Silver Cross
EMS System
September 2012
Silver Cross EMD CE


Sudden or gradual decrease in the patient’s
level of responsiveness
Use the AVPU scale to assess mental status:
◦ Alert - are they awake and talking
◦ Verbal – do they respond to your voice
◦ Pain – do they respond to physical stimulation
◦ Unresponsive – are they not responding to
anything

When assessing the patient’s mental status,
consider two factors:
◦ The patient’s initial level of consciousness
◦ Any change in that level of consciousness

What’s their orientation?
◦ Do they know:
 Person, Place, Time & Events

Conditions causing an altered level of
consciousness
◦ Head injury
◦ Shock
◦ Decreased level of oxygen to the brain
◦ Stroke
◦ Slow or irregular heart rate
◦ High fever or extreme temperature changes

Conditions causing an altered level of
consciousness (cont’d)
◦ Infection or Sepsis
◦ Poisoning or Substance Abuse
◦ Low level of blood glucose
◦ Insulin reaction
◦ Psychiatric condition
◦ Fainting (Syncopal Episodes)
 What
are some of the Chief
Complaints in your EMDPRS
that you would refer to for
AMS until you get more
specific information?

Unconscious
Unknown Problem
Sick Person

With more specific information


◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Bleeding/Shock
Chest Pain
Heat/Cold Exposure
Diabetic Problems
DIB
Drug Overdose
Psychiatric
Seizure
Stroke
Traumatic Injuries, etc.
The following slides will review
some of the more common causes
of Altered Mental Status

Caused by sudden episodes of uncontrolled
electrical impulses in the brain

Generalized seizures
◦
◦
◦
◦

Produce shaking movements
Involve the entire body
Last 1 to 2 minutes
Usually leave patients unconscious and incontinent
Postictal State
◦ Period of time after seizure when patient is
drowsy, confused and trying to recover.

Generalized seizures caused by a sudden
high fever
◦ Called febrile seizures
◦ Occur in infants and young children

Absence seizures
◦ Result in only a brief lapse of consciousness
◦ Patients may blink, stare vacantly, or jerk one part
of their body

Seizures can be caused by:
◦ Epilepsy
◦ Trauma
◦ Head injury
◦ Stroke
◦ Shock
◦ Low Blood Sugar
◦ Low Oxygen Levels

Seizures can be caused by: (cont’d)
◦ High fever
◦ Infection
◦ Poisoning
◦ Brain tumor or infection
◦ Complication of pregnancy
◦ Substance Abuse or Withdrawal

Treatment
◦ Usually, the seizure will be over by the time you
receive the call.
◦ If it has not ended, focus on protecting the patient
from injury. Do not advise caller to hold patient or
put anything in their mouth. Items should be
moved away from patient to make area safe.
◦ Once the seizure stops, ensure an open airway and
place the patient in the recovery position.
◦ If no breathing, begin steps of CPR.



Leading cause of brain injury and disability in
adults
Most strokes are caused by a blood clot that
blocks blood supply to a part of the brain, but
can also be cause by bleeding in brain.
Signs and symptoms
◦ Dizziness
◦ Confusion
◦ Facial Droop
◦ Unsteady Gait
◦ Weakness

Signs and symptoms (cont’d)
◦ Drooling/Difficulty Swallowing
◦ Severe Headache
◦ Numbness/paralysis on one side of the body
◦ Difficulty seeing
◦ Unequal pupil size
◦ Patient may be alert, confused, unresponsive, or
unable to speak
◦ Seizures

Signs and symptoms (cont’d)
◦ Unconsciousness
◦ Incontinence
◦ Respiratory arrest

Cincinnati Prehospital Stroke Scale
◦ Used by EMS providers and hospital staff to
determine whether a patient may have experienced
a stroke
◦ Requires no special equipment
Cincinnati Stroke Scale
Test for arm drift by having patient
hold arms straight out with eyes
closed.
Test for slurred speech by having them
repeat a simple phrase.
Test for facial droop by having them
smile.
Any abnormal findings, indicate
possible stroke.

Treatment
◦ The first priority is to maintain an open and clear
airway.
◦ Make sure head and shoulders are elevated.
◦ Provide emotional support.
◦ If the patient is having a seizure, follow that
protocol.
◦ Be prepared to administer rescue breathing.

Treatment (cont’d)
◦ Place an unresponsive patient in the recovery
position.
◦ Some patients can be treated with drugs to
dissolve the blood clot in their brain.
◦ Arrange for prompt transport.
◦ Monitor the patient until EMS arrives.


Caused by the body’s inability to process
and use glucose
The body produces insulin, which enables
glucose to move into individual cells.
◦ If the body does not produce enough insulin, the
cells become “starved” for sugar and diabetes
results.

Insulin shock (Low Blood Sugar)
◦ Occurs if the body has enough insulin but not
enough blood glucose
◦ Signs and symptoms
 Pale, moist, cool skin
 Rapid, weak pulse
 Dizziness or headache
 Confusion or unconsciousness
 Sweating
 May appear intoxicated

Insulin shock
◦ Signs and symptoms (cont’d)
 Hunger
 Rapid onset of symptoms (within minutes)
◦ A person experiencing insulin shock may appear to
be drunk or have personality changes.
◦ If the patient is able to swallow, have him or her
eat or drink something sweet.
◦ Nothing by mouth if they are unconscious or
unable to follow directions.

Diabetic coma
◦ Occurs when the body has too much blood glucose
and not enough insulin
◦ Signs and symptoms
 History of diabetes
 Warm, dry skin
 Rapid pulse
 Deep, rapid breathing
 Fruity odor on the patient’s breath

Diabetic coma (cont’d)
◦ Signs and symptoms (cont’d)
 Weakness, nausea, and vomiting
 Increased hunger, thirst, and urination
 Slow onset of symptoms (days)
◦ Misdiagnosis is common—it is not always easy to
distinguish between insulin shock and diabetic coma.
◦ In general, give conscious diabetic patients sugar by
mouth and arrange for prompt transport.
◦ If the diabetic patient is unconscious, arrange for
prompt transport.
◦ WHEN IN DOUBT, GIVE SUGAR!
May result from…




Patient stands up too quickly after being
dehydrated, illness, giving blood, heat stress,
etc.
Severe emotional challenge, fear or stress.
Medications that lower blood pressure
Sudden cardiac arrhythmias which can cause a
lack of oxygen to the brain



When patient stands up, momentary decrease in perfusion
to the brain.
Patient faints.
Once flat on ground, circulation is restored to the brain,
and patient wakes up.
Treatment:
Rule out injury from the fall
Open airway & assess breathing
Elevate feet if patient’s face is pale and cool
Do not allow the patient to stand immediately.
Could be a symptom of something more
serious!
The body's response to an overwhelming infection.
Can be limited to a particular body region (tooth abscess) or can be
widespread in the bloodstream ("septicemia" or "blood poisoning").
More likely to affect:
•Very young (premature babies) or very old
•Weakened immune system
•Have wounds or injuries, such as those from burns or trauma
•Abusers of alcohol or drugs
•Receiving IV’s, wound drainage, urinary catheters
•Chronically ill patients
•Follow a recent illness
•Genetic factors
•Cool, pale extremities
•High or very low temperature, chills
•Lightheadedness
•Low blood pressure, especially when standing
•Low or absent urine output
•Palpitations
•Rapid heart rate
•Altered mental status: restlessness, agitation, lethargy, or
confusion
•Shortness of breath
•Skin rash or discoloration

Extreme changes in body temperature can
cause AMS.
◦ Patients with heat exhaustion or heat stroke
◦ Patients with hypothermia
◦ Fever
Treatment includes:
◦ Monitor patient’s ABCs
◦ Try to restore normal body temperature


Behavioral emergencies are situations in which a
person exhibits abnormal, unacceptable behavior
that cannot be tolerated by the patient
themselves or by family, friends, or the
community.
Psychiatric illnesses
◦ Depression
◦ Panic/Anxiety
◦ Psychotic behavior

Mind-altering substances
◦ Alcohol
◦ A wide variety of chemical substances
Potential for violence! Responder safety is
important.
◦ Maintain the patient’s ABCs and normal body
temperature.
◦ Keep the patient from additional harm.
◦ Provide emotional support.



Traumatic Injuries and blood loss can cause
shock, which will cause a lack of oxygen to
the brain.
Injuries to the head can cause brain injuries
and AMS.
An overview of these problems will be review
in the following slides.

Shock deprives the body of sufficient blood to
function normally.
◦ As shock progresses, the body alters its functions in an
attempt to maintain sufficient blood supply.

Signs and symptoms of shock
◦
◦
◦
◦
◦
◦
◦
Confusion, restlessness, or anxiety
Cold, clammy, sweaty, pale skin
Rapid breathing
Rapid, weak pulse
Nausea and vomiting
Weakness or fainting
Thirst

Head and spinal cord injuries are common
causes of death. Account for approximately
50% of all traumatic deaths.
◦ Can also lead to irreversible paralysis and
permanent brain damage
◦ In a closed head injury, bleeding and swelling
within the skull may increase pressure on the
brain, leading to brain damage and death.
◦ An open head injury usually bleeds profusely

A blow to the head or face may cause
concussion of the brain.
◦ Closed injury with a temporary loss or alteration of part
or all of the brain’s abilities to function without
demonstrable physical damage to the brain
◦ About 90% of patients do not experience a loss of
consciousness.

A patient with a concussion may be confused or
have amnesia.
◦ Retrograde (can’t remember events before)
◦ Anterograde (can’t remember events after)
◦ Repetitive questioning

Usually a concussion lasts only a short time.

Far more serious than a concussion

Involves physical injury to brain tissue


May sustain long-lasting and even
permanent damage
A patient may exhibit any or all of the signs
of brain injury.

Signs and symptoms of head injuries
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Confusion
Unusual behavior
Unconsciousness
Nausea or vomiting
Blood from an ears or nose
Decreasing consciousness
Unequal pupils
Paralysis
Seizures
External head trauma (bleeding, bumps, bruises)
Bruising under eyes or behind ears (late signs)
◦ Keep the head in a neutral position and advise
patient not to move.
◦ Maintain an open airway and Monitor ABCs; be
prepared to perform CPR if necessary.
◦ Control bleeding from all wounds with dry, sterile
dressings.
◦ Examine and treat other serious injuries.
◦ Arrange for prompt transport.



Altered Mental Status can be the result of
medical, environmental, psychological,
chemical or traumatic problems. Gather
signs, symptoms and information about the
scene to determine underlying causes and
appropriate treatment.
Treatment will be focused on maintaining
ABCs, providing emotional support and
preventing injury.
Refer to appropriate flipcharts in the EMDPRS
for specific instructions.

AAOS Emergency Medical Responder:
Your First Response in Emergency Care,
5th Edition

Will County 9-1-1 EMDPRS, June 2012