October 2009 CE Site code #107200E-1209 The Patient with an Altered Mental Status Outline prepared by: Jeremy Lockwood FFPM Mundelein Fire Department Material reviewed and revised by Sharon Hopkins, RN, BSN, EMT-P To view on the website visit: www.advocatehealth.com/condell/body.cfm?id=352
Date of CE presentation: October 2009 Topic: The Patient with an Altered Mental Status Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to: 1. Identify components evaluated in determining a patient s mentation status and orientation. 2. Define altered mental status. 3. Identify the possible causes of altered mental status. 4. Identify signs and symptoms of altered mental status. 5. Identify elderly considerations of altered mental status. 6. Identify assessment procedures of patients with altered mental status. 7. Describe how to obtain an accurate Glasgow Coma Scale assessment. 8. Describe the procedure to obtain a blood glucose determinant. 9. Identify the components of the Cincinnati Stroke Scale. 10. Identify the treatment of patients with altered mental status. 11. Describe methods to restrain the combative patient. 12. Identify the indications, contraindications, complications, and documentation when using the QuickTrach airway device. 13. Given a scenario obtain the GCS. 14. Perform assessment of the Cincinnati Stroke Scale. 15. Given a manikin, demonstrate placement of the QuickTrach airway Device. References: Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices 3rd Edition. Prentice Hall. 2009 Limmer, D. O Keefe, M. Emergency Care. 10th Edition. Prentice Hall. 2005. Region X SOP s March 2007. Amended January 1, 2008. En.wikipedia.org/wiki/Endocrine_system En.wikipedia.org/wiki/Electrolyte_system En.wikipedia.org/wiki/Encephalopathy_system En.wikipedia.org/wiki/Opiate_system En.wikipedia.org/wiki/Uremia_system www.chems.alaska.gov/ems/documents/gcs_activity_ 2003.pdf www.doi.gov/nbc/eps/signsymptoms.html www.en.wikibooks.org.wiki/emergency_medicine/altered_mental_status www.nursingtimes.net www.opiates.com/opiates staff.washington.edu/momus/pb/comachan.htm www.ucsfcme.com/2008/slides/mdm08q05/01-sporer.pdf www.uic.edu/com/ferne/slides/delerium.pps
Glasgow Coma Scale Practices EYE OPENING VERBAL RESPONSE MOTOR RESPONSE 4--Spontaneous 5 Oriented 6--Obeys 3 Verbal stimuli 2--Pain 4--Confused/ disoriented 3--Inappropriate words 2--Incomprehensible sounds 1 None Pediatric Glasgow Coma Scale 5--Localizes 4--Withdraws 3--Abnormal flexion 2--Extensor posturing EYE OPENING VERBAL RESPONSE MOTOR RESPONSE 4--Spontaneous 5 Oriented, coos, babbles 6--Obeys 3 Verbal stimuli 2--Pain 4 Irritable cry but consolable 3 Cries consistently to pain 2 Moans to pain Patient #1 - Adult The patient is watching you approach. The patient speaks normally and answers questions. The patient raises their arm when you ask to take their B/P. 5 Withdraws to touch 4 Withdraws to pain 3--Abnormal flexion 2--Extensor posturing Patient #2 - Adult The patient is looking around the environment. The patient speaks normally but is confused. When you ask the patient to raise their arm, they are slow to do so but eventually raises their arm. Patient #3 - Adult The patient s eyes are closed and there is no movement even after squeezing the trapezius. The patient groans when the trapezius is squeezed. The patient flexes their arms up to their chest as they are groaning. Patient #4 - Adult Patient eyes open briefly when their name is called. Patient groans while being pinched. Patient does not follow commands and pushes you away whenever you try to treat the patient.
Patient #5 - Adult Eyes are closed and open when yelling at the patient. The patient yells don t and stop it when being touched, assessed, and Treated but is not speaking. Patient pushes the EMS provider hands away and is trying to pull off the cervical collar and pull out the IV. Patient #6 - Adult Eyes open briefly when asked to open them. The patient moans weakly when being touched. The patient tries to pull away when care is being provided (ie: IV start). Patient #7 - Adult Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyes. The patient responds verbally saying their head hurts and the lights make it hurt worse. Patient follows commands except for opening eyes. Patient #8 - Adult Eyes are open looking straight ahead. When asked what month it is, the patient responds he, umm, he, my jacket, don t. Does not follow commands. Pulls one hand away and the other hand is pushing the EMS provider away. Patient #9 (6 month old) Infant s eyes flutter when touched. Patient cries when gently touched but is consolable. Patient withdraws when first touching them. Patient #10 (9 month old) Eyelids flutter when the IO needle is placed. Patient moans during the IO insertion and when deformed extremity is handled. The patient pulls their arms into their chest wall rolling their shoulders and wrists inward.
1. Check for facial drooping: Cincinnati Stroke Scale No droop Right sided droop 2. Check for arm drift: No drift Right sided drift 3. Check clarity of speech Steps to Securing an Airway with the QuickTrach Device Procedure Takes or verbalizes Standard Precautions Assembles and checks Quicktrach equipment Positions patient supine with head slightly extended if no contraindication Locates and palpates cricothyroid membrane between cricoid and thyroid cartilages and prepares/cleanses site Secures larynx laterally between thumb and forefinger. Anchors and stretches skin Puncture the cricothyroid membrane at 90 degree angle Confirms entry of needle into trachea (aspirate air through the syringe) Change angle of insertion to 60 degrees sliding catheter sheath forward to the level of the stopper (stopper will be snug against the skin) Remove the stopper Hold the needle and syringe firmly and slide only the plastic cannula forward until the hub of the cannula is snug against the skin Remove the needle and syringe Steps Performed Begin to ventilate the patient via BVM with 100% O 2 Assesses for correct placement (bilateral breath sounds, chest rise) Secure the catheter in place (use the provided strap); make sure the hub of the catheter is flush with the neck Continues to reassess and monitor ventilatory status
Pre-Quiz Altered Mental Status Paramedic and Basic Level From CE Material October 2009 Name Date 1. List at least 3 causes of altered mental status. 2. List 3 signs or symptoms of opiate exposure. 3. What is assessed as part of a neurological assessment? 4. What s the score for best eye opening? 5. What s the score for best verbal response? 6. What s the score for best motor response? 7. When must a blood sugar level be obtained (besides when the ED requests one)? 8. What is the most important question to ask the patient with signs and symptoms of a stroke? 9. What needs to be assessed after restraining a patient? Paramedic questions: 10. What is the initial dose of Valium used for the agitated patient? 11. Identify the location of the cricothyroid membrane.