For patient's without immediate threats to life, diagnosing a patient with a change in mental status can be a daunting challenge in the prehospital setting as the sources of Altered Mental Status (AMS) can be many and varied. It is important to remember that AMS itself is not a disease, it is a symptom of an underlying pathology. Causes run the gamut from easily reversible in the field such as hypoglycemia to situations like stroke that require immediate recognition and rapid transport. Differentiating the relatively benign from the life threatening can be a real challenge as the differential diagnoses are enormous.
SAMPLE History
AEIOU-TIPS is a mnemonic acronym used by many medical professionals to recall the possible causes for altered mental status, and there are many versions. Below is the version typically used in prehospital EMS which includes the Symptoms, Medications and Pertinent Medical History elements of the SAMPLE History. Keeping a structured and systematic approach to these cases will help you develop and streamline the diagnostic workup and management of these patients with AMS.
| Mnemonic component | Examples and questions to ask | |
|---|---|---|
| A | Alcohol | Alcohol or drug intoxication - observe behavior, note smell of alcohol if any, ask about consumption |
| E | Epilepsy ElectrolytesEndocrine | Epileptic seizure (or seizure for any other reason) - look for signs, ask about history Hyponatremia; hypernatremia; hypocalcemia; hypercalcemia - ask about history of vomiting or dehydrationAdrenal insufficiency; thyroid disease - ask in history |
| I | Insulin | Hypoglycemia; hyperosmolar hyperglycemic state; ketoacidosis - ask about history of diabetes, test blood glucose, note smell of breath |
| O | Overdose | Prescription or non-prescription drug overdose - ask about medications or other drug use, look for signs of field reversible overdoses such as opioid |
| U | Underdose Uremia | Insufficient dose of prescription medications - ask what medications the patient is on, and whether they were taken that day Excess urea in the blood due to kidney failure or urinary obstruction - ask about history of kidney failure, look for shunts |
| T | Trauma Temperature | Concussion; traumatic brain injury; increased intracranial pressure due to epidural hemorrhage - ask about falls Hypothermia or Hyperthermia - take temperature during vital signs |
| I | Infection | Encephalitis, meningitis, meningoencephalitis; sepsis - note fever, ask about headache, infectious history |
| P | Poisons Psychogenic | Carbon monoxide poisoning; lead poisoning; iron poisoning - ingestion history Psychosis; pseudoseizure; conversion disorder - ask about history of mental illness |
| S | Stroke Shock | Hemorrhagic stroke, subarachnoid hemorrhage - perform a FAST scan Hypoperfusion due to cardiogenic, neurogenic, or other forms of shock - Assess for signs of shock |
Documentation
Documentation of Altered Mental Status should be included in the Patient Care Report (PCR) in the form:
- Pertinent positives and negatives should be included in a narrative. Example: "Patient has history of diabetes with poor compliance with medications. Patient BSL 820 mg/dL. Patient is obtunded AxO 2 normally AxO 4. Patient exhibits eupnea with no acetone breath odor. Patient's mother states that patient has recently been experiencing polydipsia, polyuria, and diuresis. Per mother, patient has been noncompliant with medications for x2 weeks. GFAST negative, 12 lead negative for ST elevation."
Self Assessment
- Use the AEIOUTIPS acronym and practice asking the relevant questions to determine the patient's likelihood of exposure to the altering agent until comfortable with the work flow
- Test your knowledge with this quiz
Tips and Tricks
- Even if you find a viable reason for your patient to be altered, keep checking for other possible causes. There have been many cases where an EMS crew has transported Code 3 stroke alert for a patient whose blood glucose levels were low. Similar cases have been seen where a frequent flier with an ETOH abuse history is written off as drunk despite having a life threatening brain bleed.
Additional Resources
TBD - extra videos to watch, links to other pages for more reading