Altered Mental Status

Coma and Reduced GCS Emergencies

Franko Haller, Medical English VIfranko@me.comDecember 2010

Mentor: A. Žmegač Horvat

Imagine yourself...

- A1 highway- early August- foreign tourists- high-traffic season

A 112-call

- 65 year old female- LOC- bus tour- exit Brinje, direction South- English speaking tour with Croatian guide

*

What can you expect?- 65 year old female- LOC- bus tour- exit Brinje- English speaking tour with Croatian guide

ALMOST anything!

How to approach the patient?

D DANGER

How to approach the patient?

R RESPONSEAVPU assessmentAVPU assessmentA - A - AALERTLERTV - responds to V - responds to VVOICEOICEP - responds to P - responds to PPAINAINU - U - UUNRESPONSIVENRESPONSIVE

How to approach to a patient?DR ABCDANGER, RESPONSE,

AIRWAY, BREATHING, CIRCULATION

What can you see?- 65 year old female- group of 15 Canadians

D - no danger to provider/emergency teamR - reduced LOC; not alert, does not respond to voice stimuli, responds to pain stimulus on sternum AVPUA - open, patentB - normal breathing, RR 18/minC - strong, 98 bpm, BP 120/80

SAMPLE historyS - signs & symptoms

A - allergies

M - medications

P - past medical history

L - last oral intake

E - events preceding this acute emergency

SAMPLE historyS - signs & symptoms: tired and cranky, complained of

lightheadedness

A - allergies: no known allergies

M - medications: metformin and other drugs for her

diabetes

P - past medical history: known diabetic, history of a

stroke 5 years ago

L - last oral intake: breakfast 3 hours ago

E - events preceding this acute emergency: severe and

sudden headache minutes before she lost consciousness

What should you do next?Check blood glucose

Establish an i.v. access (50 ml of 50% glucose/dextrose

flushed with NS)

Check pupils

Check reflexes

Reevaluate ABCs (consider oropharyngeal airway)

Determine GCS

What should you do next?Blood Glucose 1.1 mmol/L on glucometer

Establish an i.v. access (50 ml of 50% glucose/dextrose flushed with NS)

Check pupils - fixed and dilated, symmetric

Check reflexes - diminished, symmetric

Reevaluate ABCs - unchanged

Coma and decreased GCSTHINK ABOUT* no focal neurology: low O2, high CO2, hypotension, metabolic (glucose, Na+, Ca++, K+, acidosis, alkalosis, renal, liver failure), hypothermia, pyrexia, malignant hypertension

overdose: opiates, benzos, alcohol, insulin, some oral hypoglycemics

* focal neuro findings:CVA, tumor, hematoma, trauma, hypoglycemia

* meningism:meningitis, encephalitis, SAH

Glasgow Coma Scale (GCS)

= or < 8 requires intubation

E2 V3 M5

total GCS 10

Acute confusionConfusion

Off-legs

Acopia

Dementia

Delirium

Psychosis

acute deficit in thinking, memory, orientation or awareness medical slang for acute inability to walk in the elderlymedical slang for elderly patients no longer coping at homechronic deficit in thinking, memory and/or personalityacute onset confusion with hallucinations or illusions

hallucinations or illusions without confusion

Acute confusionTHINK ABOUT EMERGENCIES

acute

chronic

ASK ABOUT

low O2, high CO2, MI, sepsis, intracranial bleed, meningitis, encephalitis, raised ICP, CVA, arrhythmia; common: infection, metabolic, head injury, alcohol withdrawal/intoxication, post-ictal, Korsakoff’s dementia

history from family, relatives, friends, nursesPMH: lung, hear, liver, kidney, epi, dementia, psychDH: benzos, opiods, steroids, NSAIDs, B-blockers, psych drugs, alcohol, recreational drugs

Acute confusionTHINK ABOUT EMERGENCIES

Look for

Obs

Investigations

cyanosis, pulse (HR and rhythm), bronchial breathing, creps, abdo pain, signs of head injury, neck stiffness, photophobia, focal neurology, pupils, papilloedema, tone and reflexes

GCS, temp, HR, BP, RR, O2 sats

urine dipstick, middle stream, culture, swabblds FBC, U+E, LFTs, CRP, glucose, Ca++, cardiac markers, blood cultures, amylase, TFT, B12 level, ABGECG, CXR, CT, LP if CT normal

Acute confusionAbbreviated Mini-Mental(10-point test)

8 or more is normal in an

elderly patient

Thank you for your attentionLiterature:

1. Oxford Handbook for The Foundation Programme; Hurley, Dawson, Sanders, 2nd E, Oxford University Press, 2008

2. Oxford Cases in Medicine and Surgery; Guiding Your Through Diagnosis; Farne, Norris, Smith, Oxford University Press, 2010