Altered Mental Status/Behavioral 

Patient Care Goals

Identify treatable causes of altered mental status.

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ AMS ominous in peds (consider overdoses)
□ Give narcan if altered and no clear source
□ Use volume control device for Dextrose infusions
□ Upper limit BGL is 200 
□ Ask about how formula is being mixed in formula fed babies
□ Consider head trauma, non-accidental trauma		□ Decreased mental status 
□ Changes in baseline mental status. 
□ Bizarre behavior 
□ Hypoglycemia (cool, diaphoretic skin) 
□ Hyperglycemia (warm & dry skin, fruity breath, Kussmaul’s respirations, signs of dehydration)		□ Hypoxia 
□ Brain trauma 
□ Meningitis
□ CNS (Stroke, Tumor, Seizure, Infection) 
□ Cardiac (MI, CHF) 
□ Infection 
□ Thyroid (hyper or hypo) 
Shock (septic, metabolic, traumatic) 
□ Toxicological / Carbon □ Monoxide / Cyanide 
□ Acidosis / Alkalosis 
□ Heart Stroke or Hypothermia 
□ Electrolyte abnormality  

Clinical Management Options

EMT-B
• Oxygen target SpO2 92% – 96%  
• Blood Glucose Level Assessment 
• Consider narcan in the pediatric altered patient
• Basic Airway Management as needed 
Paramedic
• Vascular access as appropriate for patient condition 
• Dextrose if hypoglycemia
• Stroke Screening
• Monitor ETCO2 
• Cardiac monitor and 12 ECG 
• Advance Airway Management as Needed 
Consult Online Medical Control as Needed

Restraints Checklist

Voluntary Patients: Retrain with seatbelt locks as deemed appropriate

Involuntary Patients (and interfacility transfer voluntary patients): Must always use a seatbelt lock

□ All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation. 
□ Adequate personnel to effect restraint, with consideration to include law enforcement. 
□ Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically contraindicated. 
□ Law enforcement must be immediately available if handcuffed. 
□ EMS personnel in constant attendance. 
□ Chemical sedation administered, if required. 
□ Continuous EtCO2, SpO2, ECG, and vital sign monitoring. 
□ Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion, sensation in all extremities. 
□ Adequate personnel for transport. 
□ Excited delirium is considered. 
□ Physical and/or chemical restraints reviewed on a periodic basis. 
□ Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical sedation, Continuous monitoring, Neurovascular status evaluation

Pearls

  • Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety.  
  • It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or Glucagon.  
  • Do not let alcohol confuse your clinical practice as alcoholics frequently develop hypoglycemia and metabolic illness.  
  • Poor perfusion can cause altered mental status
  • Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants). Venous blood samples may produce artificially high blood glucose values and should be avoided.