Altered Mental Status
Coma and Reduced GCS Emergencies
Franko Haller, Medical English [email protected] 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