Altered Mental
States
…or everything you need to know
about coma, stroke, seizures, syncope,
diabetic emergencies, etc...
Altered Mental States
 Defined
as when a patient is not
thinking clearly or is incapable of
being aroused.
 Consciousness/unconsciousness
 Responsiveness/unresponsiveness
 Coma
Nervous System Anatomy
Brain Anatomy & Function
 Major
Functions:
 Brain Stem
 Cerebellum
 Cerebrum
Brain Function
Altered Mental States
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Hypoglycemia
Hypoxemia
Intoxication
Drug overdose
Head injury
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Brain tumors
Glandular
abnormalities
Poisoning
Hypo/hyperthermia
Brain infection
Differential Diagnosis
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A – Alcohol
E – Electrolyte imbalance
I – Insulin (diabetic emergencies)
O – Opiates
U – Uremia
T – Trauma
I – Infection (sepsis)
P – Psychogenic causes
S – Stroke, seizure, syncope
Stroke
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Third leading cause of death in industrialized
countries after heart disease and cancer.
Risk factors include hypertension, age, smoking,
lack of exercise, obesity, stress, with prevalence
in certain racial/ethnic groups.
High rate of successful recovery if recognized
and treated quickly!
Stroke (CVA)

Cerebral vascular accident (CVA) is the
interruption of blood flow to the brain.
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Stroke is the loss of brain function that results
from CVA when blood flow is interrupted.
 Hemorrhagic
 Ischemic
 TIA
Hemorrhagic Stroke
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Results from vessel
rupture on the surface or
within the brain.
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Subarachnoid
Intracerebral
10% of all strokes with a
50 % mortality rate.
Typically sudden onset
of signs/symptoms.
Ischemic Stroke
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Ischemic stroke results
from arterial blockage,
either:
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Thrombus
Embolis
Greater chances of
survivability if treatment
initiated within 3 hours.
Transient Ischemic Attack
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Temporary disruption of brain function due to
insufficient oxygenation. (“Mini-stroke”)
Stroke-like symptoms usually rapid in onset with
complete resolution within 24 hours.
Often proceeds a stroke.
Hard to distinguish from a stroke at onset.
Stroke: Signs & Symptoms
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One-sided weakness or paralysis (hemiparesis)
Facial droop on one side.
Altered level of consciousness (confusion to
coma).
Change in personality or mood
Headache or dizziness
Impaired speech, blurred vision, poor
coordination.
Stroke: Signs & Symptoms

Left Hemisphere Problems:
Aphasia
 Receptive aphasia
 Expressive aphasia
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Right Hemisphere Problems:
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Dysarthria
Neglect
Stroke Mimics
 Hypoglycemia
(Insulin reaction)
 Postictal state after a seizure
 Head injury:
 Epidural bleed (rapid onset)
 Subdural bleed (slower onset)
Assessment
Scene Safety/BSI
Initial Assessment (Sick/Not Sick)
Focused Exam
Detailed Exam
Assessment
Treatment and Plan
Stroke ALS Indicators
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Unconsciousness
Decreased level of consciousness
Severe hypertension (systolic > 200 mmHg or
diastolic > 110 mmHg with neurologic signs)
Hypotension and severe bradycardia
Seizures
Severe headache/vomiting
Airway problems
Progression of stroke symptoms
Physical Exam
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Baseline vitals signs
Blood glucometry
Neurological function (Cincinnati Prehospital
Stroke Scale:
Facial droop
 Arm drift
 Speech
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Check for stroke mimics!
Cincinnati Stroke Scale
Patient History
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Chief complaint and time of onset are key in
the assessment of stroke.
Signs/symptoms (hypertension, HA, numbness
or weakness, difficulty with speech/movement)
Allergies
Medications (blood thinners or anticoagulants)
Past medical history ( previous stroke or TIA,
AVM, cerebral aneurysm)
Last oral intake
Events leading to call
Treatment and Plan
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Revascularization by clot dissolving medication
must be initiated within 3 hours of a stroke.
If a stroke is of recent onset, very short scene
and transport times are CRITICAL!
Determine time of onset of symptoms and
notify hospital as soon as possible.
Arrival at hospital is critical within first two
hours of onset of symptoms.
Patient Care
ABCS!
Medics?
Position of comfort
Oxygen
Maintain body temperature
Monitor vitals signs
Calm and reassure
Minimize patient movement
Rapid transport
Seizure
Defined as generalized, uncoordinated
muscular activity associated with a loss of
consciousness; a convulsion.
 Catergorized as:
 Generalized (grand mal)
 Absence (petite mal)
 Simple partial (focal motor)
 Complex partial (psychomotor)
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Generalized Seizure
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Usually presents with an aura.
May be unifocal with progression to convulsion
 Loss of consciousness
Tonic phase
Clonic phase
Postictal phase
Be concern with status epilecticus
Absence Seizure
 Also
known as petit mal seizures
 Most common in children
 No loss of consciousness
 No loss of postural tone
 “Spacing out”
Simple Partial Seizure
 Focal
motor seizure or “Jacksonian”
seizure.
 Characterized by a rhythmic jerking of
limb or one side of the body.
 No loss of consciousness
Complex Partial Seizure
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Also known as pyschomotor seizures
Involve loss of consciousness
Characterized by stereotyped movements
(automatisms)
Movements may look purposeful but they are not
 Lip smacking, movement of hands
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Typically present as intoxication, drug OD, or
“psych patient”
Febrile Seizures
 Common
in children under age of 2
years
 Caused by spike in fever, usually
patient has had cold or flu-like
signs/symptoms.
 Presents similar to grand mal seizure
with accompanying postictal phase.
Causes
Congenital defects (epilepsy)
Febrile or high fever
Brain structural problems (trauma)
Metabolic disorders
Chemical disorders (poisons/overdoses)
Seizure: Signs & Symptoms
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Cyanosis
Abnormal breathing
Obvious head injury
Loss of bowel control/incontinence
Severe muscle twitching/motion
Bite marks on tongue
Postictal state with unresponsiveness/labored
breathing
Assessment
Scene Safety/BSI
Initial Assessment (Sick/Not Sick)
Focused Exam
Detailed Exam
Assessment
Treatment and Plan
Seizure ALS Indicators
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Status seizures
Seizure lasting longer than 5 minutes or postictal
stage > 15 minutes without change in LOC
Seizures in pregnant female
Seizures due to:
Hypogylcemia (Insulin reaction)
 Hypoxia
 Head trauma
 Drugs or alcohol
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Physical Exam
Look for signs of trauma, overdose
Baseline vital signs
Blood glucometry
Patient History
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Chief complaint, description and length of
seizure are key to seizure assessment
Signs/symptoms (witnessed event?)
Allergies
Medications (anticonvulsants)
Past medical history (previous seizure history?)
Last oral intake
Events leading to call (historians?)
Treatment & Plan
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If patient is in active seizure, allow seizure to
run it’s course. Protect patient from further
harm.
Airway management (most common cause of
seizure deaths are postictal airway loss!)
Treat trauma.
Know when to call for medics!
Do not assume that all seizures are epilepsy.
Patient Care
ABCS!
Medics?
Position of comfort
Oxygen
Maintain body temperature
Monitor vitals signs
Calm and reassure
Minimize patient movement
Transport
Diabetes
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Diabetes affects over 20 million people in the
US alone, 7% of the total population!
Condition in which the body does not produce
or use insulin properly.
Complications can include kidney failure,
blindness, heart disease, stroke, and lower
extremity amputations.
Risk factors include: genetics, obesity, lack of
exercise, and certain racial/ethnic groups.
Diabetes
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Type I:
Juvenile diabetes
 No insulin production
 Controlled with insulin injections
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Type II:
Adult onset diabetes
 Inadequate insulin production with increased tissue
resistance to insulin effects
 Controlled with diet, exercise, oral medications
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Diabetic Emergencies
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Hypergylcemia (high blood glucose level)
Diabetic Ketoacidosis (DKA)
Hyperosmolar coma (HHNC)
Hypogylcemia (low blood glucose level)
Insulin shock
Diabetic Ketoacidosis (DKA)
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Pancreas not producing enough or effectively
insulin.
Slow onset over several days
Cells metabolizing fat for energy
Result of:
Too little insulin
 Not enough exercise
 Too much food
 Stress, fever, infection
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DKA: Signs & Symptoms
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Kussmaul respirations
Weak, rapid pulse (possibly irregular)
Warm, dry skin
Normal to profoundly decreased blood pressure
Fruity odor on breath (ketones)
Nausea, vomiting, abdominal pain
Altered level of consciousness
Polyuria, polydipsia, polyphagia
Hyperosmolar Coma
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State of unconsciousness resulting from:
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Hypergylcemia
Ketoacidosis (no fruity breath)
Profound dehydration
Signs & symptoms:
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3 – P’s
Dry skin, mucous membranes
Tachycardia, hypotension
Insulin Shock
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Insufficient glucose stores necessary for blood
oxygenation
Sudden onset, life threatening
Occurs as a result of:
Too much insulin – accidental or intentional
 Low food intake
 Too much exercise
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Insulin Shock: Signs & Symptoms
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Cold, clammy, pale skin
Abnormal, bizarre, or hostile behavior
Shaking, trembling, weakness
Full, rapid pulse
Normal or elevated blood pressure
Normal or elevated respirations
Dizziness, headache, blurred vision
Extreme hunger
Slurred speech
Seizures, loss of consciousness
Assessment
Scene Safety/BSI
Initial Assessment (Sick/Not Sick)
Focused Exam
Detailed Exam
Assessment
Treatment and Plan
Diabetic ALS Indicators
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Altered level of consciousness
Patient unable to protect airway (absent gag)
Unstable vital signs
Rapid respirations
Shock signs and symptoms
Failure to respond to oral glucose
Suspected DKA
Seizures
Physical Exam
Mental status/level of consciousness
Airway management (ability to swallow?)
Baseline vital signs
Blood glucometry
Patient History
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Chief complaint, think about other possibilities.
Signs/symptoms: DKA vs. Insulin shock
Allergies
Medications (Using insulin/meds? Last used?)
Past medical history (Diabetic?)
Last oral intake (Last meal or food)
Events leading to call (Changes in health, stress
level, exercise routine)
Treatment & Plan
Perform glucose check
Position patient upright and
give oral glucose if able
to swallow (intact gag)
Document times and blood
glucose levels, patient
responses to oral glucose
Patient Care
ABCS!
Medics?
Position of comfort
Oxygen
Maintain body temperature
Monitor vitals signs
Calm and reassure
Minimize patient movement
Transport
King County Guidelines
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Patients on insulin may be safely left at
home:
 Blood glucose level is > 60
 Able to eat and drink normally
 Someone is able to stay with them
 After care instructions left with repeat
blood glucose level check and proper
documentation
Overdose
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Overdose is an excessive exposure, either
accidental or intentional, to a chemical
substance.
Majority of calls will involve habitual drug users
and attempted suicide with prescription
medications.
Observations at the scene and accurate history
are critical in assessment of these patients.
Overdose: Signs & Symptoms
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Altered Mental Status:
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Paranoia
Agitation
Nonsensical conversation
Aggression
Lethargy
Coma
Hallucinations
Rapid speech
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Skin Signs:
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Diaphoretic
Pale
Flushed
Cyanotic
Look for needle track
marks and/or abcesses
Overdose: Signs & Symptoms
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Pupil Reaction:
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Normal
Dilated
Constricted
Cardiovascular:
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Respiratory:
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Tachypnea
Bradypnea
Apnea
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Hyper/hypotension
Tachycardia
Bradycardia
Arrhythmias
Cardiac Arrest
Temperature:
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Hyperthermia
Hypothermia
Overdose: Signs & Symptoms
CNS depressants,
sedatives,
tranquilizers
 SSRI’s
 Stimulants
 Antidepressants
 Acetaminophen
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Pyschedlic drugs
(LSD)
Alcohol Intoxication
Opiates/narcotics
Cannabis
Inhalants
GHB
ASA
Poisoning
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2.2 million poison exposures reported in the U.S. in
2000, that’s 1 every 15 seconds.
90% occur at home with > 50% under the age of 6
years.
Poisoning occurs through the following routes:
 Ingestion
 Inhalation
 Injection
 Absorption
Common Toxidromes:
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Carbon Monoxide Poisoning:
Headache
 Tachypnea
 Nausea and vomiting
 Altered level of consciousness
 Pink, flushed membranes
 Coma
 Inaccurate SpO2 readings
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Common Toxidromes
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Organophosphate Poisoning:
Decreased level of consciousness
 Bradycardia/hypotension
 Vomiting/excessive salivation
 Miosis
 Diaphoresis
 Bronchospasm
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Common Toxidromes
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Cyanide Poisoning:
Headache
 Burning sensation in mouth or throat
 Confusion
 Decreased level of consciousness
 Agitation or combative behavior
 Shortness of breath
 Bitter smell of almonds
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Assessment
Scene Safety/BSI
Initial Assessment (Sick/Not Sick)
Focused Exam
Detailed Exam
Assessment
Treatment and Plan
Altered LOC ALS Indicators
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Decreased LOC
Respiratory distress or compromise
Signs/symptoms of shock
Signs of inadequate perfussion
 Sustained tachycardia
 Hypotension
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Unstable vital signs
Cyanosis
Scene Safety
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Protection of yourself and crew are your first
priority! Do not become part of the problem!
Scene secure? Police back-up needed?
Contamination/exposure issues?
Watch for needles!
Stay alert!
Restrain a patient whenever there are safety
concerns!
Focused Exam
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Airway! (check gag reflex)
Chief complaint
Baseline vital signs (pupil check, lung sounds)
Blood glucometry
Neurological exam (GCS)
Ask pertinent SAMPLE/OPQRST questions
Look for ALL possible clues…do a thorough
exam!
Pupillary Reaction
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Dilated = Reactive:
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Dilated = Non-reactive:
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Anoxia, profound ETOH, SZ, drugs (LSD)
Dilated/Unequal/Non-reactive:
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Hypoxia, alcohol, stimulants (cocaine, meth)
CVA (hemorrhagic), head injury
Constricted = Non-reactive:
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Opiate/barbituate OD, brainstem injury
Patient Care
ABCS!
Medics?
Position of comfort
Oxygen
Maintain body temperature
Monitor vitals signs
Calm and reassure
Minimize patient movement
Transport
Syncope
Fainting
 Sudden loss of
consciousness
 Usually caused by
lack of blood flow
to the brain

Syncope Causes
Stress, fright, pain (vasovagal syncope)
 Orthostatic hypotension (standing BP
drop)

 Decreased
blood volume
 Increased size of vascular space
Decreased cardiac output
 Prolonged, forceful coughing
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Syncope
Fainting or passing out is a sign that
something is not working right. Look for
the underlying cause, be a good detective.
 All syncope should be evaluated in the ER,
although 60% of all syncope is
undiagnosed.
 ALS indicators?
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Remember…
…it’s okay if you do not
diagnose the patient’s
problem. It’s not okay if you
fail to take care of what you
are trained to take care of.