altered mental states

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.



Central Nervous System (CNS)

Includes the brain and spinal cord Helps control all of the body systems

and organs



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



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



The Brain

thought personality memory

motor skills tactile (touch) speech vision

cerebrum



The Brain, continued

coordination balance basic movement

muscle tone

cerebellum



The Brain, continued

heart function respiration autonomic nervous

system digestion glandular secretions

brain stem



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.



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.



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.



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.



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.



Acidosis

Acidosis is the increase in the acid level inthe body. Its causes include:

diabetes

shock

poisoning

overdose

kidney failure

impaired breathing



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.



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.



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.



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.



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.



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

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