Altered Mental Status – Unknown

SB201/M406

Alcohol/drug overdose is suspected, go to Toxocological Emergencies protocol

Dysrhythmia, assess for abnormal pulse or perfusion and go to appropriate cardiac treatment protocol

Head Injury

  • Maintain airway and administer oxygen as necessary to maintain SpO2 >95%
  • Respiratory goal is to maintain normal rate of 10-12/min to maintain ETCO2 of 35-40 mmHg
  • ONLY with assymetric pupils (> 1mm dif) and comatose, hyperventilate to goal ETCO2 of 30 mmHg
  • Stop hyperventilation if pupils normalize
  • ONLY with assymetric pupils (>1 mm dif) and comatose, consider 500 ml of 3% saline

Hyperglycemia

  • If rapid glucose test >400 mg/dL or glucometer reads “HIGH”
  • Administer a fluid bolus of 500-1000 ml IV/IO during transport if no evidence of pulmonary edema
  • Place on monitor for possibility of dysrhythmia

Hypoglycemia

  • If rapid Glucose test < 70 mg/dL or glucometer reads “LOW”
  • Able to swallow and maintain airway – oral glucose 15g (or high glucose fluids like orange juice)
  • Unable to maintain airway, administer Dextrose in one of the following manners until an improvement in mental status:
    • 6.25-25g (12.5-50ml) Dextrose 50% IV/IO
    • 6.25-25g (25-100ml) Dextrose 25% IV/IO
    • 6.25-25g (62.5-250ml) Dextrose 10% IV/IO
    • Doses may be repeated if repeat blood glucose assessment remains below 70 mg/dL
    • Dextrose must be given through a patent IV/IO. If any suspicion of extravasation is present notify receiving Emergency Department
    • It is acceptable to dilute Dextrose with normal saline due to the high viscosity based on IV size and vein conditions
  • If unable to establish IV/IO access, administer Glucagon (Glucagen) 1 mg IM
  • Narcan 0.4 to 2 mg IV/IM if signs of possible narcotic overdose are present

Hypertension

  • Symptomatic HTN (BP systolic >200 and one of the following: headache, confusion, vomiting, blurred vision, chest pain, respiratory difficulty) should not be treated for the blood pressure in the pre-hospital setting
  • Treat symptoms per the appropriate protocol
  • Assess patient for stroke symptoms; assess blood pressure in the opposite arm of initial reading
  • If positive for stroke, refer to stroke protocol for treatment

Hypoxia

  • Maintain airway and administer Oxygen
  • Allow patient to sit up in a position of comfort
  • Apply cardiac monitor when available
  • Monitor vital signs
  • Consider CPAP
  • If patient has chest pain suggestive of cardiac origin and/or cardiogenic shock, dyspnea, no evidence of trauma, AND systolic BP <80, OR systolic BP 80-100 and HR>120, skin changes suggestive of shock, altered mental status, clear lungs,
    • Initiate large bore IV and administer 500 ml normal saline fluid challenge.
    • May repeat if lungs remain clear.  If lungs are not clear, run IV at a keep open rate.
    • If patient is hypotensive and 12-lead ECG does NOT show an inferior MI, consider push dose epinephrine titrated to clinical effect (0.5-2 ml of a 10 mcg/ml solution every 2-5 minutes (5-20 mcg)).
  • If the patient has a dysrhythmia, treat the dysrhythmia per protocol.
  • If the patient is unable to speak, airway obstruction, or possible foreign body aspiration, OR exhibits stridor lung sounds,
    • Encourage the patient to cough if possible;
    • If not, perform Heimlich maneuver until successful;
    • If Heimlich is unsuccessful, attempt to remove object above vocal cords with laryngoscope, a suction device and/or Magill forceps or, if object is suspected below vocal cords, intubate the trachea and push foreign body down right mainstem bronchus with the ET tube to aerate the left lung.
    • If pediatric patient, follow adult instructions for patients greater than 1 year old; for infants less than one year old with complete obstruction, initiate 5 back blows alternating with 5 chest thrusts until successful or, if unsuccessful, attempt to remove object above vocal cords with laryngoscope, a suction device and/or Magill forceps or, if object is suspected below vocal cords, intubate the trachea and push foreign body down right mainstem bronchus with the ET tube to aerate the left lung.
    • If pediatric patient with stridor, consider normal saline mist via nebulizer, place patient on cardiac monitor, and contact medical control if considering nebulized epinephrine.
  • If the patient has a history of asthma, emphysema, or COPD, AND complains of a worsening shortness of breath,
    • Albuterol (Proventil) or Duoneb via HHN. May repeat to a total of 3 treatments
    • For first treatment may add ipratropium bromide or use Duoneb
    • For asthma only, consider epinephrine 1:1000 0.3 ml IM if patient is unable to breathe in HHN
    • Consider CPAP if available
    • Consider 60 mg Prednisone PO or Solumedrol 125 mg IV
    • If the patient is pediatric and is experiencing respiratory distress with a history of asthma or wheezing:
    • Assess the need for assisted ventilation
    • Allow patient to sit in a position of comfort
    • If wheezing, albuterol 0.5 ml in 2.5 ml 0.9% NaCl nebulized
    • Initiate transport
    • May give 3 albuterol nebulized treatments. May consider adding 1 vial Ipratropium Bromide (0.5% of 0.02%) to the albuterol treatments, or substituting Duoneb. Contact medical control for consideration of epinephrine 1:1000 IM 0.01 ml/kg (max 0.3 ml)
    • For patients ages 3-16 y.o. who are awake, oriented, can take oral medications, have known asthma or reactive airway disease, or history of multiple episodes of wheezing responsive to albuterol, and are NOT currently taking steroids, have a history of cancer, diabetes, or immune deficiency, administer one of the following:

Prednisolone 3 mg/ml liquid

  • Age 3 – 7 years: 30 mg (10 ml)
  • Age 8 – 16 years: 60 mg (20 ml)

Prednisolone 20 mg tablets

  • Age 3 – 7 years: 30 mg (1.5 tabs)
  • Age 8 – 16 years: 60 mg (3 tabs)

Solumedrol IV solution to be administered PO (125 mg/2ml)

  • Age 3 – 7 years: 30 mg (0.5 ml)
  • Age 8 – 16 years: 60 mg (1 ml)
  • If the patient has a history of heart disease, a respiratory rate greater than 24 and a systolic blood pressure greater than 100 mm Hg,
    • CPAP if available
    • Evaluate for contraindications to nitroglycerin:
    • Systolic BP <100 mmHg
    • Viagra/sildenafil in the last 24 hours
    • Levitra/vardenafil in the last 48 hours
    • Cialis/tadalfil in the last 72 hours
    • Medications for pulmonary hypertension (ex: Flolan, Revatio, Adcirca)
    • Assess vitals, acquire 12-lead ECG and establish IV
    • Consider nitroglycerin administration as described below (if inferior MI evident on ECG, contact medical control prior to nitroglycerin administration):
    • 0.4 mg SL every 5 min X3 for MILD symptoms (HR<100, SBP 100-150, RR<25) or:
    • 0.8 mg SL every 5 min X3 for MODERATE or SEVERE symptoms (HR>100, SBP>150, RR>25) or;
    • Topical nitroglycerin:
    • 1” for SBP 100’150
    • 1.5” for SBP 150-200
    • 2” for SBP>200
    • Reassess blood pressure after each nitroglycerin dose, do not readminister if SBP<100 mmHg
    • Monitor LOC & respiratory status; do not readminister if status changes that cause concern for aspiration based on patient’s clinical status
  • If the patient has hives, itching, or swelling,
    • Epinephrine 0.3ml 1:1000 IM if either hypotension or severe respiratory distress is present
    • Albuterol (Proventil) 2.5mg in 2.5ml NS via HHN if wheezing or bronchospasm is present
    • If hypotension infuse 1 liter NS IV WO rate
    • Benedryl 25-50mg IV/IM/PO; may be given without preceding epinephrine in mild cases
    • If hypotension persists, consider push dose epinephrine (5-20 mcg every 2-5 minutes; discontinue IM dosing)
    • Persistent symptoms w/ known β blockers consider Glucagon IN/IV
  • If pneumothorax is suspected be aware that this can develop into a tension pneumothorax. Patient will have one or more signs, including absent breath sounds on affected side (possible to be both sides), respiratory distress, hypotension, asymmetric chest rise and fall, jugular vein distension, tracheal shift away from affected side, difficulty with manual ventilation, and hypoxia
    • Maintain airway and administer oxygen. Discontinue automatic ventilator if using
    • Fully expose the entire chest and clean the procedure area of the affected side
    • Prepare for the procedure using appropriate commercial device or one of three techniques:
    • Attach a 2” or longer large bore (10-14g) IV catheter and needle to a large syringe
    • Use the IV catheter and needle with a one-way, multiposition valve (3 way stopcock) or commercial device
    • Use the IV need and catheter alone leaving it open to air
    • Insert the large bore IV catheter and needle assembly in one of two locations: a) over the top of the rib in the second or third intercostal space in the midclavicular line, or b) over the top of the rib of the fifth or sixth intercostal space in the midaxillary line
    • If a tension pneumothorax is present, then a rush of air may be heard of the plunger of the syringe will be easy to pull back
    • Remove the needle from the catheter and leave the plastic catheter in place
  • If patient is in impending respiratory failure, apply any of the following that are within the provider’s scope of practice and appropriate for patient condition:
    • Head-tilt, chin-lift
    • Jaw thrust maneuver
    • Basic airway adjuncts such as NPA or OPA
    • Rescue airway device
    • Tracheal intubation (including RSI when available)
    • Surgical airway approved by EMS Medical Director
  • Consider alternate causes of hypoxia, including CO poisoning

Infection, especially meningitis

  • Assess for fever
  • Utilize appropriate level of PPE for all patients/providers/bystanders

Myocardial Ischemia/Infarction

  • Groups with atypical AMI presentations include the elderly, females, diabetics, and chronically hypertensive patients
  • 12 lead ECG ASAP (<10 min) and transmit or relay findings
  • 324 mg baby aspirin (chewable) if not contraindicated
  • Determine erectile dysfunction or pulmonary hypertension drug use
  • Nitroglycerin 0.4 mg SL q 5 min X 3 or 1″ topical Nitroglycerin
  • Morphine Sulfate 1-5 mg (10 mg total) or Fentanyl 25-50 mcg IV/IO (200 mcg total) if BP>100mm Hg and pain persists
  • If medic interprets rhythm as STEMI, minimize on-scene time to <15 min, treat during transport, and request cath lab activation

Psychiatric

  • Rule out medical causes using differential diagnosis
  • For medically stable patients manifesting unusual behavior including violence, aggression, altered affect, or psychosis refer to M407 for treatment

Shock

  • Identify possible causes of shock and treat via appropriate protocols (Hemorrhagic, Cardiogenic, or Anaphylactic)

Seizure

  • Patient suspected to have had grand mal seizure based upon description of eyewitnesses, incontinence, or history of previous seizures
  • Patient may or may not have current seizure activity
  • Assess for spinal injuries and treat/immobilize appropriately
  • If actively seizing give Versed 10mg IM
  • Versed 2-4mg/min IV/IM/IO, until seizure resolves or a total of 10mg is given
  • Dextrose 50% 12.5 – 25g IV/IO or Glucagon 1 mg IM if Glucose < 70
  • Narcan 0.4 to 2mg IV if suspect narcotic OD
  • If in the 3rd trimester of pregnancy- or up to 6 wks postpartum -actively seizing with no seizure history consider magnesium sulfate 4g IVP slowly over 15 mins (transport to OB-capable facility)

Stroke

  • Age >16; may or may not have altered level of consciousness
  • Assess ABCs and suspicion for trauma
  • Assess patient with Cincinnati Stroke Scale
    • Facial droop (big smile)
    • Pronator drift (extend arms, palms up, eyes closed: one arm drift = positive; both = unclear)
    • Speech (“The sky is blue in Cincinnati”)
  • Assess and record the exact time the patient was last known to be normal
  • Glucose level should be >70mg/dL
  • Rapid transport and pre-notify destination Emergency Department
  • Minimize scene time to <10 mins; do not delay unnecessarily for procedures; attempt IVs and other procedures during transport
  • Refer to ED capability chart for transport destination selection
  • Consider transport to a JCC Primary or Comprehensive Stroke Center if:
    • Stroke center is <15 mins farther than a non-stroke center
    • Last known normal <12 hours
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