Shall we talk about Levels of Consciousness? We shall!
One of your main clues about how sick or injured someone might be is their mental status. Altered mental status tells you that Something Big Is Going Wrong. We little emergency workers use mnemonics to help us keep all this stuff straight (because at two in the morning, with freezing rain dripping down your collar, you just might miss a step otherwise).
First stop on the Mnemonic Express is AVPU. That stands for Alert/Verbal/Painful/Unresponsive. All that “alert” means is “looks at you.” Normally, when you walk into the room, someone will look at you; the eyes will track. That’s the A in Alert. V for Verbal means the guy’s eyes open when you talk to him, but drift closed else. P for Painful means that if we do something noxious to the patient (rubbing a kuckle — hard — on the sternum; pinching the big strap muscle under the armpit) that his eyes open, but otherwise not. U for Unresponsive means Elvis has Left the Building. Nothing we do (and we can get really obnoxious if we have to) will get a response from this person.
After level of alertness, we come to Orientation. Orientation is to Person, Place, Time, and Events. Those are in the order that you can remember them. Does the person know his own name? Who you are is the last thing that goes. Does he know where he is? Does he know the time (this can be in general terms), the day? The month? The year? Last is Events, as in “What happened?” How did this guy come to be lying in a ditch at two in the morning with freezing rain falling on him?
There “I was coming back from Pittsburg down 145, doing around 50 mph when I felt the back end start to slide. I jammed on the brakes, and it spun. The back of my car hit a tree, and after that I opened the door and got out. Then I started felling really tired, so I lay down here” is a lot better answer than “I don’t know.”
You abreviate these in this manner: Alert and Oriented is A Ox4. A patient who responds to Painful stimuli and only knows his name is P Ox1. The patient I talked about in the hyperthermia post was A Ox2: Looked at us as we walked up, knew who she was and where she was, didn’t know what the day (or the season) was, or what she’d been doing that day that led her to be sitting in her garden surrounded by EMTs. Unresponsive is just U. U folks aren’t oriented at all — they just lie there and won’t talk to you. On a scale from Good to Bad, this is over on the Bad side.
(The joke version of AVPU is Alert, Vomiting, Puking, Upchucking. That’s a lot more … well, welcome to EMS.)
Okay, so now you know the Levels of Consciousness (abbreviated LOC). (This is the first part of the Glasgow Coma Scale, of which I may write more later. Level of Consciousness is also the last step of Rapid Triage: Ask the patient his/her name and what happened. If the patient does not reply or answers inappropriately, Red Tag.
Now we get to the fun stuff: figuring out why a person might have an altered LOC. If you know why, you might have a shot at fixing what’s wrong. There is (as you might have suspected) a mnemonic for that. It’s AEIOU-TIPS.
Taking it from the top: A stands for Alcohol. This is pretty obvious: Alcohol will alter someone’s mental status; that’s what it’s for. (If you go to an automobile wreck after midnight and you don’t find a drunk, keep looking: You haven’t located all of your patients yet.)
E is Epilepsy (or any seizure-disorder). A person who’s just had a grand mal seizure will have an altered level of consciousness. Also under E: Environment. Too hot or too cold can make people goofy.
I is Insulin. A person who’s having a diabetic problem may have an altered mental status. Either too much or too little sugar in the bloodstream will slow you down.
O is Overdose. This can be fun drugs; your heroin or ecstasy. Or it can be your prescribed drugs (Granny takes her meds, forgets that she took ‘em, and takes ‘em again), or your accidental poisonings (Junior gets into Mommy’s purse and eats an entire bottle of Flintstones Vitamins). One of the more interesting ones I remember was a guy whose significant other was planning to kill herself with an overdose of pills. Thinking fast, he grabbed the pills right out of her hand and — didn’t throw them down the sink or out the door. He swallowed them himself. (Alcohol was also involved.) Or there was the guy who had a headache, so he took a couple of his dad’s Lasix tablets. This didn’t help his headache (which you wouldn’t expect anyway — Lasix is a diuretic) so he took a couple more. Then more after that. Then the whole bottle. He was pretty dehydrated when we got to him. And he had an altered mental status.
When you think about Overdose, think also about Underdose. Granny forgets to take her pills at all. Or, when the money runs out, folks can’t afford to refill their prescriptions. That happens more often than I like to think.
Think about drug interactions while you’re thinking about Overdose/Underdose. A guy who took nitroglycerine after taking Viagra will have a way altered mental status.
U is for Uremia. This is, essentially, Pee on the Brain. The kidneys aren’t functioning, toxins build up, bad things happen to Mental Status. (The hyperthermic lady I mentioned above had uremia — when the nice nurses at the hospital put a catheter into her bladder the urine return looked like thin molasses.)
On to TIPS:
T is for Trauma. Someone hits you upside the head, your mental status can really change, really fast. Or, someone hits you upside the head and you get a slow bleed, your mental status can change three days from now. We keep asking “Did you fall? Did you hit your head? Did you get knocked out, even for a second?” For that matter, someone who’s bleeding out from a severed artery — that person’s mental status is going to change and not in a good way. With internal injuries someone can bleed out entirely into his abdominal and pelvic cavities without a drop of blood showing on the outside. Hypothermia fits here. Granny breaks her hip and lies on the floor all night — the reason she may not remember might be because she’s cold.
I is for Infection. A high fever will change someone’s mental status, as will the assorted toxins that are floating around in the bloodstream. Watch for UTI (Urinary Tract Infections) in little old ladies. If you can’t figure out what else is going on, think about infections.
P is Psychiatric. Not a lot we can do about this in the field. But mental illness can manifest as altered level of consciousness.
Last comes S for Stroke. A blood clot in one of the arteries in the brain can cause a person to be less than A Ox4. As can a bleed in the brain. Neither one is conducive to long life and good health. S can also stand for Space-Occupying Lesion: a tumor. Something organic is going on with the brain. The signs and symptoms will depend on how big it is and exactly where it’s located.
Bottom line: any time someone around you is showing signs or symptoms of altered level of consciousness and it isn’t just bedtime, consider calling the nice EMTs. Altered mental status can be the very first sign that something serious is wrong.
Copyright © 2006 by James D. Macdonald
I am not a physician. I can neither diagnose nor prescribe. This post is presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.
AVPU by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.
(Attribution URL: http://nielsenhayden.com/makinglight/archives/007918.html)