Patient with Altered Mental Status

Patient with Altered Mental
May 2014 CE
Condell Medical Center
EMS System
Site Code: 107200E-1214
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 5.13.14
Upon successful completion of this module, the EMS provider will be
able to:
• 1. Describe common causes of altered mental status.
• 2. Describe components of a field neurological examination.
• 3. Describe required field assessment of the patient with a possible stroke
including documentation of time of onset, blood sugar level, and
Cincinnati Stroke Scale.
• 4. Define the characteristics of excited delirium syndrome (ExDS).
Objectives cont’d
• 5. Describe field interventions for the patient experiencing an episode of
excited delirium syndrome (ExDS).
• 6. Given a variety of patient presentations, assign a Glasgow Coma Scale score
• 7. Actively participate in review of revised Region X SOP’s.
• 8. Actively participate in review of a variety of EKG rhythms and 12 lead EKG’s.
• 9. Actively participate in case scenario discussion.
Objectives cont’d
• 10. Review responsibilities of the preceptor role.
• 11. Describe use of the CAT device as a means to control bleeding.
• 12. Describe the benefits and procedure to use QuikClot gauze as a means
to control bleeding.
• 13. Actively participate in return demonstration of preparing the Flow Safe II
CPAP device for patient application.
• 14. Successfully complete the post quiz with a score of 80% or better.
The Brain
A complex organ that weighs approximately 3 pounds
Makes up 2% of our body weight
The cerebrum makes up the majority of the brain
We are all born with the same number of brain cells
Personal experiences, education, and social environment shape the
person we are
The Brain
• Divided into 2 hemispheres –
right and left brains
• Strongly symmetrical
• Left brain controls all muscles
on right side of body
• Right brain controls all muscles
on left side of body
The Brain
• Left brain
• Has region of speech and language
• Broca’s area (expressive aphasia) & Wernicke’s areas (receptive aphasia)
• Associated with mathematical calculations and fact retrieval
• Right brain
• Role in visual and auditory processing, spatial skills, and artistic ability
• Spatial skills – to understand problems with physical spaces, shapes, forms
Regions of the
• Normal consciousness requires arousal and cognition
• Ability to think, understand, learn, and remember
• Display of orientation, judgment, and memory
• Think of the questions we ask patients testing these areas
• Person, place, time, and event
• Arousal requires an intact and functioning brainstem
What is Altered Mental Status?
Altered behavior
Change in higher cerebral
Change in attention
Change in awareness
Change in judgment
Change in memory
Obtaining a Baseline
• Determine when patient last seen normal
• Evaluate for allergies and current medications
• Inquire regarding recent hospitalizations, infection, trauma,
psychiatric illness
• Check environment for bottles (medications, alcohol, poisonings)
• Family extremely helpful to indicate subtle changes noted
Evidence of Changes in Brain Function
• Confusion
• Amnesia
• Loss of alertness
• Loss of orientation
• Person, place, time, event
• Defects in
• Poor regulation of emotions
• Disruption in perception,
psychomotor skills, behavior
Content of Thought and Speech
• Can patient stay focused?
• Is their speech tangential (abruptly moving off topic)?
• Is patient oriented?
• Is patient concerned and focused on the issue?
• Are they asking repetitive questions?
“Alert & Oriented”
• What is this reference to?
• A & O x3 or A & O x4???
• Depending on what you test:
 x1 - Alert & oriented to person – their name
 x2 - Alert & oriented to place – do they recognize where they are
 x3 - Alert & oriented to time – time / day / date / season (any is reasonable)
 x4 - Alert & oriented to event – what just happened or what is happening
Components of Field Neurological
• Level of alertness – AVPU and GCS scales
• Ability to keep person awake
• 12 cranial nerves (CN)
• CN 3 (oculomotor nerve) checked in the field – pupillary response
• Bilateral motor and sensory responses
• Gait – not consistently able to observe in the field
Neurological Assessment - AVPU
• An assessment scale not as detailed as GCS
• Can be performed very quickly
• Provides global picture of level of responsiveness
• Most important is monitoring for changes in a response
• A – alert
• Not necessarily oriented; just awake
• V – responds to verbal commands
• Difficult to distinguish if patient responded to voice or touch as they are often done
simultaneously in the field
• P – responds to pain or tactile stimulation
• U – unresponsive, flaccid, no response at all
Glasgow Coma Scale (GCS)
• Assesses overall level of arousal
• Originated in Glasgow, Scotland
• A tool originally designed to predict prognosis in traumatic brain injured
• Used to diagnose, provide outcome, and evaluate progression of disease
• Change in 2 or more points represents significant change in patients
level of consciousness
• Evaluate BEST RESPONSE to 3 components:
best eye opening, verbal response, and motor response
• Assign a score of 3 to 15
• The higher the score the more favorable the outcome
• Not just useful in traumatic head injury
• 13 - 15 usually indicate minor head trauma
• 9 – 12 usually indicate moderate head trauma
GCS – Eye Opening
• Need to approach patient and attempt to illicit eye opening response to verbal
stimuli prior to making physical contact with the patient
• Not always easy or in the best interest of the patient
• May need to apply manual c-spine control as soon as patient contact made
4 – eyes open spontaneously
3 – eyes open to command spoken or shouted
2 – eyes open after painful/noxious/tactile stimuli applied
1 – no eye response at all
GCS – Verbal Response
• 5 – oriented to person, place, time, event
• 4 – confused; not oriented to person, place, time, and/or event
• 3 – Inappropriate words – not able to speak in sentences; uses random
words; swearing is common
• 2 – Incomprehensible sounds – moaning and groaning; no distinguishable
words heard
• 1 – not making any verbal sounds
GCS – Motor Response
• 6 – obeys commands
• 5 – Purposeful movement – generally able to cross center of body; reaches
for noxious stimuli to remove it (i.e.: IV, B/P cuff, c-collar, your hands)
• 4 – Withdraws to pain – pulls arm/shoulder into body (adduction)
• 3 – Abnormal flexion – arm/shoulder abducted, extremity bends/flexes
• 2 – Abnormal extension – extremities straighten and rotate, back generally
• 1- no response to all; flaccid
Potential Causes Altered Mental Status
• A – Alcohol
• E – Endocrine, encephalopathy,
• I – Insulin (hypoglycemia)
• O – O2 (hypoxia), opiates
• U – uremia (kidney disease)
T – Toxins, temperature, trauma
I – Infection
P – Psychiatric, porphyria
S – stroke, shock, subarachnoid
hemorrhage, space-occupying
lesion (i.e.: tumor)
Potential Causes Altered Mental Status
• S – substrates (glucose, thiamine
deficiency), sepsis
• M – meningitis
• A – Alcohol, accident
• S – Seizure, stimulants, hallucinogens,
• E – electrolytes, encephalopathy
• D – drugs (intoxication/withdrawal),
illicit drugs, CO poisoning, steroids,
• H – Hyper/hypo (B/P, thyroid, temp,
hypercarbia, hypoxia)
• Injury or death to brain tissue
• Usually from an interruption in cerebral blood flow
• Tissue deprived of oxygen and glucose
• 2 components brain cells rely on to function
• 3rd leading cause of death and disability
• Can strike any age
• Increased risk with history of atherosclerosis, heart disease, or hypertension
Occlusive Strokes
85% Incidence
• Cerebral artery blocked by clot or other foreign matter
• Ischemia  infarction
• Embolic stroke – usually occur suddenly
• A mass, generally a clot
• Often a thromboemboli traveling from diseased vessels or from chambers in
• Thrombotic stroke – usually develop gradually
• Clot developed in and obstructs cerebral artery usually related to
Hemorrhagic Strokes
15% Incidence
• Usually bleeding within brain (intracerebral)
or space around outer surface of brain
• Onset marked with sudden, severe headache
• Often related to history hypertension or congenital abnormalities
in blood vessels
Risk Factors for Stroke
 Hypertension
 Diabetes
 Abnormal blood lipid levels (elevated cholesterol)
 Oral contraceptive use
 Sickle cell disease
 Some cardiac dysrhythmias (i.e.: atrial fibrillation)
Assessment of the Patient With A Possible
Acute Stroke
• Onset of signs or symptoms or last known normal with exact time
• Blood glucose level
• Cincinnati Stroke Scale
• An abnormal finding in any one parameter associated with 72%
probability of stroke
 Facial droop
 Arm drift
 Change in speech
Acute Stroke Assessment cont’d
• Medication history of anticoagulant use
• Coumadin - Warfarin
• Xarelto - Rivaroxaban
• Pradaxa - Dabigatran
• Eliquis – Apixaban
• Lovenox – Enoxaparin
• History of antiplatelet use less of concern but still helpful to recognize
• Aspirin and Plavix - Clopidogrel
Motor and Sensory
• Noting that responses
generated from different areas
of the brain, evaluator can
predict area of infarct by
noting the deficit
• Important to document
specific results of assessments
Region X SOP – Stroke/Brain Attack
• Determine time of onset / last known normal
• Obtain and record blood sugar level
• Intervene if <60
• Perform Cincinnati Stroke Scale
• Watch for rapid neurological deterioration
• Consider drug assisted intubation to protect airway if necessary
Rapid Neurological Deterioration
• Assess patient for changes indicating a worsening of
Unequal pupils
Extensor posturing
Lateralizing signs
• A function attributed to one side of the brain
• Evaluate for deficits from patient’s normal or baseline
Treatment Rapid Neurological
• Brain reliant on adequate supply of oxygen and glucose to function
• Need to provide oxygenated blood
• Need to avoid blowing off too much carbon dioxide to prevent
potential vasoconstriction that would limit brain blood flow
• Ventilate adults 1 breath every 3 seconds via BVM (20 bpm)
• Ventilate children 1 breath every 2 seconds via BVM (30 bpm)
• Ventilate infants 1 breath every 1.7 seconds via BVM (35 bpm)
Excited Delirium (ExDS)
• Sudden, unexplained onset with rapid progression
Delirium – fundamental manifestation
Acute distress
Unusual physical strength
Acidosis – prominent role in cardiovascular collapse; usually leads to
brady-asystole or PEA
Excited Delirium (ExDS)
• Exact cause uncertain but felt to have multiple etiologies
• No “test” exists for diagnosis
• Need to differentiate from bad behavior, drunken behavior, and excited
delirium (ExDS)
• Hallmark
 Profuse sweating
 High body temperature (105.20F (40.70C) common on autopsy
 Delusional behavior
Excited Delirium - ExDS
• Increased risk of death with physiologic stress
• Immediate sedation decreases risk of death
• Stressful encounter increases chemical imbalance in brain
• Process progresses rapidly
• Most patients that die exhibit severe aggression and are non-compliant to
requests to halt their behavior
• Most patients that die found with evidence of trying to cool down
• Disrobed, empty ice trays in the environment
Excited Delirium – ExDS
and Chronic Cocaine Abuse
• Suspected to be co-existing risk factor causing death
• Contributes to development of coronary artery disease
• Acts as potent adrenergic agonist leading to chronic
catecholamine toxicity
• Hypertrophy
• Microangiopathy
• Myocardial fibrosis
Excited Delirium – ExDS
CNS Dysfunction
• Central nervous system (CNS) dysfunction of dopamine signaling with
aberrant dopamine processing blamed for clinical presentation
• Mimics of ExDS
Hypoglycemia – rule out by obtaining blood sugar
Heat stroke
Serotonin syndrome and neuroleptic malignant syndrome – but no
aggressive violent behavior
Psychiatric issues
Excited Delirium (ExDS)
Typical Presentation
Male, mean age 36
Hyperaggressive, bizarre behavior
Impervious to pain
Tachycardic, tachypnea
No rational thoughts for safety
Tolerance to pain
Non-compliant, no remorse or fear
Does not tire
Unusual strength
Inappropriately clothed
Occ attraction to glass & mirrors
Excited Delirium (ExDS)Treatment
• Aggressive chemical sedation required
• Treatment is concurrent with evaluation for other precipitating causes or
additional pathology
• Physical struggle increases the catecholamine surge leading to metabolic
acidosis and increasing risk of death
• Most patients that die are non-compliant and exhibit severe aggression
• Need to minimize time spent struggling while safely achieving physical
Region X SOP Field Interventions
Behavioral Emergencies
• Personal, personnel, and scene safety
• Utilize law enforcement support
• Must have prior dialogue to determine how these 2 agencies
will best work together in this potentially violent situation
• Restrain as necessary
• Document reasons, type, time, patient response
Region X SOP
Behavioral Emergencies cont’d
• Consider medical etiologies
• Hypoxia
• Substance abuse/overdose
• Excited delirium/hyperthermia
• Neurologic disease – CVA, intracerebral bleed
• Metabolic problem – hypoglycemia
• Routine Medical Care as warranted
Region X SOP
Behavioral Emergencies cont’d
• For severe anxiety or agitation
• Versed 2 mg IN
• Avoids exposure to potential needle stick
• If needed, may repeat Versed 2 mg IN every 2 minute titrated to desired effect
• Maximum dose of 10 mg
• If additional sedation required
• Valium 5 mg IVP over 2 minutes
• Can repeat up to maximum of 10 mg
• OR: Valium 10 mg IM
Versed and Valium
• Sedative agents
• Relatively short acting - Versed® shorter than Valium® but more potent
• Caution
• Relatively slow onset (Versed® IN 3 – 5 minutes)
• Unpredictable action if not IVP
• Need for repeated dosing
• Potential for respiratory depression – support ventilations via BVM if
Medication Via Intranasal (IN) Route
• IN route medications do not pass through the gut; dosing is not diminished
• Med absorbed directly into cerebral spinal fluid via a nose brain pathway
• May cause a burning sensation for 30-45 seconds after delivery
• Ideal volume 0.5 ml per nares; max 1 ml per nares
• More volume would run out nose
• Insert wedge into nostril
• Aim to same side ear and depress plunger to create mist
FYI - Differentiating Delirium vs Dementia
Updates to Region X SOP
• Increase to adult dose of Fentanyl to 1 mcg/kg IVP/IO/IN
• For managing adult pain appropriately – use of TCP
• General adult pain management
• Adult weight based medication reference chart reflects changes
• Oral glucose gel (Glutose) 15 G can be used for the adult diabetic
• If patient is able to tolerate oral preparation
• Patient has an intact gag reflex
• Patient able to protect their own airway
New Oral Glucose Gel – Glutose 15
• A monosaccharide (simple sugar) medication primarily of dextrose and water
• Absorbs directly through oral tissue
• Once squirted into mouth, generally swallowed for absorption via small intestine
• Can remain in mouth momentarily for absorption via oral cavity first
• Provides 15 grams of glucose
• No common side effects reported
• Store room temperature away from heat, light, and moisture
Duoneb Update
• Ipratropium (Atrovent) added to 1st and 2nd Duoneb treatments
Adult asthma/COPD with wheezing
Stable adult allergic reaction with airway involvement if wheezing
Pediatric asthma in mild to moderate distress
Pediatric croup
Stable pediatric allergic reaction with airway involvement if wheezing
Zofran Update
• Zofran ODT oral route
• Remains same dose at 4 mg
• ODT = orally disintegrating tablet
• Dissolves quickly as soon as placed in the mouth on the tongue
• Some patients initially complain of brief nauseous sensation
• For adult nausea management
• For pediatric nausea management if > 40 kg (88 pounds)
Zofran ODT - Ondansetron®
• Prevents nausea and vomiting by blocking a chemical that causes the
• Avoid use in congenital long QT syndrome
• Rhythm could degenerate into polymorphic VT – Torsades
Take tablet orally with or without food or water
Tablet dissolves instantly and can be swallowed with saliva
Document: Time given; “Zofran ODT”; “4 mg”; route – “po”
Long QT Syndrome
• Can cause aberrant ventricular electrical
• Increases risk for ventricular
dysrhythmias, esp torsades de pointes
• Can lead to syncope and death
• Normal QT interval 0.42 seconds
Ventricular Tachycardia
Monomorphic VT
Polymorphic VT
Region X SOP Review
Stable Monomorphic Wide Complex
• Adenosine 6 mg rapid IVP followed immediately with rapid 20 ml
saline flush
• Rhythm may be SVT with aberrancy
• Conduction took detour which widens out QRS width
• If no effect in 2 minutes
• Amiodarone 150 mg diluted in 100 ml D5W IVPB over 10
Region X SOP
Stable Polymorphic Wide Complex
• Need an antidysrhythmic to be administered
• Amiodarone 150 mg diluted in 100 ml D5W IVPB over 10 minutes
• Place primary IV line
• Piggyback medication into port as close to patient as possible
• Both bags can hang at equivalent height
• Both bags will drip independent of each other
Additional SOP Revisions
• Pediatric near drowning
• If patient is to be intubated, ventilations provided at a rate of 1 breath every
6 – 8 seconds via advanced airway
• Document this as 8 – 10 breaths per minute assisted
• Tourniquet use
• Guidelines providing directions for use of a tourniquet placed in skill section
• CAT device distributed to departments in Region X
May be black or orange in color
• Life threatening extremity hemorrhage
• Amputation or failure of direct pressure
• Place as far distally as possible and proximal to wound
• Tighten windlass until bleeding stops and distal pulse no longer
• Record time tourniquet placed
• Consider pain management
Note: Part of the EMT –Basic curriculum so is a Basic skill
GCS Practice
• Remember
• Always assign the highest score possible
• Deterioration in patient’s condition becomes more
• More important than any one score is the score over
the course of time
GCS Practice #1
25 year old found sitting on bench
• Eyes are spontaneously open
• Patient keeps saying “I”, “I”, “I”
• Slaps at your hands; pulling off equipment
• Eye opening – 4
• Verbal response – 3
• Motor response – 5
• Total - 12
GCS Practice #2
50 year old male found on ground
• No eye movement
• Occasionally groaning
• Withdrawing to pain
• Eye opening – 1
• Verbal response – 2
• Motor response 4
• Total 7
GCS Practice #3
27 year old male found in garage
• Eyes pop open when patient touched and then they close
• Randomly cries out “mom”, “don’t”, “no”, “ok”
• Pulling off collar, IV, other equipment, slapping at your hands
• Eye opening – 2
• Verbal response – 3
• Motor response – 5
• Total 10
GCS Practice #4
12 year old found prone at grocery store
• Eyes are open but with vacant stare; not focusing
• Talking about being at skateboard park; not responding to commands
• Trying to pull off B/P cuff
Eye opening – 4
Verbal response – 4
Motor response – 5
Total - 13
GCS Practice #5
8 year old found laying in bed
• Eyes close tighter when touched
• Crying and whimpering
• Pulling away when touched or equipment applied
• Eye opening – 2
• Verbal response – 2
• Motor response – 4
• Total - 8
GCS Practice #6
62 year old male found at home on couch
• Eyes open to command and then close
• Mumbling and yells out random words
• Right arm flaccid; left pulls back and withdraws to pain
Eye opening – 3
Verbal response – 3
Motor response – 4
Total - 10
GCS Practice #7
30 year old at home suddenly slumped over
• Eyes are open and following you around room
• Yelling out spontaneous words and swearing
• Moves all extremities but not to command; swatting at your hands
Eye opening – 4
Verbal response – 3
Motor response – 5
Total - 12
Preceptor Role
• Useful role to have in place for:
New students
Person new to the role
In presence of new skill to learn
When a person is new to the environment
• Preceptor to develop & validate competencies of another
Preceptor Role Demonstrated
 Teacher / coach
 Leader / influencer
 Facilitator
 Evaluator
 Protector
 Role model
How do you fill this role???
FlowSafe II CPAP
Continuous Positive Airway Pressure
• Goal: to maintain open airways
• CPAP works by keeping airways from collapsing closed during exhalation
• Takes lots of energy to reopen closed airways
• Outcome
• Improved pulmonary air exchange
• Increase in intrathoracic pressure that reduces preload and afterload
•  preload – less blood returning to the heart
•  afterload – less vascular resistance heart has to pump against
• Continuous airway pressures delivered throughout respiratory cycle
• CPAP is to be delivered simultaneously with medications
• CPAP begins to work and bridges gap waiting for medications to work
• Nitroglycerin is to be administered after patient assessment and as CPAP is
being set up
• Continue to deliver Nitroglycerin during CPAP treatment
• An effective, predictable, rapid acting method to reduce preload
FlowSafe II CPAP
• Connect oxygen tubing nipple to gas source
• Secure mask snugly to patient’s face
• Adjust flowmeter to CPAP of 10 (13 – 14 liters per minute)
• Note ranges provided on yellow tag on O2 tubing
FlowSafe II CPAP
• Patient should respond to treatment within minutes
• Patient needs encouragement and support especially first few minutes of mask use
• If needed for wheezing, can add in-line nebulizer treatment
Case Review
• Read the following cases
• Discuss important aspects of assessment related to the
• Determine your working diagnosis
• Discuss treatment/interventions required
Case Review #1
• EMS is called for a patient who is acting bizarre and running
through the streets
• While responding, you verify police have been dispatched
• Upon arrival, you note approximately 5 police officers wrestling
with a male subject
• What is your impression?
• Consider behavioral emergencies, especially excited delirium
• Consider other causes of altered mental status
Case Review #1
• After scene safety, what is the most important intervention to
consider for this patient?
• Sedation
• What are you considering administering?
• Versed 2 mg
• May repeat every 2 minutes to max of 10 mg
• What route would be safest and why?
• IN – avoids risk of needle exposure
Case Review #1
Important note:
• Delay in administering sedation increases risk of death for patient
• Tough call: need to get patient held down/manually restrained, for EMS to
get close enough to perform quick essential assessment and deliver sedation
• Then EMS moves out and lets police take over to continue to restrain patient
• Remember: this patient will not obey command, cannot be reasoned with
Case Review #2
35 year old male presented with weakness to left arm and slurred speech
Co-workers felt initially that he was “drunk”
Upon your arrival patient is sitting in chair leaning to the side
Eyes open, following your movement in the room
Attempts to follow commands
Speech is garbled; becoming agitated that you cannot understand him
Case Review #2
• What is included in your assessment?
Time last known normal
Typical vital signs, pulse oximetry, AVPU/GCS
Blood glucose level
Cincinnati Stroke Scale
Case Review #2
• Why is the speech unintelligible?
• Different functions arise from different areas of the brain
• Deficits can point to area of brain most likely affected
Case Review #2
• Why is blood sugar level necessary if patient is alert and
oriented presenting with a stroke?
• Required by AHA/ASA
• American Heart Association/American Stroke Association
• Best practice related to assessing the potential stroke patient
Case Review #3
EMS responds to a “fight” in progress between police and a subject
Patient reportedly naked running through the streets yelling/screaming
Upon your arrival police are attempting to mechanically restrain patient
As you walk up to the scene, you no longer hear the patient screaming or
• You notice the patient’s head rolling to the side with eyes closed
• Patient appears unconscious
• What are you going to do???
Case Review #3
• As quickly as possible, evaluate the patient
• Patient is apneic and pulseless
• Now what do you do?
• Begin CPR with compressions
• Get the monitor on and interpret the rhythm as soon as possible
What do you do as soon as you see a rhythm?
Check for a pulse; if no pulse, begin CPR
Case Review #3
• What is the rhythm and what do you do?
• CPR 30:2 ratio (1 and 2 man CPR)
• Search for treatable causes – the H’s and T’s
• Fluid challenge 200 ml increments
• Assess lung sounds first
• Epinephrine 1:10,000 1 mg IVP/IO – repeat every 3 – 5 minutes as
Case Review #3
• What are the most likely treatable causes to search for and
treat for this patient?
• H – hypovolemia – provide fluid challenges if lungs are clear
• H – hypoxia – ventilate with supplemental oxygen
• H+ ion - Acidosis – ventilate to get rid of the acid CO2
• Toxins – if ExDS suspected, then cocaine abuse is most likely
Case Review #3
• Would treatment be any different if the initial presenting
rhythm is asystole?
• No
• Treatment is the same for PEA and asystole
• PEA is treated the same regardless of the rate of the
presenting rhythm
• But, check for pulses every 2 minute pause in setting of PEA
Case Review #4
• EMS responds to a work environment for a 64 year old with
complaints of left upper extremity numbness
• Are you already thinking possible stroke?
• What information is important to obtain if thinking stroke?
 Last known normal
 Blood glucose level
 Cincinnati Stroke Scale results
 Baseline vital signs
Case Review #4
AVPU – alert and oriented x3 (or x4)
VS: B/P 150/90; P – 76; R – 16; SpO2 98%; Blood sugar 130
GCS 4/5/6 (total 15)
History of hypertension and diabetes
Meds: enalapril, metformin
Denies: headache, weakness, vision or gait problems
Cincinnati stroke scale – no facial droop, no arm drift, speech clear
Case Review #4
• Need to think “out of the box”
• Be suspicious of person having a stroke for unusual
 Legs don’t work
 Numbness, tingling, weakness not explained
 “Something is just not right”
• Better to err on side of worst case scenario
Case Review #5
76 year old calls 911 for sudden onset dyspnea
Upon arrival patient is in chair, tripod position
Extremely anxious, diaphoretic, labored & rapid breathing
Quick assessment:
• Patient responds verbally (level of consciousness intact)
• Patient has a rapid, regular radial pulse (if distal pulse felt, B/P must be
Case Review #5
Further Assessment
• Lung sounds – bilateral crackles half way up
• VS: B/P 170/98; P – 104; R – 28; SpO2 93%
• What is your working diagnosis?
• Acute pulmonary edema
• What else do you need to consider happening simultaneously to this
• Acute MI
• Not sure if AMI causes acute pulmonary edema or if pulmonary edema led to
Case Review #5
• What action do you need to take for this patient?
Determine that patient is relatively stable
Administer nitroglycerin 0.4 mg sl – may repeat every 5 minutes x3 total
Begin CPAP
Lasix 40 mg IVP (80 mg IVP if on Lasix at home)
If B/P >90 Morphine 2 mg IVP slowly over 2 minutes; may repeat every
2 minutes (max 10 mg)
Case Review #5
• What is benefit of nitroglycerin?
• Venodilator to open vessels  decreases preload and afterload
to reduce workload on heart
• What is benefit of CPAP?
• Keeps airways open
• Improves gas exchange
Case Review #5
• What is benefit of Lasix?
• More immediately causes venodilation to decrease preload and
• Acts as a diuretic (can take up to 20 minutes to kick in)
• What is benefit of morphine sulfate?
• Anxiolytic – to reduce anxiety level of patient
• Does cause venodilation to a degree
• A new tool currently being piloted in Region X by volunteer
• Department members must be in-serviced before tool put into use
• To be used in uncontrollable bleeding
• If an extremity, special 4x4 placed after tourniquet use has failed
• Requires direct pressure be maintained
• Avoid urge to peek at site
Video Clips for Behavioral Emergencies
• Patient on bath salts
• Patient out of control
• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th
edition. Brady. 2013.
• Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady.
• Region X SOP’s; IDPH Approved January 6, 2012.
Bibliography cont’d
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