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

Sanello, Ashley; Gausche‐Hill, Marianne; Mulkerin, William; Sporer, Karl A.; Koenig, Kristi L.; Rudnick, Eric M.; Salvucci, Angelo; Gilbert, Greg

doi:10.5811/westjem.2018.1.36559

Cited by 25 publications

(31 citation statements)

References 91 publications

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“…Patients with an altered level of consciousness are often encountered by emergency medical services (EMS) in the prehospital setting and by emergency department (ED) personnel in-hospital [1,2]. Common causes of altered levels of consciousness include epilepsy, hypoglycemia and intoxication by alcohol or other substances [2].…”

Section: Introductionmentioning

confidence: 99%

A potential method of identifying stroke and other intracranial lesions in a prehospital setting

Saviluoto

Harve‐Rytsälä

Lääperi³

et al. 2020

Scand J Trauma Resusc Emerg Med

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Background: Identifying stroke and other intracranial lesions in patients with a decreased level of consciousness may be challenging in prehospital settings. Our objective was to investigate whether the combination of systolic blood pressure, heart rate and age could be used to identify intracranial lesions. Methods: We conducted a retrospective case-control study including patients with a decreased level of consciousness who had their airway secured during prehospital care. Patients with intracranial lesions were identified based on the final diagnoses at the end of hospitalization. We investigated the ability of systolic blood pressure, heart rate and age to identify intracranial lesions and derived a decision instrument. Results: Of 425 patients, 127 had an intracranial lesion. Patients with a lesion were characterized by higher systolic blood pressure, lower heart rate and higher age (P < 0.0001 for all). A systolic blood pressure ≥ 140 mmHg had an odds ratio (OR) of 3.5 (95% confidence interval [CI] 1.7 to 7.0), and > 170 mmHg had an OR of 8.2 (95% CI 4.5-15.32) for an intracranial lesion (reference: < 140 mmHg). A heart rate < 100 beats/min had an OR of 3.4 (95% CI 2.0 to 6.0, reference: ≥100). Age 50-70 had an OR of 4.1 (95% CI 2.0 to 9.0), and > 70 years had an OR of 10.2 (95% CI 4.8 to 23.2), reference: < 50. Logarithms of ORs were rounded to the nearest integer to create a score with 0-2 points for age and blood pressure and 0-1 for heart rate, with an increasing risk for an intracranial lesion with higher scores. The area under the receiver operating characteristics curve for the instrument was 0.810 (95% CI 0.850-0.890). Conclusions: An instrument combining systolic blood pressure, heart rate and age may help identify stroke and other intracranial lesions in patients with a decreased level of consciousness in prehospital settings. Trial registration: Not applicable.

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Section: Introductionmentioning

confidence: 99%

A potential method of identifying stroke and other intracranial lesions in a prehospital setting

Saviluoto

Harve‐Rytsälä

Lääperi³

et al. 2020

Scand J Trauma Resusc Emerg Med

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“…In an effort to improve quality and decrease variability in EMS practice in California, EMDAC has endeavored to create evidence-based recommendations for EMS protocols. 11 – 14 …”

Section: Methodsmentioning

confidence: 99%

Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care

Hodroge

Glenn

Breyre

et al. 2020

WestJEM

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Introduction We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California. Methods We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations. Results PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94–96% for most acutely ill medical patients and to 88–92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol. Conclusion Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.

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“…The assessment of the comatose patient begins in the prehospital phase and continues in the emergency department [ 8 ]. During first evaluation, emergency care providers frequently formulate – explicitly or implicitly – an initial diagnosis which often determines the first approach to the patient in the ED in order to benefit from a fast treatment [ 9 , 10 ]. In CUE, the initial diagnosis often relies on sparse information, which may lead to errors and misdirect emergency management.…”

Section: Introductionmentioning

confidence: 99%

The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness

Lutz

Möckel

Lindner

et al. 2021

Scand J Trauma Resusc Emerg Med

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Background Management of patients with coma of unknown etiology (CUE) is a major challenge in most emergency departments (EDs). CUE is associated with a high mortality and a wide variety of pathologies that require differential therapies. A suspected diagnosis issued by pre-hospital emergency care providers often drives the first approach to these patients. We aim to determine the accuracy and value of the initial diagnostic hypothesis in patients with CUE. Methods Consecutive ED patients presenting with CUE were prospectively enrolled. We obtained the suspected diagnoses or working hypotheses from standardized reports given by prehospital emergency care providers, both paramedics and emergency physicians. Suspected and final diagnoses were classified into I) acute primary brain lesions, II) primary brain pathologies without acute lesions and III) pathologies that affected the brain secondarily. We compared suspected and final diagnosis with percent agreement and Cohen’s Kappa including sub-group analyses for paramedics and physicians. Furthermore, we tested the value of suspected and final diagnoses as predictors for mortality with binary logistic regression models. Results Overall, suspected and final diagnoses matched in 62% of 835 enrolled patients. Cohen’s Kappa showed a value of κ = .415 (95% CI .361–.469, p < .005). There was no relevant difference in diagnostic accuracy between paramedics and physicians. Suspected diagnoses did not significantly interact with in-hospital mortality (e.g., suspected class I: OR .982, 95% CI .518–1.836) while final diagnoses interacted strongly (e.g., final class I: OR 5.425, 95% CI 3.409–8.633). Conclusion In cases of CUE, the suspected diagnosis is unreliable, regardless of different pre-hospital care providers’ qualifications. It is not an appropriate decision-making tool as it neither sufficiently predicts the final diagnosis nor detects the especially critical comatose patient. To avoid the risk of mistriage and unnecessarily delayed therapy, we advocate for a standardized diagnostic work-up for all CUE patients that should be triggered by the emergency symptom alone and not by any suspected diagnosis.

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

Cited by 25 publications

References 91 publications

A potential method of identifying stroke and other intracranial lesions in a prehospital setting

A potential method of identifying stroke and other intracranial lesions in a prehospital setting

Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care

The accuracy of initial diagnoses in coma: an observational study in 835 patients with non-traumatic disorder of consciousness

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