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West J Emerg Med. 2018 May;19(3):527-541. doi: 10.5811/westjem.2018.1.36559. Epub 2018 Mar 8.

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

Author information

1
Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.
2
David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California.
3
Harbor UCLA, Department of Emergency Medicine, Torrance, California.
4
EMS Medical Directors Association of California.
5
Stanford University, Department of Emergency Medicine, Stanford, California.
6
University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.
7
County of San Diego, Health & Human Services Agency, Emergency Medical Services, San Diego, California.
8
University of California, Irvine, Department of Emergency Medicine, Orange, California.
9
NorCal EMS Agency, Redding, California.
10
Ventura County EMS Agency, Oxnard, California.

Abstract

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 evidence-based 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.

PMID:
29760852
PMCID:
PMC5942021
DOI:
10.5811/westjem.2018.1.36559
[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

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