Altered Mental Status Scenario

[Anjel]

Well than you would want to inform the student not to give anything orally per AMS

Per Oakland County protocol

If patient is NOT ALERT or vital signs are unstable:
A.

Evaluate and maintain airway, provide oxygenation and support ventilations
as needed.

B. If no suspected spinal injury, place the patient on either side.

C. Administer small amounts of oral glucose paste,buccal or sublingual.

SO... That is technically what I am supposed to do. However with an average time of 2-3 min for ALS to arrive, I think I would hold off on putting frosting in an unconscious persons mouth.

 

[chaz90]

SO... That is technically what I am supposed to do. However with an average time of 2-3 min for ALS to arrive, I think I would hold off on putting frosting in an unconscious persons mouth.

I've actually seen that exact thing on a call. Unconscious diabetic, and the family completely stuffed the woman's mouth with thick frosting to try to get her BGL up. My partner had to use the Yankauer as a spoon and scoop goop out of the ladies mouth. Frosting really hasn't appealed to me since...

 

[kaisardog]

so as a summary for us students: BSI gloves, is scene safe, , No. of Pts =1, call ALS due to high index of suspicion for head/neck injury from fall, GI =young man sitting , ao4, having fallen down stairs 20 ft , w/ suspect head/neck/cSp injuries due to Mechanism of Injury ( which is significant due to height), (BSNAGi survey thus complete.)

now put ghost EMT holding manual C Sp, then student assesses and Rxs ABC's -primary life threats: 1 ghost EMT holds manual stabilize of Head/neck while student is assessing head/neck/chest for need for Rx for life threats Airway Breathing . these are OK as pt is talking , GCSv=4 , AO4 (answering ?s, name , can swallow, =airway, OK) breathing is normal since air going in and out , lungs bilaterally inflate/deflate w/ normal Resp rate and depth after check with stethoscope, chest neg for DCAPTbls, no adventitious sounds. Circulation assessed as normal by pulse/ color/temp /turgor and no visible bleeds. student applies C Sp collar after ABC/head/neck , instructing ghost how to release head/neck stabilization. student continues rapid trauma 90 sec assessment for rest of body while ghost is instructed to prepare to apply o2 NRB 15 L. student finishes neg RapTrau assessment for head/neck/other trauma injuries, student begins OPQRTS/SAMPLE trauma w/ focused neuro assessment for CSp=hd injury. reassess C Collar,, checking PMS on all extremities. Then begin medical assessment w/ focused assessments on Diabetic issues, check pt's own glucometer since EMTs in our state can't carry them, Rx of buccal Glu since AO4 and swallowing. Package: don't want full supine B/B as supine increases ICpressure, so apply KED or short b/b and position in semi Fowler on wheeled stretcher, rapid transport due to CSp /neuro issues complicated by Db. , vitals every 15 , reassess ABCs and interventions ?

question: do you apply C Collar and O2, as part of ABC, then only after finishing full trauma/med secondary survey OPQRSTSAMPLE give the Glu ? and is this pt an ALS and rapid transport ?

now same MOI, but sitting patient, very altered AMS ie making no sense AOx 2 or less, GI now poor/ AO2 sitting pt having fallen w possible head/neck C Sp and AOx2, can't answer 'Can you swallow' question so no oral glu, suspect fall and hit head from environmental/ bystander MOI info, so definiately call ALS in d/t AMS all the r est is the same except no glucose because of AMS and vitals every 5 not 15..reassess all interventions after KED app.

am i forgetting anything? this is a combined trauma/med scenario which i don't think i really understand too well, because our book AAOS only has a few pages on what you are supposed to do...
thanks as usual for your insights. you may not realize how extremely helpful the advice from this board has been in our scenario exams..

 

[SpecialK]

Your post makes absolutely no sense because I cannot understand half of the abbreviations you are using so have a very poor idea of what you are on about.

So, a patient fell 20 feet down some stairs. This is indeed a "fall from height" and there is significant potential for traumatic brain injury, fractures to long bones or the spine, or damage to organs such as the liver, lungs, spleen or kidneys. If the fall is associated with a decreased level of consciousness that is more than being a bit "dazed and blurry eyed" for a minute or so i.e. somebody who is unconscious post-fall and remains unconscious, or who does not regain consciousness completely then the patient has a traumatic brain injury until proven otherwise.

If the patient has a normal (or near normal) level of consciousness then you can leave them sitting up in whatever position is most comfortable for them; if they have a decreased level of consciousness with airway needing intervention then they should be flat on their back, receiving a good two handed jaw thrust and airway management as appropriate noting that the airway always takes precedence over the cervical spine; always, always, always with absolutely no exceptions.

In this patient the cervical spine should be immobilised unless the patient is awake with no altered neurological signs and has a completely normal motor examination and no midline cervical tenderness. It is important to note that lateral muscle tenderness is not cervical spine injury and that if the patient is conscious they can have a well fitted hard collar applied but they do not need their head held; the best person to keep the patients head still is themselves!

There is no role for the KED in this patient; they should be combi-carried to the stretcher (or whatever extrication device you use) and allowed to lay flat on the stretcher in the nose-to-toes position.

You should immobilise the cervical spine if it is indicated after the primary survey has been completed i.e. the patient has a patent airway established and any major bleeding has been extinguished.

It would be appropriate to give the patient oxygen provided they are hypoxic i.e. have an SpO2 of < 96% on room air (noting there are several reasons why a patient may be hypoxaemic on oximetery but have a normal level of oxygen bound to their Hb e.g. CO poisoning, so clinical judgement is required) however we need to get away from the historic dogma of giving oxygen to everybody who looks a bit sick or has something more serious than a cut finger, indeed patients who have significant supratherepautic levels of oxygen administered are at risk of having their capillary and arteriolar bloodflow attenuated due to vasoconstriction; remember when back in first year hari kari seemed like a good idea because one of the million seemingly useless facts that had to be learnt was that the lone controller of the precapillary sphincter was CO2 saturation, well it just came in handy.

It would also be appropriate to check a blood sugar on this patient; a dysglycaemic incident could have triggered the fall noting that it is overwhelmingly likely to be hypoglycemia as the vast, vast majority of patients who have an acute hypergylcemia problem (i.e. DKA or HHNK) have a normal level of consciousness and if they are that sick to have an altered level of consciousness they've been unwell for some time (think days) and are likely to feel so unwell they aren't up and about moving around; but never the less, check a blood sugar.

You can give somebody glucose or glucose containing food so long as they are awake enough to swallow them so an altered level of consciousness if not an absolute contraindication but you should be careful. Something like a jam sandwich, soft drink or sugar in water is often a quick fix for somebody who has had a hypo; although in this situation if the patient is hypoglycaemic it would be more appropriate to give them some glucagon, or glucose parenterally if you have it as part of your scope of practice.

This patient should be referred to the emergency department and should be taken there by you. Just because they fell 20 feet down some stairs does not mean you need to race them to hospital at breakneck speed with sirens blasting as if they had a normal or near normal level of consciousness (GCS > 9) and normal or near-normal physiological signs then they by definition do not meet major trauma criteria however a discretionary trauma call can be placed at the decision of the person on the other end of your hospital call; however, if the patient has an altered level of consciousness with GCS < 9 then they meet major trauma criteria and conveying them to hospital on a 1 might not be a bad idea. While we are on the subject of transport; I can see people jumping up and down and getting all bug eyed and screaming for a helicopter if the scene is more than a stones throw from the hospital; remember, to actually save time with a helicopter the total time to transport the patient to hospital must be greater than one hour unless of course you need the helicopter anyway for backup e.g. for RSI.

 

[Melclin]

This patient should be referred to the emergency department and should be taken there by you. Just because they fell 20 feet down some stairs does not mean you need to race them to hospital at breakneck speed with sirens blasting as if they had a normal or near normal level of consciousness (GCS > 9) and normal or near-normal physiological signs then they by definition do not meet major trauma criteria however a discretionary trauma call can be placed at the decision of the person on the other end of your hospital call; however, if the patient has an altered level of consciousness with GCS < 9 then they meet major trauma criteria and conveying them to hospital on a 1 might not be a bad idea. While we are on the subject of transport; I can see people jumping up and down and getting all bug eyed and screaming for a helicopter if the scene is more than a stones throw from the hospital; remember, to actually save time with a helicopter the total time to transport the patient to hospital must be greater than one hour unless of course you need the helicopter anyway for backup e.g. for RSI.

Not to derail the thread but that seems like some pretty conservative trauma activation criteria. You wouldn't consider a person with that mechanism who did have a GCS of 15 and then say dropped fairly rapidly to 13 and vomited several times to be a good candidate for a trauma centre? I assume you do but is that sort of thing not written into the official criteria somehow? I'd be interested to her about it if you wanna PM.

 

[SpecialK]

Not to derail the thread but that seems like some pretty conservative trauma activation criteria. You wouldn't consider a person with that mechanism who did have a GCS of 15 and then say dropped fairly rapidly to 13 and vomited several times to be a good candidate for a trauma centre? I assume you do but is that sort of thing not written into the official criteria somehow? I'd be interested to her about it if you wanna PM.

Sorry, the GCS for activating a trauma call is < 13.

GCS 14 or 15 is considered "normal" LOC and a "minor" problem
GCS 10-13 is considered an "abnormal" LOC and a "serious" problem
GCS of 13 or less is considered "coma" and a "critical" problem

I reckon the GCS is a bit of a misnomer to be honest, a GCS of 10 might be made up of a E4, V5 and M1 yet if we accept that motor score is the most important prognostic component then this patient is arguably far more time urgent than somebody who has has a GCS of E1, V1 and M6 yet the latter would get priority.

 

[Trailrider]

I am in a EMTB class in nj. Today we had a scenario where I, a first responder, respond to unknown medical. On arrival pt was sitting up against a wall. When I introduced myself the pt was obviously altered with no by bystanders. To open his airway I layed him down and applied o2. Checked CTC bleeding signs of shock etc. When others arrived someone did a rapid trauma while I took vitals. Pt had back neck pain so we back boarded. After my instructor asked why I played the pt down and I said I did it to open his airway but he said that was wrong. My question is how should I have managed the airway.

Altered how?GCS?PHI?stroke scale?diabetic? what causes altered states?

So the patient has a sore neck and back,how ?MOI? what would warrant you to collar him and board him? Are you able to put patient in semi fowlers on the board? what were his vitals?

So you layed him down,applied o2,did a trauma assessment,vitals then a collar? I would likely get the collar on prior to a patent airway,but that's just me.

 

[CPRinProgress]

Altered how?GCS?PHI?stroke scale?diabetic? what causes altered states?

So the patient has a sore neck and back,how ?MOI? what would warrant you to collar him and board him? Are you able to put patient in semi fowlers on the board? what were his vitals?

So you layed him down,applied o2,did a trauma assessment,vitals then a collar? I would likely get the collar on prior to a patent airway,but that's just me.

Well we didn't get dispatched as unknown medical so I was thinking that I would do ABC's and when I did rapid trauma, pt moaned when I palpated his neck and Back, that is why I didn't put the collar on right away. Apparently we were at the base of a staircase but they didn't tell us that until after. He was supposed to have fallen and that is what caused AMS. Vitals were within normal range and gcs was 11

 

[Handsome Robb]

Well we didn't get dispatched as unknown medical so I was thinking that I would do ABC's and when I did rapid trauma, pt moaned when I palpated his neck and Back, that is why I didn't put the collar on right away. Apparently we were at the base of a staircase but they didn't tell us that until after. He was supposed to have fallen and that is what caused AMS. Vitals were within normal range and gcs was 11

I bolded an important learning point above when it comes to testing.

You need to ask about your surroundings in your scene size up. Where are we? Do I see any source of potential mechanism? Any drugs/paraphernalia around? Any medications visible we can look at? Anyone see a glucometer? Did we find insulin in the fridge?

Scenarios are tough because everything needs to be vocalized. You may be thinking all these things but the proctor can't read your mind.

You were correct to board this patient. Worst case you board him, fix the hypoglycemia, he becomes a&o and denies neck/back pain and can be cleared with either CSS or NEXUS or flat out refuses treatment and you take the collar and board off.

Another key point, you keep talking about what you were dispatched to. Wipe that out of your head. If I had a nickel for every time dispatch was wrong about the complaint I'd have bought a brand new truck rather than my 06... I'd say they're correct probably 1/3rd of the time, it's not they're fault they have to go off the information they're given from the RP.

 

[Melclin]

You need to ask about your surroundings in your scene size up. Where are we? Do I see any source of potential mechanism? Any drugs/paraphernalia around? Any medications visible we can look at? Anyone see a glucometer? Did we find insulin in the fridge?

Scenarios are tough because everything needs to be vocalized. You may be thinking all these things but the proctor can't read your mind.

Hells yes, I love getting my law and order on and going through people's rubbish and personal affects looking for clues. Maybe I'm in the wrong job.

But yeah, +1 one on this in general OP, for scenarios time constraints usually come second to getting an accurate picture of whats going on. You might spend 3 minutes discussing the scene before actually doing anything, where as in real life you could just see it all and dive in.

 

[Handsome Robb]

Hells yes, I love getting my law and order on and going through people's rubbish and personal affects looking for clues. Maybe I'm in the wrong job.

Glad I'm not the only one.

As far as trauma center criteria, here any patient with a GCS <13 is a "Trauma Red", one of the most "severe" categories only second to a trauma pre alert that spins an OR and brings anesthesia to the trauma bay.

 

[Handsome Robb]

It won't let me edit my last post for some reason.

With that said about the GCS, if you have something like hypoglycemia present you have to fix that problem to make sure it isn't what's causing the ALOC before reporting to the TC that they're severely altered.

 

[Tigger]

Glad I'm not the only one.

As far as trauma center criteria, here any patient with a GCS <13 is a "Trauma Red", one of the most "severe" categories only second to a trauma pre alert that spins an OR and brings anesthesia to the trauma bay.

GCS equal or less than 12 will bring the full trauma alert hear, with nothing else provided it makes sense (i.e. the person is not usually GCS=12). Went to a talk the other day given by a local trauma center regarding callins and trauma alerts (two levels; full and merit), mental status plays by far the biggest roll in it for them, which I was not aware of.

I thought they had a genie next to the radio that told them what to call.