1 / 130

Altered Mental Status Medication Review Lung Sounds MAD Device QuickTrach Kit

Altered Mental Status Medication Review Lung Sounds MAD Device QuickTrach Kit. February 2010 CE Advocate Condell EMS System Prepared by Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider will be able to:

kamea
Télécharger la présentation

Altered Mental Status Medication Review Lung Sounds MAD Device QuickTrach Kit

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Altered Mental StatusMedication ReviewLung SoundsMAD DeviceQuickTrach Kit February 2010 CE Advocate Condell EMS System Prepared by Sharon Hopkins, RN, BSN, EMT-P

  2. Objectives Upon successful completion of this module, the EMS provider will be able to: • Describe elements of normal mental status. • List the components of a neurological examination in the field. • Describe patient assessment of a neurological examination. • List the three components of the Glasgow coma scale. • Calculate the GCS. • Review Region X SOP Altered Mental Status

  3. Objectives cont’d • Review Cincinnati Stoke Scale • Introduce FAST concept • Explain the differences between the adult and the pediatric airway. • Describe the assessment of the airway and respiratory system. • Describe the various lung sounds auscultated during assessment. • Discuss the methods for measuring oxygen and carbon dioxide in the blood in the prehospital setting.

  4. Objectives cont’d • Identify indications, contraindications, dosing, side effects, and special considerations of Dextrose, Glucagon, Narcan, Albuterol, Epinephrine 1:1000, Benadryl, Lasix, and Morphine. • Describe the indications, contraindications, dosing, side effects, and special considerations for administering Narcan via the MAD tool. • Describe the MAD tool and the procedure for using the MAD tool.

  5. Objectives cont’d • Describe indications, contraindications, complications, and the process for performing a cricothyrotomy. • Given a manikin, demonstrate the cricothyrotomy procedure. • Demonstrate medication administration with the MAD device.

  6. Normal Mental Status • Consciousness • Person is fully responsive to stimuli and demonstrates awareness of the environment • Altered level of consciousness • Some form of dysfunction or interruption in the central nervous system

  7. Normal Mental Status • Patient is awake • Patient is alert – aware of surroundings • Patient is oriented to person, place, & time • Patient is cooperative • Patient carries on normal conversation • Patient able to follow/obey commands • Gait is even and steady

  8. Altered Level of Consciousness Hallmark sign of central nervous system injury or illness

  9. Did You Know? • When perfusion is declining, the first indicator is a changing level of consciousness • The last indicator is a falling blood pressure

  10. Assessing Mental Status - AVPU • A – awake • V – responds to verbal stimuli • P – responds to painful stimuli • U- unresponsive

  11. A – “Awake” • Patient is awake, alert and aware of surroundings • OR • Patient may be awake but confused • Report what the patient is oriented to • “Oriented to person but not place or time” • Key is watching for a change in level of consciousness from the baseline taken

  12. V – Verbal Response • This would need to be evaluated prior to touching the “unconscious” patient • Problem: If trauma is involved, need to manually control the C-spine before causing the patient any movement of the c-spine • If possible, call the patient’s name to check for response to verbal stimuli prior to making physical contact

  13. P – Painful Response • Does not necessarily mean you have to perform a painful task to check for response • Start with simple tactile contact – touch • Add deeper stimulation if needed • Sternal rub • Pinch of thumb web space • Trapezius muscle squeeze (near neck) • Do not cause so much trauma as to leave marks/bruises • Observe for some kind of response with muscles

  14. Patient Response • Patient response can include: • Opening of eyelids even briefly • Fluttering of eyelids • Wrinkling of brows • Most important is looking for changes in the patient’s response from one evaluation/assessment to the next

  15. U - Unresponsive • The patient has NO response at all • No moaning • No muscle twitch at all • No eyelid flutter • No wrinkling of the eyebrow • Muscles are flaccid with absolutely no response regardless of stimuli

  16. Neurological Exam In the Field • AVPU – what is level of consciousness? • Pupillary response • Movement of distal extremities • Wiggling fingers and toes • Sensation of distal extremities • Ability to feel contact with fingers and toes • GCS • <10 or deteriorating mental status patient is considered critical and categorized as Category I trauma

  17. Glasgow Coma Scale - GCS • The best score possible is given • More important is watching the trend than relying on any one score • Objective tool • All using the tool on the same patient should get the same score • Evaluate • Best eye opening • Best verbal response • Best motor response

  18. GCS – Eye Opening • 4 – Spontaneous; patient’s eyes are open • Does not have to be focusing • 3 – Eyes open or motion is made to verbal stimuli • Start with soft voice, may have to yell at patient to open eyes • 2 – Eyes open with tactile or painful stimuli • Start with gentle touch; may need to add more intense stimuli • 1 – No eye opening; no muscle motion at all

  19. GCS – Verbal Response • 5 – Oriented to person, place, and time • 4 – Pleasantly confused • 3 – Inappropriate words • You can understand the word(s) spoken but they are not within context • 2 – Incomprehensible words – sounds • No intelligible word understood; moans and groans; makes noises • 1 – Silent; no noise is made at all

  20. GCS – Motor Response • 6 – Obeys commands • 5 – Localizes pain / purposeful movement • Can push you away or grab at the noxious stimuli (IV, collar, bandaging, your hands) • 4 – Withdrawal • No longer localizing, just withdraws/pulls away to get away from annoying/painful stimuli (IV, collar, bandaging, your hands)

  21. Motor cont’d • 3 – Flexion to pain • Arms flex/bend slowly toward center of chest when any stimuli applied • 2 – Extension to pain • Arms slowly extend and curl inward and legs straighten when any stimuli applied • 1 – No movement at all

  22. GCS Results • Score range 3 – 15 • Minor head injury – 13 – 15 • Moderate head injury – 9 – 12 • Severe head injury (coma) - <8 • Significant mortality risk • Consider intubation or other means to secure the airway

  23. GCS Practice • Read the following case scenarios • Determine the best eye opening, verbal response, motor response • When the response is asymmetrical, award the highest points possible • Don’t guess or assume what you think they really can do • Award points for what is performed • Be objective

  24. GCS Case #1 • Patient lying in the bed (no trauma), eyes are closed • You need to yell the patient’s name and then the eyelids flicker • They are mumbling • They are grabbing at your hands and pushing you away. They have pulled out the IV.

  25. GCS Case #1 Score • Eye opening – 3 • Responded to loud voice • Verbal response – 2 • Mumbling is incomprehensible words/sounds • Motor response – 5 • Patient can recognize (localize) what feels obnoxious and what he wants to stop so they are grabbing at you and pulling at equipment • Total GCS - 10

  26. GCS Case #2 • Patient is lying in the street watching you approach • They mumble as you talk to them • They are grabbing at your hands and pushing you away

  27. GCS Case #2 Score • Eye opening – 4 • Spontaneous; doesn’t necessarily indicate focusing • Verbal response – 2 • Mumbling, moaning, groaning • Motor response – 5 • Purposeful movement by grabbing at what the patient perceives as noxious stimuli • Total GCS - 11

  28. GCS Case #3 • Patient watches your approach and acknowledges your presence • Patient answers most questions and thinks you are their nephews come to visit • Patient able to move left arm to command but not able to move right arm (new onset – possible stroke)

  29. GCS Case #3 Score • Eye opening – 4 • Spontaneous • Verbal response – 4 • Pleasantly confused • Motor response – 6 • Highest possible score based on the arm that can and does move • Total GCS - 14

  30. GCS Case #4 • Child’s eyelids flicker when deformed extremity is manipulated • Child moans out when painful areas are manipulated • Child pulls away when touched and tries to turn away from EMS

  31. GCS Case #4 Score • Eye opening – 2 • Response to painful stimuli • Verbal response – 2 • Moans and groans are incomprehensible words / sounds • Motor response – 4 • Withdrawing from what is sensed as painful stimuli • Flexion would be slow flexing of arms toward center of chest – this patient’s response is not flexion • Total GCS – 8 (Protect airway; consider intubation)

  32. GCS Case #5 • Patient’s eyes remain closed; no eyelid movement at all • There are no sounds heard from the patient • The patient straightens their arms, twists their wrists, arches their back, and straightens their legs when stimulated

  33. GCS Case #5 Score • Eye opening – 1 (no response) • Verbal response – 1 (no response) • Motor response – 2 • Abnormal extension • The worse level of response prior to no response at all • Total GCS – 4 • Patient is critical; Category I • Patient usually needs some airway intervention

  34. Common Causes of Altered Mental Status • A – acidosis, alcohol • E – Epilepsy • I – Infection (brain, sepsis) • O – Overdose • U – Uremia (kidney failure) • T – Trauma, tumor, toxins • I – Insulin – hypo or hyperglycemia • P – Psychosis, poison • S – Stroke, seizure

  35. Initial Patient Assessment • Airway • Open or obstructed • Maneuvers needed to open • Head tilt / chin lift • With trauma, modified jaw thrust • Breathing • Quality • Quantity (eyeball assessment at this time)

  36. Initial Assessment cont’d • Circulation • Quality • Quantity (don’t count; get estimate of range) • Disability – need to obtain baselines • AVPU • GCS • Expose to examine • Can’t evaluate or fix what you can’t see

  37. Assessment Tools • AVPU • Alert (interpreted as an awake patient) • Responds to verbal stimuli • Responds to painful stimuli • Unresponsive

  38. Assessment Tools • GCS • Best eye opening response • Best verbal response • Best motor response • Scores range from the lowest of 3 to highest of 15 • Obtain and document GCS on all patient calls

  39. Cincinnati Stroke Scale • Obtain for suspicion of TIA or stroke • Evaluate for facial droop • Check the patient’s symmetry during a broad, big smile (teeth showing) • Evaluate for arm drift • Check for weakness in holding arms outstretched, palms up, for 10 seconds • Evaluate for clear speech • Have patient repeat words listening for clear speech patterns

  40. Airway Protection and the Stroke Patient • Crucial - high mortality rate for aspiration • Is airway patent and can patient protect their own airway? • Check if patient is able to handle & swallow own saliva • Detailed/involved swallow study done in-hospital • Patient speaks in clear unobstructed voice • Interventions to consider • Have suction on and ready • Ability to quickly turn patient onto their side

  41. FAST - Public Educational Tool • Tool developed by organizations for public recognition of stroke and to encourage FAST action

  42. Region X SOP – Altered Mental Status • Consider etiology • If cause of problem can be identified, then interventions can be focused • Diabetes – check blood sugar • Drug overdose – what are the environmental clues • Poisoning – environmental evidence around • Alcohol related – environmental evidence; use your nose

  43. SOP – Altered Mental Status • Maintain airway • Patency extremely important • Evaluate rate and quality • If respirations inadequate, ventilate • 1 breath every 5-6 seconds all patients – infancy to elderly • Intubate as necessary • Use C-spine precautions as indicated • If any doubt, err on side of extra precautions • Provide Routine Medical Care • IV – O2 - monitor

  44. SOP – Altered Mental Status • Obtain blood glucose level • If <60 – treat • Adult - Dextrose 50% 50 ml IVP • Child 1 – 15 – Dextrose 25% 2 ml/kg • Infant <1 – Dextrose 12.5% 4 ml/kg • Dilute 1:1 ratio D 25% with normal saline • Equal amounts of product make 1:1 dilution (Dextrose and normal saline)

  45. Treating Altered Mental Status • In absence of IV access • Adult – Glucagon 1 unit (1 ml) IM • Pediatrics < 15 – Glucagon 0.1 mg/kg IM • Max dose of 1 mg • Practice: 44 pound child – no IV access • How many kg? • 44  2.2 = 20 kg • 20 x 0.1 = 2 mg • How much Glucagon do you give? • Max of 1 mg

  46. Altered Mental Status cont’d • If patient not alert, respirations decreased, or narcotic overdose suspected: • Narcan 2mg IN/IVP/IO • Repeat every 5 minutes as needed until desired effect • Quality of respirations have improved • Don’t need patient to be 15 on GCS • Don’t need patient awake necessarily • Maximum total dose 10 mg • Transport

  47. Altered Mental Status cont’d • Note: • Attempt to identify substances involved • If not a safety hazard, obtain and transport substance container with the patient • Consider use of restraints prior to administration of Narcan • Patient may become violent when level of consciousness improves

  48. Adult Airway Pediatric airway • Note funnel shaping of pediatric airway

  49. Notice Difference in Tongue Size • Adult airway • Pediatric airway tongue

  50. Pediatric airway Differences • Jaw smaller • Teeth softer and more fragile • Tongue relatively larger • Potential to produce more obstruction • Epilgottis floppier and rounder • Recommend straight Miller blade over curved Macintosh for intubation • Larynx more superior & anterior • Higher and more forward • Funnel shaped due to underdeveloped cricoid cartilage • Under age 10 cricoid cartilage narrowest part of airway • Ribs and cartilage softer and more pliable • Children rely on diaphragm muscle for breathing

More Related