Altered Mental Status: 6 reasons why a complete assessment is critical
A complete patient assessment and consideration of multiple causes will help make sure the patient's altered mental status is correctly assessed
Altered mental status is a simple yet definitive indicator that something is wrong with the patient. AMS is relatively easy to determine in the field, but getting to the root cause of AMS requires a complete patient assessment. Here are six reasons, from actual patient cases, that demonstrate why it is critical to perform a complete patient assessment with every AMS patient.
1. Anything can cause altered mental status.
One of the core duties of EMS practitioners is to determine the root cause of AMS in a patient. In practice, however, this can be a challenge because AMS can result from almost anything. Is the root cause hypoglycemia, an acute MI, sepsis, a head injury, stroke or hypoxia? The only way for the EMS practitioner to get to the root cause quickly and accurately is by performing a complete patient assessment.
2. The patient can’t always tell you what is wrong.
AMS patients are usually not alert and thus unable to give the EMS practitioner much reliable information. Even when the patient is somewhat conscious, they often find it difficult to describe what is wrong. This occurs because the AMS has made it difficult to communicate, or because the patient's signs and symptoms are odd, vague or difficult to describe. The patient only knows that something is wrong.
For example, a paramedic crew responded to a call at a business for a middle-aged male patient whose only complaint was that he could not stay awake. The patient was alert, oriented and able to answer all questions appropriately. In between questions, however, the patient would close his eyes and drift off, as if he were asleep.
The first responders on the scene conveyed to the paramedic their private opinion that the patient was just trying to get out of work, because he appeared to be fine. As a result, the first responder's initial assessment was incomplete and consisted of vital signs and a 3-lead ECG.
However, because this patient was so adamant that something was wrong, the paramedic did a complete assessment, including a full neurological evaluation. The patient's arm drift and unequal pupils clearly demonstrated that he was having an acute stroke. If the paramedic had not detected the stroke during his complete assessment, the patient would have been transported to his preferred hospital 20 miles away, rather than to the primary stroke center just four miles away.
3. What is wrong today isn’t necessarily what’s been wrong before.
Many providers make the faulty assumption that a patient’s problem today is the same issue that was affecting them before. This can cause important medical issues to be missed because a complete assessment was not performed — patients who are regular 911 callers are especially vulnerable to this problem. Regardless of what the EMS practitioner thinks is wrong, it is critical that they perform a complete assessment on every patient, every time.
A certain paramedic crew responded to a residence for a syncopal patient. The patient was unresponsive in a kitchen chair with agonal respirations. The crew placed the patient in the supine position, and the paramedic performed a complete assessment that revealed bradycardia.
Their interventions, following the ACLS bradycardia algorithm, woke the patient up. The patient was obviously surprised at first, and asked the crew, "Is my stroke acting up again?"
The emergency department nurse and physician found it difficult to believe that the patient's problem was not a result of a previous condition because the patient was now fully alert and had a normal heart rate. The complete assessment ensured that the underlying problem was correctly identified.
4. The patient can have multiple issues at once.
Often, the patient can have multiple issues at once, and the EMS practitioner will focus only on the most visible problem and miss the true root cause of their AMS. Many paramedics have learned this lesson the hard way.
A rookie paramedic once responded to an AMS call. The patient was an older male with a history of insulin-dependent diabetes. The paramedic assumed that the patient was hypoglycemic, so the initial assessment consisted of vital signs and a glucose check. The patient was indeed hypoglycemic, so the paramedic administered dextrose in an attempt to wake the patient and obtain a refusal.
The paramedic was very surprised when the patient did not regain consciousness after receiving the dextrose bolus. The paramedic, now forced to do a complete assessment, discovered that the patient actually had several simultaneous issues, including a stroke and significant cardiac dysrhythmias. What might have happened if the patient actually did wake up, and refused transport?
5. The big problem results in a little problem that gets all the attention.
Sometimes, the patient’s initial complaint is just a symptom of a much more serious medical condition. The EMS practitioner must take care not to let minor symptoms take up their full attention.
This is common when seeing patients who fell because of a syncopal episode. Often, the patient's complaints will mostly be about injuries caused by the fall, rather than about the condition that caused the syncope in the first place. More than once, an EMS practitioner has missed an acute MI or other life-threatening condition because they were too focused on the superficial problems.
6. Assumptions will get you in trouble.
Every EMS student is taught to never make assumptions, but even the most experienced veterans can forget this rule from time to time.
A veteran paramedic responded to a non-emergency call at an assisted living center. The facility nurse reported that an elderly female had experienced a sudden onset of dementia and was exhibiting "unacceptable behaviors." Though the nurse said she had already performed a complete assessment on the elderly patient, the physician wanted her transferred to the emergency department for a psychological evaluation.
En route to the hospital, the paramedic suddenly remembered that dementia is not an acute condition.
He decided, albeit a little bit late, to perform a glucose check as part of a complete assessment, which revealed that the patient was hypoglycemic. One ampule of dextrose later, the patient's 'dementia' was reversed. The patient was now alert, and a little confused as to why she was in an ambulance. A complete assessment spared the veteran paramedic from looking silly at the ED.
These reasons clearly demonstrate that EMS practitioners must perform a complete assessment on every AMS patient to get to the root cause of the problem and provide the correct treatment.