Rapid evaluation and support of airway, breathing, and circulation (ABCs) are the initial management priorities. All patients should receive 100% oxygen via face mask. Comatose patients who are apneic or have lost their protective airway reflexes require assisted ventilation with a bag-valve-mask device or endotracheal intubation. If head injury is suspected, immediately immobilize the cervical spine using in-line manual stabilization or placement of a cervical spine collar. Spine immobilization must then be maintained during airway management and endotracheal intubation. Patients in shock require rapid IV access, IV fluids, and possibly inotropic support after airway and breathing are controlled.
B. What is patient's level of consciousness? 1. Altered states of consciousness include:
a. Confusion. Impaired cognition manifested by disorientation, memory deficits, or difficulty following commands.
b. Delirium. Disconnection of ideas with disorientation, fearful-ness, agitation, and irritability. Hallucinations may be present.
c. Lethargy. Minimally reduced wakefulness with attention deficit. Easily distracted but able to communicate verbally or by gesture.
d. Obtundation. Decreased alertness and interest in environment. Patient spends more time sleeping, and drowsiness persists when awakened.
e. Stupor. Responsive only to vigorous, repeated, or painful stimulation and return to unresponsiveness when left alone.
f. Coma. Complete unresponsiveness.
2. Glasgow Coma Scale (GCS). This tool provides a more reliable method for describing level of consciousness (see Appendix F, p. 765).
C. What is patient's dextrose level? Hypoglycemia is a common cause of altered mental status and is readily detected by bedside determination. Timely glucose administration to hypoglycemic patients can be lifesaving.
D. Is drug overdose suspected? Does patient have small pupils? Consider administering IV naloxone for opiate overdose.
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