Headache, Confusion, Altered mental status, Seizures.

Delirium Tremens (DTs)

Serious alcohol withdrawal syndrome occurring after abrupt cessation of drinking.

Signs of alcohol withdrawal

Profuse sweating, Seizures, Hypertension, Tachycardia.

Alcohol withdrawal may also cause

Tremors and hallucinations.

Important treatments for AMS patients

Monitor vital signs, Treat for shock, Gather history, Watch for seizures, Transport to a medical facility.