WEEK 6 - Altered Mental Status

Question 1

Causes of altered mental status

Answer 1

A – alcohol (and acidosis)
E – epilepsy (and electrolytes)
I – insulin
O – overdose (and oxygenation)
U – uraemia (and underdose)
T – trauma (and temperature)
I – infection
P – psychiatric (and poisoning)
S – stroke (and shock)

Question 2

Signs and symptoms of alcohol intoxication include:

Answer 2

decreased GCS
behaviour changes (placid or aggressive)
altered judgement/decision making
slurred speech
ataxia and poor coordination
nausea and vomiting

Question 3

Alcohol Considerations:

Answer 3

Does the patient have an odour on their breath?
Does their environment suggest alcohol consumption? (empty bottles)
How much alcohol have they consumed? (standard drinks)
What type of alcohol have they consumed? (beer, wine, spirits, mixed etc.)
Over what time period have they consumed the alcohol? (a few hours, a whole day etc.)
What have they been doing during the time that the have consumed alcohol? (dancing, eating, sitting etc.)
How much alcohol do they normally consume? (in a usual session of alcohol consumption)
How often do they consume alcohol? (regularly – every day, once a week, 3 times a week?)

Question 4

Prehospital management of alcohol intoxication

Answer 4

In the prehospital setting you will come across varying levels of alcohol intoxication. Depending on any injuries and the way the patient is presenting, the paramedic will need to decide whether the patient requires hospitalisation (for monitoring due to a decreased GCS) or can be taken home and cared for by a responsible adult. Some patients who are severely affected may require airway support and oxygen administration

Question 5

What is a seizure?

Answer 5

A seizure is a sudden episode of abnormal and excessive electrical activity in the brain, and results in an AMS in which paramedics are commonly presented wit

Question 6

What is epilepsy?

Answer 6

Epilepsy is a neurological disorder whereby a person experiences recurring seizures of unknown origin, however seizures in general are often as a result of an underlying condition or pathology.

Question 7

How do electrolyte imbalances alter mental state?

Answer 7

Electrolyte disturbances can also alter conscious state by affecting homeostasis and normal functioning of the CNS and CVS. For example a patient with high potassium levels may have bradycardia resulting in decreased CO, poor perfusion and hypoxia, which subsequently causes confusion and drowsiness.

Question 8

Some causes of seizures include:

Answer 8

drugs and alcohol
brain tumour/infection
stroke/TIA
trauma/head injury
electrolyte disturbances
fever
medication or alcohol withdrawal

Question 9

Signs and symptoms of seizures include:

Answer 9

decreased GCS
abnormal body movements/jerking
rapid eye movements
snoring/stridor noises
altered respiratory pattern/periods of apnoea
diaphoresis
tachycardia
urination

Question 10

Seizure Considerations:

Answer 10

Does the patient have a history of epilepsy or seizures?
What was their seizure like? Did they have an aura (sensation prior to the seizure)?
Does the patient take any medications for seizures?
Has the patient recently commenced, ceased or changed a dose of their seizure medication or other medication?
Has the patient recently been withdrawing from alcohol?
Has the patient sustained any oral trauma or been incontinent of urine?
Is there evidence of repetitive focal movement.
Was the onset of altered mentation sudden?
Does the patient have any other related signs or symptoms? (e.g. paediatric patient with a fever - febrile seizure)

Question 11

Prehospital management of a seizure

Answer 11

When treating a patient in the ambulance environment your first action is to stop the seizure! Give the patient midazolam and provide supplemental oxygen. Ensure you assess ABCs, paying close attention to airway and treating any underlying cause of the seizure if possible. You may find that patient’s with epilepsy who have seizures frequently do not usually go to hospital after every seizure. All first-time seizures however should be transported for further investigation.

Question 12

Signs and Symptoms of abnormal BGL levels include:

Answer 12

altered conscious state
confusion/agitation
diaphoresis
tachypnoea
polydipsia, polyphagia, polyuria
dehydration

Question 13

Hypoglycaemia/Hyperglycaemia Considerations:

Answer 13

Does the patient have a history of diabetes?
Are they on insulin? What other medications/dosages?
Have they taken their medication as per normal? Any recent changes?
Have they been unwell recently? Any vomiting/diarrhoea?
Have they eaten today? What have they eaten and what time?
Do they normally have hypo events?
How long do they take to recover normally when treated?
Do they normally go to hospital if they have a hypo?

Question 14

Prehospital management of glycaemic emergencies

Answer 14

In the prehospital setting patients with a low BGL should be administered the appropriate medication to raise their sugar levels, backed up by complex carbohydrates when the patient can tolerate it. In the event of hyperglycaemia, IV fluid therapy may be required. Some patients with diabetes who have frequent hypoglycaemic episodes may refuse to go to hospital. Transportation should be considered in all other situations.

Question 15

Signs and Symptoms of Overdose include:

Answer 15

altered conscious state (and fluctuations)
decreased perceptions
hallucinations
nausea and vomiting
arrhythmias
changes in all vital signs (depending on substance)

Question 16

Overdose Considerations:

Answer 16

If medication bottles are present, does the pill count add up?
Is there evidence of drug use at the scene?
What is the pupil size and respiratory rate?
Has there been a mixture of substances/drugs taken?
Remember that not all overdoses are intentional or deliberate!
Do the police need to be involved?
Is this an acute hypoxic event? (assess ABCs early)
If the patient is on home oxygen ensure that the supply is uninterrupted.

Question 17

Prehospital management of an overdose

Answer 17

In the ambulance environment you must pay particular attention to danger, and then assess ABCs early. Naloxone should be administered in the event of opiate overdose effecting respiratory effort and airway patency, and supplemental oxygen administered. Other overdoses are managed as symptoms arise, and mainly revolve around supporting ABCs. In some instances you may require the police to safely transport a patient to hospital who is exhibiting irrational or unpredictable behaviour as a result of substance abuse. All children who have had an overdose should also be transported to hospital (usually these are an accident). In the ambulance environment you must pay particular attention to danger, and then assess ABCs early. Naloxone should be administered in the event of opiate overdose effecting respiratory effort and airway patency, and supplemental oxygen administered. Other overdoses are managed as symptoms arise, and mainly revolve around supporting ABCs. In some instances you may require the police to safely transport a patient to hospital who is exhibiting irrational or unpredictable behaviour as a result of substance abuse. All children who have had an overdose should also be transported to hospital (usually these are an accident).

Question 18

Signs and Symptoms of Uraemia are:

Answer 18

altered cognition
weakness and fatigue
loss of apetite
nausea and vomiting
dehydration
jaundice
thirst
uraemic frost

Question 19

Uraemia (and underdose) Considerations:

Answer 19

Does the patient have a history of renal failure or renal disease?
Have they been urinating? Frequency?
Is the patient on dialysis?
Do they display any of the above mentioned signs and symptoms?
Has this been a rapid or slow onset?
Has the patient been prescribed any medications?
Are they taking their prescribed medications appropriately?

Question 20

Prehospital treatment of uraemia/renal failure

Answer 20

If a patient appears to be displaying symptoms associated with renal failure then they must be transported to hospital. Treatment will involve managing any symptoms and monitoring ABCs, but is very limited in the prehospital setting.

Question 21

Signs and Symptoms of Trauma and Temperature Issues:

Answer 21

decreased consciousness
confusion/agitation (possible combativeness)
bruising and deformities
CSF/blood leaks
hypothermia (<35 degrees)
hyperthermia (>38 degrees)
diaphoresis
cyanotic or flushed skin

Question 22

Trauma and Temperature Considerations:

Answer 22

Any obvious trauma despite their location/history?
Does the story match the presentation?
Have they been assaulted and is SAPol required?
Are they likely to deteriorate?
Does the patient feel cold, normal, hot?
Is the patient’s skin normal, pale, cyanosed or flushed?
Has the patient been exposed to the elements? (laying outside in the cold/hot?)
How long has the patient been exposed to the weather elements or outside environment?
Is it a particularly cold/hot day or week?
Has the patient’s water intake been sufficient given the environment they are in?
Has the patient had adequate urine output?
When was the last time the patient was seen? (e.g. have they been lying on the floor of their house for the past 3 days?)

Question 23

Signs and Symptoms of Infection include:

Answer 23

fever
tachycardia
dehydration
visible wound/exudate
cough/flu-like symptoms
hypotension
confusion/altered LOC

Question 24

Infection Considerations:

Answer 24

Is there a source of infection?
Has the patient been ill recently?
Is the patient immuno-compromised?
Are they in a high risk category for sepsis?
Are there symptoms of a UTI?
How has their urine output been? (e.g. amount, colour, frequency, burning)
Do they have, or have they had pain? (especially in their abdomen)
Have they been sweating? Shivering? Do they have rigors?
What is their temperature? (Do they have a fever?)
Any recent overseas travel?
Remember PPE!

Question 25

Prehospital management of infectiob

Answer 25

If paramedics are called for an AMS due to an infection, it is likely to be a UTI in the elderly, or sepsis in the general population. Normally it is an advanced stage of the underlying pathology which will result in neurological impairment. The patient may require IV fluids on top of symptom management, and should be transported to hospital for further management (possibly IV ABs). You may consider consulting with an ECP/clinician if the situation allows.

Question 26

Signs and Symptoms of Psychiatric issues include:

Answer 26

obvious ‘acting’ unconcious (e.g. resists movement, eyelids fluttering, lowers arms to ground when raised etc)
decreased GCS despite all vitals in normal ranges
no obvious trauma or injury
evidence of attempted suicide or self-harm
recent emotional episode
smells in environment to indicate poisoning

Question 27

Psychiatric Considerations:

Answer 27

Does the patient have a history of psychiatric events?
Is the patient dangerous?
Could the current presentation be a simple episode of catatonia or some sort of psychosis?
Has there been a recent emotional stressor preceding the event?
Is SAPol needed in the event of a ‘care and control’ situation?
Could this be a natural progression of dementia or Alzheimer’s disease?
Is delirium possible?
Has the patient been taking their prescribed medications properly?
Could this be a deliberate overdose or attempted suicide?
Has there been a medication review recently? (is the medication and dose still helping the patient with their symptoms?)
Does the environment suggest poisoning (e.g. farm, industry, factory etc.)

Question 28

Prehospital management of Psychiatric cases

Answer 28

Even if a psychiatric issue is suspected, the paramedic must rule out the more serious potential differential diagnoses first. Management of an unconscious patient from an acute psychotic episode is limited in the prehospital setting, and so all cases should be transported to hospital for a thorough mental health assessment and required support. If poisoning is the cause of AMS, then treating symptoms and managing ABCs becomes the priority, and consider urgent transport depending on the presentation (e.g. organosphosphates and tricyclic antidepressants).

Question 29

Signs and Symptoms of Stroke include:

Answer 29

altered GCS
hemiparesis
dysphagia
dysphasia
ataxia
facial droop

Question 30

Stroke (and Shock) Considerations:

Answer 30

What was the time of onset?
Has the patient had a change of medications?
Is the patient on anticoagulants?
Has the patient experienced a TIA/CVA in the past?
Has there been a lucid period before overall deterioration in GCS?
Was the patient independent with ADLs prior to this presentation?
Remember to obtain the patient’s resuscitation status (as these patients are likely to rapidly deteriorate or never return to previous level of functional capacity).
A full neurological evaluation should be conducted to detect motor deficits.
Ensure that a ROSIER score is conducted on any patient presenting with stroke-like symptoms as this is a proven tool to positively predict likelihood of a stoke.

Question 31

Prehospital management of a stroke

Answer 31

In the prehospital setting a patient experiencing a stroke may require airway support and so paramedics must focus on ABCs, consider administering oxygen, and conduct a thorough neurological examination and ROSIER. The patient should be rapidly transported to a stroke centre with notification.

Question 32

Different levels of consciousness: (7)

Answer 32

Confusion - marked by the absence of clear thinking and may result in poor decision-making

Disorientation - the inability to understand how you relate to people, places, objects and time.

Delirium - observed through confused and illogical thoughts. Delirious patients are often disorientated and may express fear, anger and agitation.

Lethargy - consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.

Obtundation - a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.

Stupor - a deep level of decreased consciousness where a patient may only respond to painful stimuli.

Coma - the deepest level of impaired consciousness where a patient does not respond to stimuli (GCS 3).