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Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care

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Evidentiary Tables

Summary of the available and salient clinical research used to develop these evidence based recommendations.

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EVIDENTIARY TABLE

INTRODUCTION

In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California.

METHODS

We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management.

RESULTS

Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol.

CONCLUSION

Protocols for patients with AMS vary widely across the State of California. The evidencebased recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols. [West J Emerg Med. 20XX;XX(X)XX-XX.]

Level Recommendations

The State of California divides the EMS system into 33 local EMS agencies (LEMSAs). One set of governmental medical control policies regulates EMS response in each county-wide or region-wide system. Medical directors of those agencies, along with other interested EMS medical directors within the state, make up the EMS Medical Directors Association of California (EMDAC). EMDAC supports and guides the various agencies and makes recommendations to the California EMS Authority about policy, legislation and scope of practice. In an effort to improve the quality of EMS care in our state, EMDAC has endeavored to create evidence-based recommendations for EMS protocols. 23 These recommendations are intended to assist medical directors of the LEMSAs to develop high-quality, evidence-based protocols.

A subcommittee of EMDAC developed this manuscript and chose by consensus the elements that should be included in any protocol for a patient found to have AMS by EMS personnel. The subcommittee then created a narrative review of the existing evidence for prehospital treatment of a patient with AMS. Clinical questions regarding those interventions were developed in the PICO (population, intervention, control and outcome) format. In answering these questions, our population consisted of those patients in the prehospital setting with undifferentiated AMS, not those with clear causes for their AMS.

We relied heavily on recommendations made by various organizations that have performed systematic reviews and meta-analyses regarding treatment interventions. We supplemented the recommendations from those organizations with additional literature searches through PubMed from 1966 to 2017 for each question. The initial literature review of PubMed searched for the term “Prehospital and Altered Mental Status.” That yielded 42 articles, only five of which were published in English and pertinent to the topics identified by the EMDAC subcommittee (Figure). This search was supplemented with additional PubMed searches for each clinical question. See Appendix table for additional search terms.

We assigned levels of evidence (LOE) and graded our recommendations based on the American College of Emergency Physicians (ACEP) process of creating clinical policies,4 with slight modification, such as the EMDAC committee members performed literature search and assigned classes of evidence to diagnostic, therapeutic and prognostic questions, instead of a professional librarian or methodologist. This committee of EMDAC reviewed studies and assigned LOE based on the study design, including features such as data collection methods, randomization, blinding, outcome measures and generalizability.

LOE I consisted of randomized controlled trials, prospective cohort studies, meta-analysis of randomized trials or prospective studies or clinical guidelines/comprehensive review. LOE II consisted of nonrandomized trials and retrospective studies. LOE III consisted of case series, case reports, and expert consensus.


After assigning LOE to the studies, we translated those to clinical grades of recommendations using the following standards:

Level A recommendations

Prehospital recommendations with a strong degree of certainty based on one or more LOE I studies or multiple LOE II studies.

Level B recommendations

Prehospital recommendations with a moderate degree of certainty based on one or more LOE II studies or multiple LOE III studies.

Level C recommendations

Prehospital recommendations based on only poor quality or minimal LOE III studies or based on consensus.

No recommendation

No recommendation was given in those cases where only preliminary data or no published evidence exists and we had no expert consensus.We also withheld recommendation when studies, no matter their LOE, showed conflicting data.


After answering the clinical question and providing recommendations for diagnostic and treatment interventions, we reviewed each current AMS protocol from the 33 agencies for consistency with the recommendations.


The clinical protocols were reviewed during the months of November 2016 and July 2017.

PATIENT AND SCENE ASSESSMENT

Clinical Question

What patient and scene assessment should be performed by EMS for patients with AMS?

Current Prehospital Treatment Recommendation

Level A Recommendations

In a patient with AMS, obtain history of present illness, past medical history and cause for past episodes of AMS from patient or caregiver. A thorough physical examination is needed on all patients with AMS.

Level B Recommendations

EMS should examine the scene for any evidence as to the cause of AMS (e.g., toxins) and communicate this finding to receiving personnel

Level C Recommendations

To evaluate for the etiology of AMS, consider using the acronym AEIOU TIPS to provide a differential.

No Recommendation

N/A

Summary of Current Evidence

Patients with an abnormal GCS are more likely to have a history of the condition known to be associated with their confused state, especially alcohol use disorder/hepatic encephalopathy, diabetes, illicit substance use, stroke/transient ischemic attack (TIA) and seizure.1 This is particularly true if they have had a history of transient AMS in the past.5 Obtaining the patient’s history of present illness and past medical history often leads to identifying the cause of AMS.6,7

EMS providers have a unique opportunity to obtain pertinent history from family and bystanders who have knowledge of the patient’s underlying medical conditions and access to materials found in the home. Often, if the history does not clarify the cause for AMS, the physical examination and environment will provide the needed clues.2,8 If evidence as to the etiology of their AMS is found during scene assessment, these findings should be relayed to receiving ED personnel.

Given that neurologic causes (seizures, TIA/stroke), toxicologic causes, hypoglycemia and infection are the most common reasons for AMS, it would be prudent to check for signs of these pathologies. A full examination focusing on neurological and traumatic findings is important to evaluate for the subtle stroke, seizure, or traumatic brain injury.1,5,6,8-10 If the history and physical examination do not immediately elucidate the cause of AMS, the acronym AEIOU TIPS (Alcohol, Epilepsy/Electrolytes, Insulin/Inborn Errors of Metabolism, Overdose/Oxygen, Uremia, Trauma, Infection, Psychiatric/Poisoning, Stroke/Subarachnoid Hemorrhage (SAH)/Shock) can be used to consider a broader differential.11

POINT-OF-CARE TESTS

Clinical Question

What point-of-care tests should EMS perform on patients with AMS?

Summary of Current Evidence

Apart from a study in Finland,8 most research on causes of AMS focused on patients seen in the ED, rather than in the prehospital setting. However, from this information, we can deduce the possible causes of AMS in the prehospital setting, as many of these patients are brought to the ED by EMS, and can infer probable point-of-care tests that would be helpful. In this review, we define point-of-care tests as bedside testing, or diagnostic testing at the time of patient assessment.

In several studies, patients with an abnormal GCS were found to be more likely to have a history of conditions known to be associated with their current altered state, the most common of those being neurologic, toxicologic, diabetic-related, and infection.5,6,8,9 Hypoglycemia is one of the most common causes of AMS in adult patients in the prehospital setting; thus, rapid glucose testing is recommended for patients with AMS.8,10 Upon literature review, other point-of-care tests that have been evaluated for the use of evaluating AMS were 12-lead electrocardiogram (ECG), pulse oxygen (O2)-oximetry, pulse carbon monoxide (CO) oximetry, and end-tidal carbon dioxide detection (ETCO2).

Several studies demonstrated cardiac etiologies of AMS in the general population were infrequent, suggesting that a routine 12-lead ECG would not be helpful.1,5-9,12 but the exact etiology of many AMS patients is unknown. Patients often manifest vague symptoms, thus, AMS\ndiagnosis and treatment are highly challenging for emergency physicians. The aim of this study is to\nprovide a framework for the assessment of AMS patients. This assessment should allow providers to\nbetter understand the etiology of mental status changes and therefore improve diagnostic skills and\nmanagement.\nMETHODS: This is a prospective cohort observational study. We recruited all adult patients with undifferentiated AMS at a single center tertiary care academic emergency department over 24\ nmonths (June 2009 to June 2011 However, if a dysrhythmia was noted on the cardiac monitor, obtaining a 12-lead ECG was useful to clarify the rhythm.9 In populations aged 65 years and older, there is a higher prevalence of cardiac causes of AMS, such as myocardial infarction (MI), complete heart block. 5,6 This suggests that for the elderly population with AMS there may be a benefit in obtaining a 12-lead ECG. Lastly, if an overdose is suspected with medications known to cause cardiac toxicity, such as antipsychotics, sodium channel blockers (tricyclic antidepressants ([TCAs]), diphenhydramine, beta-blockers (BB) and calcium channel blockers (CCB), consider obtaining a 12-lead ECG.13–15dose, ECG, and outcomes (arrhythmias and death

Another cause of AMS is hypoxia, especially in the elderly population, which can be evaluated with pulse oximetry and may be considered the fifth vital sign.16-17 A similar point-of-care test is the pulse CO-oximeter. When looking at studies that compared Rad 57 (a type of pulse CO-oximeter) to the gold standard blood test, the evidence was conflicting, with wide ranges of precision and accuracy found.18-20 Since CO poisoning is not a common cause of AMS and since pulse CO-oximeter’s clinical accuracy remains unclear, we do not currently recommend evaluating for CO poisoning in the undifferentiated AMS patient.

Hypercapnia is a well-known cause of AMS. It is commonly observed with exacerbation of chronic obstructive pulmonary disease (COPD) and status asthmaticus, but may also be associated with pulmonary edema, neuromuscular respiratory failure, central hypoventilation, aspiration, and obesity hypoventilation syndrome.21,22 To evaluate hypercapnea in the field, ETCO2 is available. However, some researchers demonstrated a strong correlation between the gold standard PaCO2 and ETCO223 while others have only demonstrated a correlation in the healthy state.24,25 It is our opinion that the causes of high and low ETCO2 measurements appear to be too numerous and complex to apply in the field for undifferentiated AMS at this time. However, extremes of measurement such as a high measurement >80mmHg would usually indicate high PaCO2.22 This would be a change in how ETCO2 is used in the prehospital setting since currently it is measured in those receiving positive pressure ventilation.24,26,27,

Of note, breathalyzers, urine drug screens and lactate might be useful in some systems, but no prehospital studies on the use of these tests to evaluate patients for AMS were found during this literature review and they are not currently allowable for field use by paramedics in California.

Current Prehospital Treatment Recommendation

Level A Recommendations

Place all patients with AMS on a cardiac monitor. Obtain pulse oximetry on all patients with AMS. Check blood glucose on every patient with AMS. Consider evaluating for a cardiac cause of AMS in the patient 65 years or older with a history of present illness or past medical history that suggests cardiac etiology.

Level B Recommendations

Consider obtaining a 12-lead ECG on patients with AMS if they have a history of possible ingestion/overdose/intoxication, have an abnormal rhythm strip.

Level C Recommendations

None given.

No Recommendation

N/A

GENERAL TREATMENT FOR AMS

Clinical Question

What treatment is recommended in the prehospital setting when no cause of AMS has been identified?

Summary of Current Evidence

Most of the literature on AMS in the field and ED focuses on identifying the etiology. Once the cause is identified, the provider will implement the treatment pathways based on that assessment. Therefore, upon literature review, no evidence was found for a universal treatment that is appropriate for every patient with AMS. The empiric treatment of AMS with a “coma cocktail” has largely been abandoned. This cocktail included one or more of the following medications: dextrose, naloxone, thiamine, and flumazenil. These medications are not without risk, so a more focused approach to treatment is required.28,29

Current Prehospital Treatment Recommendation

Level A Recommendations

Not given.

Level B Recommendations

Not given.

Level C Recommendations

The empiric treatment of undifferentiated AMS with a “coma cocktail” should not be used.

SUPPLEMENTAL OXYGEN

Clinical Question

Should patients with AMS in the prehospital setting be treated with supplemental oxygen?

Summary of Current Evidence

Hypoxia can be detrimental to patients; even in healthy volunteers with <90% readings on pulse oximetry, the middle cerebral artery dilates.30but data from human studies are limited and have often relied on invasive methodology. The ability to detect a threshold for hypoxic vasodilatation in humans may be clinically useful, particularly in patients with impaired intracranial compliance.

Because physiology may differ among subjects, it would be advantageous to measure such thresholds using noninvasive bedside techniques that could be readily applied to individual patients. We have attempted to identify thresholds of hypoxic vasodilatation in volunteers using noninvasive methods of measurement. Thirteen healthy volunteers were studied using transcranial Doppler sonography. Time-averaged middle cerebral artery maximal flow velocity (MCA FVx Hypoxia should be treated in a stepwise manner, with a goal of maintaining oxygen saturation ≥94%.31,32and analysis of the use of O2.\nDesign This was a single-centre cohort study with 4 weeks\nof observation before and after the introduction of an O2 treatment algorithm. The main outcome measures were the proportion of patients treated with O2, distribution of indications for O2 therapy and occurrence of hypoxia and\nhypercapnia as undesired effects.\nResults The 4-week period before the intervention included 2190 patients and the 4-week period after the intervention included 2122 patients. The indications for O2 therapy were very similar in the two periods. After the intervention, the proportion of patients with supplemental\nO2 therapy was reduced from 11% (246 Care should be taken to prevent hyperoxia because this can also be detrimental. In healthy volunteers, providing 100% oxygen for 10-15 minutes was associated with a 20-30% decrease in cerebral blood flow.33

Specific complaints and diagnoses that have historically led to the administration of empiric oxygen can result in worse outcomes when hyperoxia occurs. These include MI, dyspnea in COPD, and stroke. Hyperoxia may increase MI size, impair cardiac performance, and worsen heart failure.34-36 In COPD patients, hyperoxia can lead to hypercapnia, thus providing supplemental oxygen to keep saturations between 88% and 92% is recommended.37 Hyperoxia decreases cerebral blood flow from vasoconstriction and can increase ischemia in stroke and can decrease survival.38, In the setting of trauma, especially with traumatic brain injury, patients with significant hyperoxia (PaO2 >487) did worse.39,40

The surviving sepsis campaign guidelines also recommend that peripheral oxygen saturation be maintained between 88% and 95% in septic patients with adult respiratory distress syndrome, and advocate the avoidance of hyperoxia.28 In general, hyperoxia seems to impair oxygen delivery to patients during sepsis.42,

Current Prehospital Treatment Recommendation

Level A Recommendations

Provide supplemental oxygen to maintain O2 saturation ≥94%, unless COPD is present, then maintain a saturation of 88%-92%. Prevent hyperoxia in patients with MI, heart failure, stroke or COPD exacerbation.

Level B Recommendations

Not given.

Level C Recommendations

Not given.

USE OF A STANDARDIZED SYSTEM OR SCORE TO MEASURE LEVEL OF CONSCIOUSNESS

Clinical Question

Is a standardized scoring system characterizing level of consciousness useful in the treatment of AMS in the prehospital setting?

Summary of Current Evidence

The GCS is the most widely used prehospital coma assessment tool. The GCS was originally developed to assess the head-injured patient, but has been adopted more broadly over the years to describe level of consciousness in patients with AMS of many etiologies, with subsequent studies suggesting that the GCS is valid in patients who are altered from toxicologic causes.43,44 Numerous studies have shown significant variability in inter-rater reliability for these scores, even among experienced physicians45-47 as well as more broadly across healthcare teams and inexperienced users.48–50 One study showed only moderate agreement between GCS determined in the prehospital setting and in the ED.51 The GCS is heavily weighted towards the motor score; therefore, low motor scores due to inability to cooperate may be misleading when predicting patient outcome particularly in patients with AMS.52

More recently, the Full Outline of UnResponsiveness (FOUR) score has been developed as an alternative to the GCS,53 with several studies showing this to be valid in both adults54-56 and children,52 while providing some additional prognostic information about brain stem injury. Most studies do not show a significant difference in inter-rater reliability between GCS and FOUR scoring systems.54,56,57

Another score that is used frequently in the prehospital setting is AVPU (awake, verbal stimuli, painful stimuli, and unresponsive/unconscious). This was introduced as a tool for rapid assessment of trauma patients as part of the Advanced Trauma Life Support course,58 with good correlation to GCS.59

Current Prehospital Treatment Recommendation

Level A Recommendations

Not given.

Level B Recommendations

Choose a standardized scoring system, such as GCS or FOUR scale to assess level of consciousness in the prehospital setting for patients with AMS. The AVPU score can be used for rapid assessment of alertness, since it correlates well with GCS.

Level C Recommendations

Not given.

Background photo courtesy of CodeSTEMI.tv
EVALUATE FOR SEIZURE

Clinical Question

Are patients with AMS in the prehospital setting having a seizure or are they in postictal phase?

Current Prehospital Treatment Recommendation

Level A Recommendations

Not given.

Level B Recommendations

Consider TBI in patients with undifferentiated AMS, especially in the setting of intoxication, anticoagulation or antiplatelet therapy and in the elderly.

Level C Recommendations

Not given.

Summary of Current Evidence

Numerous studies demonstrate that seizures are one of the most common causes of AMS. 1,6,,8-10,60 When a patient exhibits obvious seizures, a seizure protocol will be implemented by paramedics instead of an AMS protocol. It is more challenging to identify prolonged postictal states, non-convulsive status epilepticus (NCSE) and partial seizures, which are all seen more frequently in elderly and pediatric populations.5,10

Most studies that examine seizures in the emergency setting do not indicate if the seizure was obvious, difficult to identify, or later identified to be NCSE. However, a study in 2014 by Zehtabchi assessed rates of NCSE confirmed with EEG and found undifferentiated altered patients had a 5% chance of being in NCSE.61 NCSE can present with discrete and subtle muscle twitching of face or limbs, increased tone, automatisms, clonic jerks, eye deviations/twitching, repetitive behaviors or prolonged postictal phase. 62,63

EVALUATE FOR TRAUMA

Clinical Question

What factors make traumatic brain injury the likely cause for AMS in the prehospital setting?

Summary of Current Evidence

Most studies excluded obvious trauma while evaluating patients with AMS. Some patients with AMS were found to have occult traumatic brain injury (TBI). Otherwise occult trauma was not found to be a major cause of AMS.5,7,8and this high-risk patient group has been poorly characterized in the prehospital setting as well. The aim of this study was to study the epidemiology and aetiology of nontraumatic impaired level of consciousness among the patients treated by an urban Emergency Medical Service (EMS If intoxication is present, especially from alcohol, the evaluation is more challenging and less accurate. Due to alcohol use, these patients as well as elderly patients and those on anticoagulation or antiplatelet therapy are at higher risk for occult TBI, especially intracranial hemorrhage.64,67

Current Prehospital Treatment Recommendation

Level A Recommendations

Not given.

Level B Recommendations

Consider TBI in patients with undifferentiated AMS, especially in the setting of intoxication, anticoagulation or antiplatelet therapy and in the elderly.

Level C Recommendations

Not given.

TREATMENT OF HYPOGLYCEMIA

Clinical Question

When and how should EMS providers treat hypoglycemia in patients with AMS?

Summary of Current Evidence

There is significant variation in how hypoglycemia is treated. About 12% of hypoglycemic patients present with AMS.68 Many EMS systems and EDs are switching from using dextrose 50% (D50) to dextrose 10% (D10). Seventy percent of agencies in the U.S. as of 2016 only allowed D50 for the treatment of hypoglycemia in adults, 8% only D10, and 22% either D10 or D50 with a trend toward increasing use of D10.69 This transition to D10 use is occurring for several reasons, including less extravasation risk, less acute hyperglycemia, less rebound hypoglycemia, and shortages of D50. D10 is less expensive and can be used in every age group. Many studies have demonstrated the feasibility, safety, and efficacy of using D10 instead of D50, with no increased time to resolution of symptoms and no significant differences in on-scene times.70,71 In comparing glucagon intramuscular (IM) to dextrose intravenous (IV), median time to full orientation for glucagon was 10-30 minutes, compared with 1-10 minutes for dextrose.72,73

The median blood glucose level threshold for treatment of hypoglycemia was 60mg/dL for patients of all ages.69 It is the committee’s opinion to treat hypoglycemia at 60 mg/dL in an adult. However, if clinically indicated hypoglycemia may be treated at higher levels in diabetic patients. The most frequently specified initial dose of glucose was 25gm of glucose for adults and 0.5 g/kg for pediatric patients.69

Current Prehospital Treatment Recommendation

Level A Recommendations

Not given.

Level B Recommendations

In patients with AMS and hypoglycemia treat with oral glucose if indicated, or if venous access is available administer IV dextrose; IM glucagon is a second line agent. The preferred medication for treatment of AMS due to hypoglycemia is D10; if not available, D25 or D50 may be substituted.

Level C Recommendations

Not given.

EVALUATE FOR TOXICOLOGIC CAUSES OF AMS

Clinical Question

How should patients in the prehospital setting be evaluated and treated for toxicologic causes of AMS?

Summary of Current Evidence

Toxicologic causes of AMS are common and result from a large number of toxins. The result is often a marked reduction in GCS.9 However, in patients >65 years old, toxicologic causes of AMS are less frequent.5 A history of depression, medication use, or illicit substance ingestion, especially alcohol, are important risk factors for a toxicologic cause of AMS. Almost 50% of alcohol-intoxicated patients who present to the ED arrive by ambulance and have higher blood alcohol levels and lower GCS scores than those arriving via private means.64

Drugs like methylenedioxymethamphetamine (MDMA), gamma-hydroxybutyrate (GHB), and synthetic cannabinoids are gaining popularity, especially by persons visiting clubs and festivals. Of those patients who seek medical help after GHB, most are altered, some with severely depressed GCS ≤9. Hallucinations, hypotension, bradycardia/tachycardia and hypo/ hyperthermia are commonly found. Cooling measures, IV fluids, and symptomatic support including benzodiazepines are treatments that may be indicated for agitated delirium or seizures in this setting.74,75

If sodium channel blocker overdose is suspected (e.g., following diphenhydramine or TCA ingestions), sodium bicarbonate may be given. For calcium channel blocker (CCB) and beta blocker (BB) overdoses, calcium gluconate/chloride and glucagon are appropriate. These interventions have been demonstrated to be safe in the ED64 but have not been studied in the prehospital setting. 76,77

Current Prehospital Treatment Recommendation

Level A Recommendations

Not given.

Level B Recommendations

If an amphetamine or another sympathomimetic is ingested, treat symptomatically with cooling, IV fluids and benzodiazepines as needed. If a sodium channel blocker ingestion/overdose is suspected in an altered patient, consider sodium bicarbonate administration. If a CCB or BB ingestion/overdose is suspected in an altered patient, consider giving calcium and/or glucagon.

Level C Recommendations

Not given.

NALOXONE FOR OPIOID OVERDOSE

Clinical Question

When should naloxone be administered in the prehospital setting in patients with AMS?

Summary of Current Evidence

Treating patients with AMS empirically with naloxone is of no benefit unless there is evidence of opioid ingestion for opioid overdose, naloxone has proven to be relatively safe. Naloxone has been found to be associated with a small but consistent rate of complications like seizures, arrhythmias, and severe agitation.78-81

Most of the criteria that studies examined when considering opioid overdose were respiratory rate ≤12, pinpoint pupils, and presence of drug paraphernalia, with AMS. These were found to be highly sensitive in predicting a response to naloxone. Miotic pupils outperformed respiratory rate as the best single criterion, with 91% sensitivity.82-84

To protect EMS personnel, several studies compared various routes of naloxone administration. IV, IM and intranasal (IN) administration of naloxone all result in reversal of opioid-overdose symptoms.85 IN naloxone is statistically as effective as IV and IM naloxone, causes improvement and withdrawal effects almost as rapidly as IV, but requires rescue doses more often.86–89 IN naloxone was shown to be faster, easier to administer and perceived as safer in those trained.90 This evidence suggests that IN is the preferred route, with IV and IM as alternative routes.

Current Prehospital Treatment Recommendation

Level A Recommendations

Administer naloxone IN for AMS patients with evidence of hypoventilation, (i.e., respiratory rate ≤12), pinpoint pupils, presence of drug paraphernalia, and AMS.

Level B Recommendations

Do not empirically administer naloxone without a clinical suspicion of opioid ingestion/overdose. Alternative routes for naloxone administration are IM or IV routes.

Level C Recommendations

Not given.

PEDIATRIC ALTERED MENTAL STATUS

Clinical Question

How are the causes of pediatric AMS different from those of an adult?

Summary of Current Evidence

The recommendations listed previously for adults apply for children as well, except for the recommendation to obtain a 12-lead ECG. Cardiac causes of AMS are exceedingly rare in children, so a 12-lead ECG is unlikely to be useful unless a dysrhythmia is suspected or evident on a rhythm strip. Studies did reveal that seizures, shock (e.g., sepsis), apparent life-threatening event (ALTE), now called brief resolved unexplained events (BRUE), hypoglycemia, and electrolyte abnormalities are common causes for pediatric AMS.10,91

Hypoglycemia can be seen in children for the same reasons as in adults, but pediatric patients are also at higher risk of hypoglycemia from toxic ingestions (e.g., ethanol), dehydration and sepsis.10 While the blood glucose level that requires treatment of hypoglycemia in children is variable, many EMS systems have used <60 mg/dL universally for all patients.

TBI is another cause of AMS in children, especially non-accidental trauma.10,91,92 Although strokes are not usually considered a common pediatric cause of AMS, they do occur and their presentations are delayed because the diagnosis of stroke in children is often unrecognized.93

ED chart reviews identified common pediatric toxicologic emergencies causing AMS that require resuscitation including ingestion of ethanol, clonidine and acetaminophen. Other toxins more rarely causing AMS in children include CCB, BB and TCA.76,77,91,94

Current Prehospital Treatment Recommendation

Level A Recommendations

Consider toxicologic causes as history and physical examination dictate and treat with naloxone if opioid ingestion is suspected in the setting of respiratory depression.

Level B Recommendations

Place all pediatric patients with AMS on a cardiac monitor. Obtain pulse oximetry on all pediatric patients with AMS.

Level C Recommendations

Check blood glucose on every pediatric patient with AMS and treat symptomatic hypoglycemia at values less than 60 mg/dL.

Results

We reviewed protocols from all 33 EMS agencies within California for consistency with the recommendations made by EMDAC for prehospital AMS management (Tables 1-3). Of the 33 LEMSAs, 30 (91%) have specific AMS protocols, often named “Altered Level of Consciousness.”

Point of Care Tests

All LEMSAs recommend evaluation of blood glucose as part of their AMS protocols. Twenty-seven percent recommend obtaining a 12-lead ECG for adult patients with AMS, while other LEMSAs only recommend placing the patient on a cardiac monitor.

General Treatment of AMS

No LEMSA suggests empiric treatment of AMS with dextrose, glucose, glucagon or naloxone without evidence of hypoglycemia or concern for opioid overdose.

Supplemental Oxygen

The most common recommendation is providing supplemental oxygen (48% of LEMSAs) as needed. Only seven (21%) agencies provide parameters for oxygen supplementation. Three (9%) recommend general high-flow oxygen for all patients, and seven (21%) do not mention supplemental oxygen in the protocol itself.

Use of a Standardized System to Score to Measure Level of Consiousness

Thirteen (39%) of the LEMSAs mention GCS in their protocols, often guiding the prehospital care provider to use the AMS protocol when the GCS <15.

Evaluation for Seizure

Nineteen (58%) of the LEMSAs suggest evaluating for seizure as a cause of AMS. Many of these systems use the acronym AEIOU TIPS to allow for this consideration.

Evaluation for Trauma

The majority of LEMSAs (79%) recommend evaluating the patient with AMS for signs of trauma.

Evaluation for Hypoglycemia

The majority of LEMSAs (67%) suggest treating at <60mg/dL, the other levels recommended for treatment are <70, <75, and <80 mg/dL. More than half the agencies (64%) use D10 to treat symptomatic hypoglycemia while the remainder use D50. There is a trend away from D50 at this time. The most common suggested first dose of dextrose for adults is 25gm (73%), though there is a trend toward smaller initial doses.

Evaluation for Toxicologic causes of AMS

Seventeen (52%) of the LEMSAs suggest evaluating for toxicologic causes of AMS, often by scene assessment and history from bystanders.

Naloxone for Opioid Overdose

Forty-two percent of the LEMSAs provide specific parameters for naloxone administration, whereas 19 (58%) advise naloxone administration if opioid overdose is likely. Of agencies that recommend specific parameters, most provide a respiratory rate below which naloxone should be administered, the most common being ≤12 breaths per minute. In terms of the route of naloxone administration, 28 agencies (85%) allow IV, IM, or IN.

Pediatric Altered Mental Status

Twenty-four (73%) of the LEMSAs have a different protocol for pediatric AMS than for adults. Of the 30% that do not provide a separate document, 21% provide pediatric recommendations in parallel to those for adults on the same document. One agency simply refers to the pediatric drug card.

CONCLUSION

A wide range of disease processes can cause AMS. Because of the rapid treatment needed for many of these causes, prompt identification is important. Though few studies address specific assessment and treatment recommendations for AMS in the prehospital setting, we have ED studies that can be extrapolated for use prehospital, although not ideal. The evidence-based recommendations presented in this paper will inform EMS medical directors and guide creation of protocols for identifying and treating patients presenting with undifferentiated AMS in the prehospital setting.

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