Welcome back. I'm sure you are starting to notice as you go through some of the lessons from the modules in this course, many of the symptoms of diseases we have talked about overlap. If you've gone through the respiratory and cardiac modules, you might have noted that shortness of breath or trouble breathing can be a symptom of a heart problem or a lung problem. Fast breathing could be from the heart, lungs, or from diabetic ketoacidosis like you learned about in the last video. Thankfully, there are usually other clues to help us distinguish what the primary problem might be, and help narrow that differential diagnosis we keep talking about. In many ways, being an EMT is like being a detective. You get to use the stories people tell, the evidence you find on scene, and your physical assessment of the problem to help guide you to hypotheses on what is actually going on. We have included the very broad topic of altered mental status in the neurology section because ultimately if someone is altered, it is because something is not functioning right in the brain. As you will see, there are countless reasons why a person could be altered and a thorough and standardize approach to the altered patient is really important in order to not miss a reversible or serious cause. Your detective work is never more important than when you come upon a patient with altered mental status. First, let's define mental status. Our mental status is a combination of two parts; Our arousal, meaning our wakefulness or responsiveness and our awareness, referring to our perception of our environment. In the brain, our arousal and awareness is controlled by the reticular activating system in the cerebrum. The reticular activating system isn't a specific structure in the brain, but instead is a network of nerve cells that are a highway of information from the environment to the cerebrum and back. Any injury or disease process that impacts the reticular activating system or cerebral hemispheres can impact a patient's mental status. You learned in the first course that the primary assessment of the mental status includes a brief evaluation using AVPU which stands for alert, response to verbal stimuli, response to painful stimuli, or is unresponsive. In addition for secondary assessment, you learned about assessing for orientation and how to further categorize decreased levels of consciousness in a trauma patient using the Glasgow Coma Scale or GCS. It is easy to identify an altered patient if they have an altered level of consciousness. It is also easy to identify patients as altered if they don't know the answer to simple orientation questions related to who they are, where they are, and the date. It is important to realize however that your assessment of a patient doesn't stop there, a patient can be both alert and oriented and still be altered. Let's look at an example. You come across a patient that has been drinking and has reached a level of intoxication, they cannot walk without falling. The patient likely is awake and talking, meaning they are alert. They might know who they are and where they are and the date suggesting that they're oriented and aware of their surroundings. However, they might be really slow to answer questions and might tell you that they are fine and not intoxicated seemingly unaware that they aren't able to safely walk. Being slow to answer questions actually suggests a decreased level of arousal or alertness and their insistence that they are fine despite being unable to walk suggest an impaired awareness of their own environment. As mentioned before, there are lots of reasons patients can be altered. As an EMT, it is really important that you're able to identify that a patient is altered quickly and also to develop some differential diagnoses or hypotheses about what the cause might be. Thinking through possible causes is important because some causes need immediate intervention or expedited transport to the hospital such as a patient with a stroke or intracranial hemorrhage. In general, all patients that are altered should be evaluated in the hospital. However, not all of them need emergency transport. For example, the previously described intoxicated patient. There's a mnemonic that is used to remember the different causes of altered mental status. We will walk through it as a way to review these. If mnemonics work for you, commit this one to memory, if not think of other ways you might keep these causes organized in your head. I remember A, E, I, O, U, TIPPSS. I'm not a big mnemonic person, but this one sticks with me for whatever reason. It's a pretty thorough list of what can cause people to be altered. First, the vowels. A is for alcohol intoxication. E is for epilepsy, also think about seizure. I is for insulin. Think about severe hypo or hyperglycemia. In fact, think about a glucose problem in any patient with altered mental status. O is for oxygen since significant hypoxia can cause altered mental status, and U is for uremia. Urea is a toxin that builds up in the blood of patients whose kidneys aren't working. As you're assessing your patients and getting history from them or family, it might be important to ask specifically about any of these things or look for evidence that these things might be a problem. For example, the patient has a medical alert bracelet that says they have diabetes. Thinking about insulin and glucose problem is important. Next is TIPPSS, T-I-P-P-S-S. T is for trauma and likely related to head injury. I stands for infection, even a mild infection can cause confusion in the elderly and an infection around the brain called meningitis which we've talked about before can also cause altered mental status. P is for psychiatric problem. P is also for poisoning such as intentional ingestion of a mind-altering substance, intentional overdoses, or exposures. S stands for shock, which we will talk more about shock in future modules. In short, shock is a state where your blood pressure falls very low and the brain doesn't get enough blood flow which as you might suspect can cause altered mental status. The final S is for stroke. As we discussed in the stroke video, ischemic strokes can cause problems with speech and understanding that lead to altered mentation. In contrast, hemorrhagic strokes frequently cause changes to the entire level of consciousness. Another way to think about some of these causes of Altered mentation or level of consciousness is to consider the causes that are reversible or typically resolve relatively quickly. This category includes a lot of the things you have learned about in this course. In the video about strokes, you learned about TIA or Transient Ischemic Attack which resolves with time. In the seizure video, you learned seizures usually stop or can be stopped with advanced life support medications and are followed by the postictal phase that is marked by confusion that slowly resolves. Singapin, which you learned about in week four, is by definition temporary and typically resolves once the patient is laying down. Altered mental status from hypoglycemia, which we covered earlier this week, can resolve if you identify it and treat it with administration glucose. Finally, opiate overdose, also if you recognize it can resolve with Naloxone. You will learn more about opiate overdose and Naloxone in future courses. There was a lot covered in this video and we will continue to review aspects of mental status throughout this specialization. It's really important as an EMT not only to feel comfortable assessing a patient to determine their level of consciousness and mental status, but also to be able to do the detective work by asking the right questions and looking for the right information to help you decide what might be causing these changes.
