Altered Level of Consciousness

ALTERED LEVEL OF CONSCIOUSNESS
4/06/12 6:57 PM
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INTRODUCTION
Optimal patient care requires that the EMT-I understand common causes of altered level of consciousness. The following topics will be discussed during this lesson: Common causes of altered level of consciousness Pathophysiology of common causes of altered level of consciousness (seizure, stroke, and syncope) Assessment of the altered patient Field management of the patients that are altered Transportation decisions for altered patients
LESSON OBJECTIVES
At the end of this lesson the participants will be able to: 1. 2. 3. 4. 5. Identify common causes of alteration in level of consciousness. Discuss the pathophysiology of common causes of altered level of consciousness (seizure, stroke, and syncope). Demonstrate field assessment of the altered patient. Verbalize field management of the altered patient. Discuss transport considerations for the altered patient.
SKILLS
Initial Assessment of the Altered Patient Focused History and Detailed Physical Examination of the Altered Patient
KEY VOCABULARY
The following terms will be used during this lesson: A.L.O.C. - an abbreviation for altered level of consciousness Aura - a sensation that precedes seizure activity (often a particular odor or vision) Consciousness - awareness of self and environment Cerebral vascular accident (CVA) - sudden change in neurologic status caused by an
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interference with blood supply to the brain Epilepsy - a condition characterized by abnormal electrical impulses in the brain which result in seizures Grand mal seizure - generalized tonic-clonic muscle contractions with a loss of consciousness Hemiplegia - paralysis of one side of the body Hypertensive encephalopathy - altered mental status caused by hypertension Hypoxia - inadequate oxygen to the cells Post-ictal - period of the altered level of consciousness following a seizure Seizure - a temporary alteration in behavior caused by a massive electrical discharge in the brain Status epilepticus - a seizure lasting longer than 10 minutes, repetitive seizures without periods of consciousness, or more than 3 seizures per hour Syncope - brief (less than 30 minutes) loss of consciousness caused by inadequate brain perfusion Transient ischemic attack (TIA) - temporary inadequate brain perfusion which results in neurological deficits and which completely resolves. Vasovagal response - temporary stimulation of the vagus nerve which causes a drop in heart rate and reduction in cardiac output
KEY CONCEPTS
The following section provides information and space for taking notes on the key concepts discussed by the instructor. ALTERED LEVEL OF CONSCIOUSNESS - OVERVIEW Causes of altered level of consciousness Structural: brain lesions that destroy tissue or occupy space that is normally occupied by the brain Epilepsy Tumors Trauma Cardiovascular: temporary or permanent interruption to the blood supply to the brain Vasovagal response CVA TIA Hypertensive encephalopathy Shock Dysrhythmias
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Metabolic: abnormally high or low levels of circulating metabolites Hypoxia Hypoglycemia Hyperglycemia Renal failure (uremia) Liver failure Infection (sepsis) Environmental: external factors that cause deterioration of central nervous system function Overdose Toxins Behavioral: abnormal mental status that results from internal factors Psychiatric disorders
Mnemonic for Causes of Altered Level of Consciousness A - alcohol, acidosis, anoxia E - epilepsy, environment I - insulin (diabetes) O - overdose U - uremia (metabolic), underdose T - trauma, toxins, tumors I - infection (sepsis) P - psychiatric disorders S - stroke (CVA) GOLDEN RULE: Altered level of consciousness is characteristic of nervous system dysfunction and warrants thorough examination to rule out all possible causes. Seizure Pathophysiology: massive electrical discharge in the brain causes a temporary alteration in behavior Causes of seizures A: alcohol withdrawal E: epilepsy I: insulin O: overdose U: underdose T: I: P: S: trauma infection psychiatric disorder stroke
Signs and Symptoms of Seizures Generalized seizures involve the entire cortex of the brain Grand mal seizures
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May have an aura Loss of consciousness Tonic-clonic movement Incontinence Clenched teeth, tongue biting Post-ictal phase
Petit mal seizures Loss of consciousness (10-30 seconds) Eye or muscle fluttering May lose muscle tone
Partial seizures are confined to a limited portion of the brain, however they may spread and become generalized Focal seizures Localized to one area of the body No loss of consciousness Psychomotor seizures Characterized by distinctive auras (ie. metallic taste) No loss of consciousness May lose touch with their surroundings for a few moments May have sudden, brief personality change
Field management of seizures: BLS Procedures: If actively seizing do not attempt to stop the seizure or push anything into their mouth to try to prevent them from biting their tongue Do not attempt to control the seizure Protect the seizing patient Maintain their airway High flow O2 by mask Left lateral position Spinal immobilize if trauma or unknown mechanism of injury Assist with ALS procedures ALS procedures Advanced airway prn Venous access Glucometer Monitor Valium for active seizures Dextrose for hypoglycemia
Syncope
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Pathophysiology A temporary interruption in cerebral blood flow results in a brief period of loss of consciousness (less than 30 minutes) Causes of syncope Cardiac dysrhythmias Transient ischemic attacks Vasovagal response Orthostatic syncope (dehydration, medication effect) Fainting (fever, prolonged standing in a warm crowded room, emotional distress) Seizures Signs and symptoms of syncope Brief period of loss of consciousness May be altered or awake, alert, and oriented Possible seizure activity Possible trauma Possible abnormal vital signs (i.e. heart rate and quality) Pale, cool, moist skin Postural hypotension Field management of syncope BLS procedures Maintain the airway High flow O2 by mask Left lateral if no trauma Spinal immobilization if trauma is present Assist with ALS procedures ALS procedures Advanced airway prn Venous access Fluid challenge if clear lung sounds and signs of shock Glucometer Monitor Valium for active seizures Dextrose for hypoglycemia Dopamine for hypotension if rales or if unresponsive to fluid challenge Atropine for symptomatic bradycardia Adenosine for SVT Lidocaine for ventricular dysrhythmias Cardioversion for poorly perfusing SVT or Ventricular tachycardia Stroke Pathophysiology Injury or death of brain tissue from an interruption in blood flow.
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Symptoms depend on the area of the brain affected. Typically the motor, sensory, or speech centers are affected. Causes of stroke Hemorrhage: rupture of a blood vessel, either intracerebral or subarachnoid. Characteristically have a sudden onset, often preceded by a severe headache. Infarction: occlusion of a cerebral artery by atherosclerosis or embolism Field management of stroke BLS procedures Maintain airway High flow O2 by mask Left lateral position if no signs of trauma Spinal Immobilization if trauma or unknown mechanism of injury Assist with ALS procedures ALS procedures Advanced airway prn Venous access Glucometer Monitor Valium if actively seizing Dextrose for hypoglycemia
INITIAL ASSESSMENT OF ALTERED PATIENTS 1). Assess environment: (may need to manipulate the environment) Safety of rescuers and environment Environmental factors Patient location (home, street, convalescent, etc.) Weapons (may indicate trauma mechanism) Medications (may offer clues to past medical history) o Witnesses (may help to explain circumstances) o Empty pill bottles may indicate an overdose Mechanism of injury Number of patients 2). Airway (determine responsiveness and patency of airway) Initiate spinal precautions if indicated Open the airway using the chin lift/head tilt or jaw thrust maneuver Remove any obstruction BLS Maneuvers until open airway is achieved
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Patient may be altered or unconscious and unable to protect or maintain their airway
3). Breathing: assess rate, rhythm, and tidal volume If the patient is not breathing, begin rescue breathing using mouth to mouth, mouth to mask, or bag-valve-mask Is the breathing labored or unlabored If labored, place the patient on oxygen Assess the lung sounds during the detailed examination if trauma is not present. Increased respirations and tidal volume- possible metabolic process, early to mid stage shock, head trauma. Decreased respirations and tidal volume- spinal or brainstem injury, stroke, late stage of shock.
4). Circulation: a). Palpate for pulse noting: rate/rhythm/quality b). Character of the pulse (weak or strong) is an indicator of the pressure and volume within the arteries. c). Heart rate- compensatory mechanism for poor perfusion, dysrhythmias, fever, and metabolic problems.
5). Skin signs: assess color, temperature and moisture Pale, cool, moist skin and delayed capillary refill are due to peripheral vasoconstriction If signs of poor perfusion, consider placing patient supine
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6). Assess neurological status: assess level of consciousness (Glasgow Coma Score) and neuro deficits Restlessness, agitation, and lethargy may be due to hypoxia and decreased cerebral perfusion. Unconsciousness and coma may be due to prolonged hypoxia, shock, head injury, metabolic disorders, neurological disorders, or other causes.
Complete GCS: Eye Opening 4. Spontaneous 3. Verbal 2. Painful 1. None Motor Response 6. Obedient 5. Purposeful 4. Withdraws 3. Flexion 2. Extension 1. None Verbal Response 5. Oriented 4. Disoriented 3. Inappropriate 2. Incomprehensible 1. None
7. Determine chief complaint
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Focused History and Detailed Physical Examination 1). Elicit history of chief complaint or problem A - alcohol, acidosis, anoxia E - epilepsy, environment I - insulin (diabetes) O - overdose U - uremia (metabolic), underdose T - trauma, toxins, tumors I - infection (sepsis) P - psychiatric disorders S - stroke (CVA)
2). Elicit personal history (HAM) H medical history/under a doctors care -seizures -diabetes -hypertension -heart problems -other chronic illnesses A allergies/age M medications-current over the counter and prescription 3). Vital signs Blood pressure - may be normal, elevated, or low depending on the cause
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Pulse - may be normal or abnormal depending on the cause Respirations - may be normal or abnormal depending on the cause Temperature - any signs of fever (hot, flushed, moist)
4). Special Questions Past medical history: seizures? Diabetes? Hypertension? Heart problems? Other chronic illnesses? Recent illness? Any witnesses to the current events? Current medications? Allergies to medications? How long have they had symptoms? When were they last known to be normal? Any drug or alcohol abuse? Any history of head trauma within the last few months? Did they complain of headache or other symptoms before they became altered?
5). Pertinent Body Check: Medical or minor traumaperform body check pertinent to chief complaint
Head to Toe Examination Trauma? Tenderness? Medic alert tags? Tract marks? Pupil size and response to light? Movement of extremities? Equal from side to side? Local neurological symptoms? Facial droop, slurred speech, numbness? General Field Management of Altered Patients BLS procedures Maintain airway: the unconscious patient may need assistance to maintain and protect their airway. They cannot control their tongue which can easily block the airway. Frequent suctioning may be needed to clear away secretions and vomitus. High flow O2 by mask: to reduce damage to the brain from
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hypoxia Left Lateral Position: if there is no trauma present this position will help the patient to maintain their airway by allowing secretions to flow out of the mouth and away from the airways. Assist with ALS procedures
ALS procedures Advanced airway prn: If the patient is deeply comatose and endotracheal tube will maintain an open airway and allow secretions to be suctioned efficiently. Venous access: There are many causes of ALOC which can be treated with medications given intravenously. Glucometer: All patients with ALOC should have a Glucometer done to rule out hypoglycemia or hyperglycemia. Monitor: may dysrhythmias can cause ALOC Valium for active seizures: Give to stop the seizure activity. Only given in the field for active tonic-clonic seizures. Respirations and blood pressure must be closely monitored following Valium administration. Fluid challenge - ALOC may be due to poor perfusion from shock. If the lungs are a clear a fluid challenge may be ordered. Dopamine drip - May be ordered for hypotension if rales are present or if there is no response to a fluid challenge. Adenosine, Atropine, and Lidocaine may be given to treat cardiac dysrhythmias. Electrical cardioversion may be needed to treat poorly perfusing cardiac dysrhythmias.
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