altered mental status -1
DESCRIPTION
NEUROLOGITRANSCRIPT
DIAH MUSTIKA HW SpS-KIC
Tutor DM 071212
“As a medical emergency, coma presents a challenge to providers because optimal care requires timely
intervention; however, information is frequently limited during the initial evaluation.”
(Pearson-Shaver and Mehta, Pediatric Critical Care Medicine Textbook, 2007, p. 855)
Mental StatusConsciousness is a condition in which
an individual is fully responsive to stimuli and demonstrates awareness of the environmentAn alteration in mental status is the
hallmark sign of central nervous system (CNS) injury or illness
Mental Status EMT’s evaluate mental status in two ways:
Responsiveness- how does a patient respond to external stimuli
Orientation- checks the patient’s memory and thinking ability
Mental Status Responsiveness is assessed using the AVPU
mnemonic. Alert- patient’s eyes are open spontaneously without
stimuli. Verbal- patient’s eyes open when spoken to. Painful- patient responds to a painful stimuli in some
way (i.e. cries, withdraws, etc). Unresponsive- patient does not respond spontaneously
to any stimuli.
Mental Status Orientation is how the patient responds verbally. This
evaluates the patient’s ability to think and test their memory. The 4 common questions used to evaluate this are: Person- their name Place- where are they Time- year, month, and approximate date Events- what happened
What is consciousness? “state of wakefulness and awareness of self and
surroundings”(Abend et al., Rogers’ Handbook of Pediatric Intensive Care Medicine, 2009, p. 256)
Neural processes that allow for patient to: Perceive Comprehend Act on the internal and external environment
Two neurophysiologic functions: Arousal Awareness
Alert: Fully conscious
Lethargic: appear somnolent, but may be able to maintain arousal spontaneously or with repeated light stimulation
Obtunded: requires touch or voice to maintain arousal
Stuporous: unresponsiveness from which the individual can be aroused only by vigorous and repeated stimulus
Comatose: state of unarousable unresponsiveness in which individual lies with eyes closed, lacking awareness of selfand environment
Levels of Arousal:
Motor Motor ResponseResponse ExampleExample ScoreScoreCommandsCommands Follows simple commandsFollows simple commands 66Localizes Localizes PainPain
Pulls examiner's hand away Pulls examiner's hand away when pinchedwhen pinched 55
Withdraws Withdraws from Painfrom Pain
Pulls a part of body away when Pulls a part of body away when pinchedpinched 44
Abnormal Abnormal FlexionFlexion
Flexes body inappropriately to Flexes body inappropriately to painpain 33
Abnormal Abnormal ExtensionExtension
Body becomes rigid in an Body becomes rigid in an extended position when extended position when examiner pinches himexaminer pinches him 22
No ResponseNo Response Has no motor response to pinchHas no motor response to pinch 11
EyeEye--OpeningOpening ..SpontaneousSpontaneous Opens eyes on ownOpens eyes on own 44
To VoiceTo VoiceOpens eyes when asked to Opens eyes when asked to in a loud voicein a loud voice 33
To PainTo Pain Opens eyes when pinchedOpens eyes when pinched 22No ResponseNo Response Does not open eyesDoes not open eyes 11
Verbal Response Verbal Response (Talking)(Talking) ..
OrientatedOrientated
Carries on a conversation Carries on a conversation correctly and tells examiner correctly and tells examiner where he is, who he is, and where he is, who he is, and the month and yearthe month and year 55
Confused Confused ConversationConversation
Seems confused or Seems confused or disorienteddisoriented 44
Inappropriate WordsInappropriate Words
Talks so examiner can Talks so examiner can understand him but makes understand him but makes no senseno sense 33
SoundsSoundsMakes sounds that Makes sounds that examiner cannot understandexaminer cannot understand 22
No ResponseNo Response Makes no noiseMakes no noise 11
Coma Scales for ChildrenActivity Infants Children ScoreEye Opening Spontaneous Spontaneous 4
To speech To verbal stimuli 3
To pain To pain 2
None None 1
Verbal Coos, babbles Oriented 5
Irritable, cries Confused 4
Cries to pain Inappropriate words 3
Moans to pain Nonspecific words 2
None None 1
Motor Normal movements Follows commands 6
Withdraws to touch Localizes to pain 5
Withdraws to pain Withdraws to pain 4
Abnormal flexion Flexion to pain 3
Abnormal extension Extension to pain 2
None None 1
Pathophysiology: Consciousness depends on proper function of both
cerebral hemispheres and the reticular activating system (RAS)
Normal function requires Adequate substrate (primarily glucose) Cofactors Waste removal Adequate blood flow needed for delivery/removal
Increased neuronal excitability Restless/Confusion Tremor/Delirium
Decreased neuronal excitability Lethargic Obtunded
Stupor Coma
Roads to coma…
Stabilization:
Stabilization: Airway
Assess for patency Assess for ability to protect
Breathing Assess ventilation Assess breathing pattern
Circulation Assess measures of cardiac output
Stabilization: D = “Da brain” Decision point
Concern for No concern for increased ICP increased ICP
Stabilization: Increased ICP Must act immediately
No increased ICP Time to consider your workup
Evaluation: History Physical Exam Laboratory and Imaging Studies
Evaluation—History: Rapid initial history:
Recent history prior to mental status changes Past medical history (seizures) Family history (specifically seizures/neurologic disorders) Trauma ? Febrile ? / Other signs or symptoms of infection Diet Exposure to drugs/toxins
Follow-up with more complete history:
Evaluation—Physical Exam: Systemic
Vital Signs Signs of trauma Signs of infection Signs of bleeding Signs of other systemic illnesses
Evaluation—Physical Exam: Rapid Neurologic Exam:
Pupils Respiratory pattern Stimuli needed to elicit response Character of the response
Neurologic Exam—Pupils:
Respiratory patterns:
Cheyne-Stokes
Central Hyperventilation
Apneustic
Cluster breathing/Gasping
Agonal breathing
Hemispheric
Midbrain
Mid/Lower Pons
Low Pons/Upper Medulla
Medulla
Location Pattern
Posturing:
Decorticate
lesion above midbrain
Decerebrate
lesion below midbrain
Etiologies—Differential by Age: InfantInfant
Infection Inborn Error of
Metabolism Metabolic Abuse Trauma
ChildChild Ingestion Infection Intussusception Seizure Abuse Trauma
AdolescentAdolescent Ingestion Intentional Trauma Drug/Alcohol
overdose
(Pearson-Shaver & Mehta in Pediatric Critical Care Medicine Textbook, 2007, p. 857)
Summary: Coma is altered consciousness with loss of arousal and awareness Stabilization
ABC’s Decide about increased ICP
Evaluation Rapid history and physical Rapid Neuro Exam—Pupils, Resp Pattern, Stimuli and Response
Etiologies Toxic/Metabolic Infectious Structural/Intrinsic Paroxsymal
QUESTIONS?