Altered Mental Status — EMT Field Protocols

Scene Size-Up — Clue Gathering ▼

BSI: Gloves (altered patients unpredictable — blood, emesis, secretions)
Safety: AMS patients may be combative — request law enforcement if needed
Environment clues: Pill bottles (overdose?), drug paraphernalia, alcohol, insulin/glucose meter, medical ID bracelet
Bystanders: Witness to collapse? Seizure activity? Time of onset?
Trauma mechanism? — blood, fall, head injury signs
Living conditions: Extreme heat/cold → environmental emergency

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Initial Assessment — ABCs + C-Spine

Airway: Maintain — jaw thrust, OPA/NPA if not responsive. Suction if needed (vomit, blood).
Breathing: Rate, depth, effort. Agonal or absent → BVM immediately.
Circulation: Pulse quality, skin signs, BP.
C-spine: If trauma mechanism present (fall, MVA, unknown) — manual inline stabilization until cleared.
Position: Recovery position if breathing and no C-spine concern.

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📊 Step 3 — AVPU Scale

Alert

Awake, aware, responds normally

Verbal

Responds to verbal stimuli only

Pain

Responds to painful stimuli only

Unresponsive

No response to any stimulus

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Hypoglycemia Treatment

BGL < 60 + conscious + able to swallow: Oral glucose gel 15-24g (BLS)
BGL < 60 + unconscious / cannot protect airway: D50 25g IV or D10 per ALS protocol (ALS)
Reassess BGL 15 minutes after treatment
Glucagon 1mg IM if no IV access and unconscious (ALS / family-administered)

🧩 Step 5 — AEIOU-TIPS Differential

Tap any category to expand. Check applicable causes to prioritize differential.

Alcohol / Drugs

Intoxication, withdrawal, CNS depressants

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Alcohol breath, pinpoint pupils (opioids), dilated pupils (stimulants), drug paraphernalia. Check: ETOH level, Narcan trial for opioid OD (ALS or authorized BLS). Alcohol withdrawal: seizures, delirium tremens — high risk.

Epilepsy / Endocrine

Seizure, postictal, thyroid storm, Addisonian

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Post-seizure: Todd's paralysis (focal weakness), incontinence, tongue biting, postictal confusion (minutes to hours). Thyroid storm: fever, tachycardia, diaphoresis, AMS. Addisonian crisis: hypotension, weakness, electrolyte derangement.

Insulin (Glucose)

Hypoglycemia, DKA, HHNS

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Hypoglycemia: <60 mg/dL — diaphoresis, tremor, confusion, seizure. DKA: fruity breath, Kussmaul breathing, dehydration, BGL >250. HHNS (Type 2): extreme hyperglycemia, no fruity breath, profound dehydration.

Overdose / Oxygen

Drug OD, hypoxia, CO poisoning

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Opioid OD: pinpoint pupils, respiratory depression, bradycardia. Hypoxia: cyanosis, SpO2 low, work of breathing. CO poisoning: cherry red skin, headache, nausea — SpO2 falsely normal (use CO-oximeter or clinical suspicion). High-flow O2 for CO.

Uremia

Renal failure, electrolyte disorders

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Uremia from acute or chronic renal failure. Uremic frost (white crystals on skin — severe). Electrolyte derangements: hyponatremia (seizures), hyperkalemia (cardiac arrhythmias). Dialysis patient who missed treatment.

Trauma

Head injury, intracranial bleed

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TBI: contusion, epidural/subdural hematoma. Signs: lucid interval then deterioration (epidural), Battle's sign (mastoid bruising), raccoon eyes, CSF rhinorrhea/otorrhea. C-spine protection. Rapid transport to trauma center.

Infection

Sepsis, meningitis, encephalitis

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Sepsis: fever/hypothermia, tachycardia, hypotension, altered LOC, infection source. Meningitis: fever + severe headache + neck stiffness (meningismus) + photophobia — use droplet PPE. Encephalitis: fever + AMS + seizures.

Psychiatric / Poisoning

Psych emergency, toxins, medications

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Psych emergency: diagnosis of exclusion. Always rule out organic cause first. Toxicology: toxic syndromes (cholinergic — SLUDGE, anticholinergic — dry/flushed/tachycardia, sympathomimetic). Document all medications found.

Stroke / Shock / Structural

CVA, hemorrhagic shock, mass lesion

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Stroke: focal deficits, Cincinnati positive → Stroke Alert protocol. Shock: any type (distributive, hypovolemic, cardiogenic, obstructive) → hypoperfusion → AMS. Brain tumor/mass: focal deficits, headache, papilledema.

📋 Priority Differentials Based on Selection

Check applicable AEIOU-TIPS categories above to see prioritized differential

🔍 Step 6 — Physical Findings Panel

👁 Pupils

Pinpoint → opioid OD
Dilated → stimulants/anoxia
Unequal (anisocoria) → herniation
Fixed & dilated → severe brain injury

🦾 Motor

Focal weakness → stroke/TBI
Decorticate posturing → cortical
Decerebrate posturing → brainstem
Flaccid → severe injury

🦴 Meningismus

Neck stiffness
Kernig's sign
Brudzinski's sign
→ Meningitis / SAH

🩷 Skin

Diaphoresis → shock/hypoglycemia
Flushed/dry → anticholinergic
Petechiae/purpura → meningococcemia
Cherry red → CO poisoning

🩺 Step 7 — Management by Etiology

General AMS Management

🛡️

BLS Airway protection first — position, jaw thrust, OPA/NPA. Suction. Recovery position if spontaneous breathing.

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BLS O2 — apply per SpO2. 100% NRB if suspected CO poisoning (do not wait for O2 sat).

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BLS Glucose: BGL < 60 + conscious → oral glucose gel. Document pre- and post-treatment BGL.

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ALS IV access, D50/D10 for hypoglycemia, Narcan 0.4-2mg IV/IM/IN for suspected opioid OD (respiratory depression + pinpoint pupils).

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BLS Temperature management: Hypothermia → warm blankets, remove wet clothing. Hyperthermia → cool with wet cloths, fan.

🚨 ALS Intercept Criteria

🔴 ALS Request — Any of the following:

AVPU below Alert — V, P, or U
BGL < 60 with unconscious patient (IV dextrose needed)
Suspected opioid overdose (Narcan)
Active seizure or postictal > 10 minutes
Signs of shock (hypotension, poor perfusion)
Suspected meningitis (droplet precautions)
Focal neurological deficits (stroke protocol)
Suspected CO poisoning (high-flow O2 only; hyperbaric consult)

📊 Step 3 — AVPU Scale

STEP 4 — GLUCOSE CHECK: IMMEDIATE PRIORITY

🧩 Step 5 — AEIOU-TIPS Differential

🔍 Step 6 — Physical Findings Panel

🩺 Step 7 — Management by Etiology