10/15/2015. Structural Lesions Brain tumor (neoplasm) Degenerative disease Intracranial hemorrhage Parasites Trauma

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1 At the end of this seminar the participant shall be able to: Generally describe the pathophysiology of altered level of consciousness Describe some of the medical causes of altered level of consciousness Describe assessment techniques to help determine the cause of the altered level of consciousness Apply the assessment techniques to scenario patients Alteration in Cognitive Systems Altered forms of consciousness result from dysfunction or interruption of the CNS Alterations may vary Minor thought disturbances Coma Two mechanisms capable of producing alterations in mental status Structural lesions Toxic-metabolic states Structural Lesions Brain tumor (neoplasm) Degenerative disease Intracranial hemorrhage Parasites Trauma Toxic-Metabolic States Anoxia (lack of oxygen) Diabetic ketoacidosis Hepatic failure Hypoglycemia Renal failure Thiamine deficiency Toxic exposure (e.g., cyanide, organophosphates) Drugs Depressants (including ) Hallucinogens Narcotics Cardiovascular Anaphylaxis Cardiac arrest Stroke Dysrhythmias Hypertensive encephalopathy Shock Respiratory COPD Inhalation of toxic gas Hypoxia Infectious AIDS Encephalitis Meningitis 1

2 Scene Size-up and Initial Assessment AVPU General Appearance Speech Skin and Facial Drooping Mood, Thought, Perception, Judgment, Memory, and Attention Attempt to correct life threats Focused History and Physical Exam History-Taking Trauma-related or medical problem Underlying medical problems Environmental clues Physical Exam Face, eyes, nose, and mouth Respiratory Patterns Any of five abnormal respiratory patterns may be observed Cardiovascular Assessment Heart rate ECG (if capable) Jugular venous distention Nervous System Status Sensorimotor Evaluation Motor System and Cranial Nerve Status 2

3 Posturing Sensorimotor Evaluation To document loss of sensation and/or motor function Decorticate and decerebrate posturing are ominous signs of deep cerebral or upper brainstem injury Motor System Status Muscle tone Muscle strength Flexion/extension Coordination Balance Cranial Nerve Status Further Mental Status Assessment Glasgow Coma Scale Three components Eye opening Verbal response Motor response May be used on adult or pediatric patient Simple tool for evaluating and monitoring 3

4 Vital Signs Cushing s Reflex Other Assessment Tools Capnography Pulse Oximeter Blood Glucometer CO Oximetry Geriatric Considerations in Neurological Assessment Ongoing Assessment General Principles Airway and Breathing Including oxygen as needed Circulatory Support Pharmacological Intervention Dextrose, thiamine, naloxone, and diazepam Psychological Support Transport Considerations Computerized tomography (CT) or magnetic resonance imaging (MRI) AEIOU-TIPS Assessment Management Initial Assessment Oxygen to maintain SpO2 between 94 and 99% Treatable Causes Hypoglycemia, narcotic overdose, suspected ic 4

5 Dispatched to Unknown Problem, male patient found in pickup in middle of street Law enforcement reports vehicle was running with transmission in park Patient is awake but confused On your arrival patient cannot answer questions Assessment Eyes open Regular breathing Open airway Good pulse Vital Signs Pulse 96 BP 160/100 Resp 20 ETOH on his breath Blood glucose 46 mg/dl Treatment? Dispatched to a local trailer court for a 36 y/o female having a psychotic break On arrival find female in back bedroom of old run-down trailer Female is thin, has dark hair with multiple tattoos and piercings She is lying in bed Appears fearful Keeps repeating phrases that make no sense 5

6 Withdraws when touched Shakes head No with every question Family denies any recent ETOH and state patient does not use any street drugs No previous history of mental illness Assessment? Vital signs Pulse 110 B/P 160/110 Resp 24 SpO2 99% on room air Blood sugar 124 mg/dl Treatment? 0830 hours called to an apartment for an Unknown Problem En route informed that law enforcement had responded to a 911 call with no verbal response Law enforcement had found a female in bed who seems unable to communicate. Unknown problem On your arrival find motorized wheelchair in bedroom near bed Patient is conscious but not speaking Has obvious deformity to jaw and hands Patient keeps waving at piece of plywood lying on floor On retrieving board you see that it looks kind of like a keyboard The patient motions for the board After a few starts you realize the patient is spelling with her little finger 6

7 She communicates that her caregiver has not arrived to get her up for the day. Her only communication capability was to call 911 The caregiver helps her get from bed, get dressed and into her wheelchair Also gets meals ready then leaves and returns at night to help with bedtime activities Patient has no other complaint What do we do for this patient? Rapid City, SD County 911 dispatcher refers a call from Ellsworth AFB hospital ER Report that a female called the base ER to request an ambulance for an off base location for a sick person Base personnel report that it sounded like a party in the background Base policy does not allow emergency response to nongovernmental location Reported address was north of I-90 in hilly country. No law enforcement dispatched Address could not be found Was determined to be a crank call Next morning another call received by 911 from same woman stating family was sick. With daylight assistance, and neighbors, house was found 7

8 New construction No tracks in snow on road Neighbors knew of new house being constructed but did not know if finished or occupied Behind thick stand of trees 2 adults and 10 year old female child found Family dog found dead in basement after patients removed Father, age 32, very confused and c/o chest pain Mother, age 33, RN c/o weakness and confusion Daughter, age 10, confused and vomiting Dad-Pulse 140 Resp 34 B/P 140/60 Mother- Pulse 120 Resp 32 B/P 144/68 Child- Pulse 132 Resp 36 B/P 120/70 All had pale/cool/dry skin Mom able to relate that they had moved in a couple of days before Christmas and had decided to stay in home until after New Years day Assessment? Treatment? At 0745 hours dispatched to a house just outside of town Late fall with temperatures in 50 s Male victim found unconscious in pickup in garage Dispatch states engine was off, carbon monoxide not suspected Law enforcement arrives first, reports scene safe On arrival find male patient, aged 44, unresponsive in driver s seat Wife reports that this is her husband and he is supposed to be on his normal sales route for his business. Had left the day before and not expected home for a few days She denies any history of ETOH abuse or street drug use No history of depression or suicidal ideations Assessment? Treatment? 8

9 Skin warm/pink/dry Pulse 86 Resp 24 B/P 136/54 SpO2 99% BG110 mg/dl 9