A person with an altered mental status may or may not be having an emergency. It may be difficult/impossible to know if they are having an emergency or not, and it is usually best to err on the side of caution and assume they are having an emergency until proven otherwise. I will show you in this article what I am looking for when I am evaluating a patient with an altered mental status (AMS). First, here are some possible reasons for an altered mental status.
AMS-Causes
There are many reasons for a person to have an altered mental status (AMS). Some are much more common than others. Since it is difficult to know what is causing a person’s reason for AMS, it is best not to assume what is causing it. For example, a person may appear to be very drunk when they have low blood sugar level. Here’s a list of some of the reasons of AMS:
- Diabetic-Low/High blood glucose level (blood sugar)
- Seizure
- CVA (stroke)
- Infection
- Fever
- Cardiac and Pulmonary problems
- Trauma
- Drugs/Alcohol
- Psychiatric (i.e. psychoses)
- Shock
- Hypoxia
- Other medical conditions
Next, I will show you what I am looking for when I am evaluation a person who I think may have an altered mental status.
Evaluation
First, I evaluate the person’s level of responsiveness on the AVPU scale (Alert, Verbal, Pain, Unresponsive). If a patient is awake, they are considered alert. If a person is unconscious, and will somewhat respond to verbal stimuli, but not wake up, they are considered responsive to Verbal Stimuli. If a person is unconscious, and wont respond to any verbal stimuli, but have some sort of response to pain (i.e. a sternal rub), then they are considered responsive to pain. If a person will not respond to any stimuli, they are considered Unresponsive. Any person that is not alert or will not become alert (a person that you just woke up out of a sleep may need a little time to become alert) can be considered to have an altered mental status, and is possibly having a medical emergency.
Second, if patient is Alert/Awake, I evaluate if the patient is oriented or disoriented. If they are disoriented, I consider them to have an altered mental status, and they may be having an emergency. If I believe that they may have an altered mental status, I will ask them 4 questions (person, place, time, event) 1. What their name is (person). 2. Where they are at (place). 3. What day/month it is (time) 4. And what the event is(example: if they were shopping at the grocery store, see if they are aware of that).
If they know all four, then they are considered alert and oriented x 4, and do likely do not have an altered mental status. If they know less than four, then they are alert and oriented x (the number of questions out of 4 they answer correctly), and have an altered mental status. Next, you need to try to find out what their baseline orientation level is.
If a person cannot answer all 4 questions correctly, that does not mean that they are having an emergency. Some patients have a baseline of less than 4. For example, many Dementia patients cannot answer all 4 questions correctly. When I evaluate a patient with Dementia, I will ask a family member or healthcare provider that knows them what the patient’s baseline orientation level is usually at.
If a patient can usually only answer 2 out of 4 questions, then their baseline is Alert and Oriented X 2, If they patient is lower than their baseline (i.e. they can usually answer 2 out of 4, but when I am evaluating them they can only answer 1 or 0 out of 4), then that may be having an emergency.
Know what your family members baseline orientation level is at. I have responded to multiple calls when the healthcare provider and family has not known what the patient’s baseline orientation level is. For example, I recently went to a call for a patient that went unconscious and woke back up, and was told by the patient’s daughter that the patient usually is very talkative and can answer questions appropriately.
The patient would not respond to any questions that I asked her, and the patient’s daughter and grand-son told me that the patient was usually talkative, and would respond to questions appropriately. I then talked to the patient’s husband, who was much more calm, and he told me that the patient rarely spoke, and had a history of dementia and usually would not respond to questions appropriately. This makes a big difference when trying to analyze a patient’s condition.
In these types of situations it is my goal to get to the hospital as quickly as possible if they are having an emergency, with as much pertinent information as possible. If you have a family member in an emergency situation, try to stay calm, and answer the questions that a first responder is asking you. Be able to tell the first responder what is different about the patient. Answer the question they are asking you, don’t give them your medical analysis unless you are a healthcare provider or have some pertinent information that makes you think that. In an emergent situation, first responders are trying get enroute to the hospital ASAP. It is good to have the patient’s allergies, medications, patient information (name, DOB), and medical history ready for the first responders; the patient may not be able to give this information themselves.
Conclusion
Just remember, a person with an Altered Mental Status may be having an emergency, and you should treat it as an emergency until it is proven otherwise. It is important to know what your families medical conditions are, and possible signs and symptoms of those conditions. If you believe someone has an altered mental status due to an injury, try to keep them from moving their neck. EMTs will hold the patient’s head in a neutral position (called C-Spine), put a C-collar on the patient, and backboard the patient if spinal injury is suspected. Consider the possibility of a stroke with any patient with AMS; these patients need medical attention immediately. Facial droop on one side, and weakness on one side of the body are possible signs of a stroke, but if they do not have either of these, it is possible they are still having a stroke Diabetic patients with an AMS are one of the most common calls that I am called to as a Paramedic. If you have a family member with diabetes, try to encourage them to manage it correctly.