Altered Mental Status Flashcards
1
Q
Assessment for Altered Mental Status
A
- ABC’s
- 100% O2 and assist ventilation prn r/t pt condition
- IV Access
- Respiratory effort
- GCS (intubation if =8)
- Pupils
- Gag reflex (intubation if absent)
2
Q
Possible Etiology
A
- Suspected or known head injury or increased ICP: intracranial bleed/mass or metabolic
- Suspected or known toxic ingestion, hypoglycemia, seizures
- Sepsis
- Shock
3
Q
Suspected or known head injury or increased ICP
A
- Watch for signs of herniation: unilateral dilated unresponsive pupil, bradycardia, HTN, Cheyne-Stokes/agonal respirations.
- Contact medical control
- Consider TBI protocol in known trauma.
4
Q
Suspected or Known Toxic Ingestion/Hypoglycemia, SZ
A
-Correct hypoglycemia if <70 mg/dl: Infant: D10W 5 mL/kg IV Child: D25W 2mL/kg IV Adolescent: D50W 1mL/kg IV -*Narcan (if toxic ingestion): <20 kg: 0.1 mg/kg IV >20 kg: 2 mg, may repeat if pt responds *May give Flumazenil if benzodiazepine OD suspected: 0.01 mg/kg (max single dose 0.2 mg), May repeat up to 0.05 mg/kg or 1 mg, whichever is lower. (Max total dose 3 mg in one hour) *Do not use Flumazenil in pt w/ known SZ disorder or chronic benzodiazepine use. -SZ; Ativan 0.1 mg/kg IV (Max 4 mg)
5
Q
Signs of Sepsis
A
- Fever
- Leukocytosis
- May be hypothermic and/or neutropenic
6
Q
Signs of Shock and Tx
A
- Delayed cap refil
- Tachycardia
- Decreased perfusion
- 20 mL/kg NS, proceed to shock protocol