# altered mental status



## c_looney2006 (Nov 18, 2009)

You arrive on scene to find a 71 y.o male sitting in his chair, slumped over. Patient is responsive to verbal stimui and can follow some comands. Patient has snoring respirations, vitals are: resp 8 shollow and irregular, bp 96/p, pr of 54 weak, glucose 251 mm/dl, puples pin point and fixed. You were told while enroute that another crew had responded about an hour eariler to the same patient for hypoglucima and oral glucose was administered, but patient refused transport. Pt is placed on 15 lpm nrb.... what's ur next step.

oh and this is a call I ran 2 nights ago on my first clinical, my first call.


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## Lifeguards For Life (Nov 18, 2009)

c_looney2006 said:


> You arrive on scene to find a 71 y.o male sitting in his chair, slumped over. Patient is responsive to verbal stimui and can follow some comands. Patient has snoring respirations, vitals are: resp 8 shollow and irregular, bp 96/p, pr of 54 weak, glucose 251 mm/dl, puples pin point and fixed. You were told while enroute that another crew had responded about an hour eariler to the same patient for hypoglucima and oral glucose was administered, but patient refused transport. Pt is placed on 15 lpm nrb.... what's ur next step.
> 
> oh and this is a call I ran 2 nights ago on my first clinical, my first call.


Most agencies in our area only allow hypoglycemic patients to refuse treatment if they had IV glucose, and only if they had someone to look after them.

I don't think this patients problems are related to the high blood glucose levels. HHNS does not typically occur with BGL's below 600. Unless it is very late in DKA(which if the patient was hypoglycemic an hour ago i'm guessing it wasn't) you wouldn't be seeing respiration's irregular and shallow at 8 breaths per minute, DKA is typically kussmauls. also DKA should present tachycardic. Rule out HHNS and DKA. Hyperglycemia does not quite fit either.



Why did you give the pt a NRB instead of bagging him?

did your patient have more of a history or open bottles, perhaps a benzo near where you found him?


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## Seaglass (Nov 18, 2009)

Lifeguards For Life said:


> did your patient have more of a history or open bottles, perhaps a benzo near where you found him?



I'd be wondering about meds as well, and would also assess for stroke.


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## Lifeguards For Life (Nov 18, 2009)

Seaglass said:


> I'd be wondering about meds as well, and would also assess for stroke.



I had hoped if it was a stroke the OP would have seen a few signs. with a stroke i would not expect a b/p palp in the 90s. Every single symptom except the hyperglycemia points to an overdose.

And i do not think a patient can go from being hypoglycemic to 251mg/dl in an hour only being given oral glucose. i'm assuming that reading may of had some alcohol from the cleansing in it and have been innacurate.


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## JPINFV (Nov 18, 2009)

c_looney2006 said:


> You arrive on scene to find a 71 y.o male sitting in his chair, slumped over. Patient is responsive to verbal stimui and can follow some comands. Patient has snoring respirations, vitals are: resp 8 shollow and irregular, bp 96/p, pr of 54 weak, glucose 251 mm/dl, puples pin point and fixed. You were told while enroute that another crew had responded about an hour eariler to the same patient for hypoglucima and oral glucose was administered, but patient refused transport. Pt is placed on 15 lpm nrb.... what's ur next step.
> 
> oh and this is a call I ran 2 nights ago on my first clinical, my first call.



8 breaths/min, bradycardic, hypotensive? Pull out a BVM and assist breathing on this one.

Medications? Allergies? Medical history? Any other HPI?


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## Lifeguards For Life (Nov 18, 2009)

Romazicon or Naloxone? I wouldnt push those meds yet. this could easily be a a patient that we would have to take over there ventilations soon. but bls before als bag this patient like was stated earlier. also fluid resuscitation


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## Seaglass (Nov 18, 2009)

Lifeguards For Life said:


> I had hoped if it was a stroke the OP would have seen a few signs. with a stroke i would not expect a b/p palp in the 90s. Every single symptom except the hyperglycemia points to an overdose.



The blood pressure would also make me lean strongly towards overdose, but in someone that age with altered LOC and pinpoint pupils, I'm always going to assess for stroke while I'm at it. It only takes a moment, and our hospitals are far enough apart so that sending him to the wrong one would mean pretty big delays in treatment.


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## Lifeguards For Life (Nov 18, 2009)

Seaglass said:


> The blood pressure would also make me lean strongly towards overdose, but in someone that age with altered LOC and pinpoint pupils, I'm always going to assess for stroke while I'm at it. It only takes a moment, and our hospitals are far enough apart so that sending him to the wrong one would mean pretty big delays in treatment.



Oh i was not disagreeing with you. definitely any assessment that may benefit a patient shoulda been done. just verbalizing some of my train of thought. I had initially also considered a pontine infarct, but had ruled it out. stroke was definately in my differential for this patient i just found O.D to fit they symptoms better.


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## Seaglass (Nov 18, 2009)

Lifeguards For Life said:


> Oh i was not disagreeing with you. definitely any assessment that may benefit a patient shoulda been done. just verbalizing some of my train of thought. I had initially also considered a pontine infarct, but had ruled it out. stroke was definately in my differential for this patient i just found O.D to fit they symptoms better.



No worries--OD does make the most sense. I was just explaining why I'm always slow to rule out stroke. It's something I'm particularly paranoid about not only because of our stroke center location, but because I always seem to be on duty when bizarre stroke presentations come in.


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## c_looney2006 (Nov 18, 2009)

Ok....I did perform the prehospital stroke test and pt presented with left side weakness, slight facial droop, sleard speach and left arm drift. Pt had a history of asthma, high choloestral and takes meds for both. Scene servey does not revile any open medication bottles in the apartment. Als puts pt on 12 lead and all appears normal..our local protocols state that als can push narcan for any pt with altered loc and dimished respiratory drive....what do u do now


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## firecoins (Nov 18, 2009)

take them to a stroke center.


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