Chapter 13: Altered Level of Consciousness Emergencies

Overview

Altered Levels of Consciousness can be caused by nearly any major illness or injury. It can also be caused by drug and alcohol overdose, choking on an object, abnormal breathing, dehydration, low blood sugar, or low blood pressure. Some of these conditions can be life-threatening and quickly result in shock, and so treatment must be applied quickly and emergency services contacted as soon as possible.

The following flowchart quickly allows you to determine the type of Altered Level of Consciousness Emergency and the appropriate treatment once the patient’s ABCDs have been assessed.

Diabetic Emergencies

The body’s cells need glucose (sugar) as a source of energy to function normally. Through the digestive process, the body extracts glucose from food, which is then absorbed into the bloodstream. Insulin (a hormone produced in the pancreas) is required for the transfer of glucose from the bloodstream to the body’s cells. Without a proper balance of glucose and insulin, the cells will starve and the body will not function properly. Diabetes mellitus is a condition in which the body either fails to produce enough insulin or does not effectively use the insulin it does produce. There are two major types of diabetes.

Type 1 diabetes (insulin-dependent diabetes) occurs when the body does not produce enough insulin for its needs. Most people with insulin dependent diabetes have to inject insulin into their bodies daily. This type of diabetes often begins in childhood and so can be referred to as juvenile diabetes.

Type 2 diabetes can be insulin-dependent or non-insulin-dependent diabetes. It occurs when the body does not produce enough insulin for its needs, or when the body does not properly use the insulin it produces.

A patient with diabetes may use an insulin pump, which is a small portable device consisting of an external pump and a small tube that fits under the patient’s skin. This device provides continuous doses of insulin throughout the day and can be adjusted to meet the patient’s insulin requirements. If you encounter an insulin pump during your patient assessment, this may be a clue that the patient’s condition could be a diabetic emergency.

Some pregnant women develop diabetes as an effect of pregnancy: This is referred to as gestational diabetes. Healthy diet and exercise can help to reduce the risk, but medication may be necessary as well. Gestational diabetes usually disappears after a woman gives birth, but ongoing monitoring may be necessary.

A person with diabetes must carefully monitor his or her diet and exercise. People with insulin dependent diabetes must also regulate their use of insulin. When a person with diabetes fails to control these factors, it leads to an excessive or insufficient glucose level, causing an imbalance in the body. The level of glucose may become too high (hyperglycemia) or too low (hypoglycemia). Either imbalance causes illness, which can become a diabetic emergency.

Hyperglycemia. Hyperglycemia is a condition in which a patient’s blood glucose level (BGL) is too high. In patients with diabetes, this usually occurs when the insulin level in the body is too low: Because this prevents glucose from transferring to the body’s cells, it results in a buildup of glucose in the blood. The body’s cells do not receive sufficient glucose from the bloodstream even though it is abundant.

The body attempts to meet its need for energy by using other stored food and energy sources (e.g., fats). Converting fat into energy produces waste products and increases the acidity level in the blood, causing a condition called acidosis. As this occurs, the patient becomes ill. If it continues, the hyperglycemic condition deteriorates into a diabetic coma.

Hypoglycemia. Hypoglycemia occurs when the BGL in the blood is too low. In patients with diabetes, this often occurs when the insulin level in the body is too high (but it may have other causes as well). A patient’s BGL can become too low if a patient  with diabetes:

  • Takes too much insulin.
  • Fails to eat adequately.
  • Over-exercises and uses glucose more quickly than it is replaced.

In this situation, the small amount of glucose in the blood is used up rapidly, and there is not enough for the brain to function properly. This can result in an acute condition called insulin reaction, which can be life-threatening.

Signs and Symptoms of Diabetic Emergencies. The signs and symptoms of hyperglycemia and hypoglycemia are somewhat different, but common signs and symptoms include:

  • Changes in the level of responsiveness, including dizziness, drowsiness, and confusion.
  • Tachypnea (rapid breathing).
  • Tachycardia (rapid pulse).
  • Feeling and looking ill.

It is not important for you to differentiate between hyperglycemia and hypoglycemia: The standard treatment for both conditions is the same. Giving glucose to a hyperglycemic patient will not cause additional harm.

Treatment for Diabetic Emergencies. If the patient is known to have diabetes (as identified in your secondary assessment) and exhibits the signs and symptoms previously stated, you should suspect a diabetic emergency.

Test the patient’s blood glucose level (BGL). If possible, find out what the patient’s average reading is. A normal BGL is usually between 4 and 7 mmol/L. After assessing the reading, determine whether you will use oral glucose. If the patient is able to follow directions and swallow safely, he or she should swallow 12g of glucose gel.

If signs and symptoms persist 5 to 10 minutes after the first dose of glucose, the patient should be placed in the rapid transport category. Provide a second dose of glucose. Supplemental oxygen is also indicated. When transferring care, ensure that you communicate about any glucose the patient has received.

Never give any patient insulin.

Glucose Gel for an Unconscious Patient. Remove any airway adjuncts that could interfere with the administration of oral glucose. Place approximately 12 grams of gel on the inside of the patient’s lower cheek. You may use a tongue depressor for this step. The more thoroughly you spread the glucose on the patient’s cheek, the more quickly it will be absorbed.

Injecting Glucagon for an Unconscious Patient. Glucagon is a substance that can be injected (intramuscularly or subcutaneously) into a hypoglycemic patient to increase his or her BGL by accelerating the breakdown of glycogen into glucose. It should be used when the patient has signs and symptoms of hypoglycemia and is unable to protect his or her airway (i.e., when oral glucose is not indicated). Glucagon should only be given to an adult with a BGL lower than 4 mmol/L or a child with a BGL lower than 3 mmol/L.

Glucagon is a fast-acting medication with a short half-life: It will be largely metabolized within 30 minutes. A patient who receives glucagon should also ingest additional sugar and/or complex carbohydrates.

Glucagon also stimulates the release of catecholamines. In the presence of pheochromocytoma, glucagon can cause the tumor to release catecholamines, which may result in a dangerous sudden and marked increase in blood pressure. Because glucagon is derived from animal products, it is contraindicated if a patient has a hypersensitivity to pork or beef proteins.

Heat Injuries (Hyperthermia)

Heat cramps, heat exhaustion, and heat stroke are conditions caused by overexposure to heat. Cramps are the least severe indicator but are often the first sign of overexposure to heat. Heat exhaustion and heat stroke are more serious emergencies.

Heat Cramps. Heat cramps are painful spasms of skeletal muscles. Heat cramps develop fairly rapidly and usually occur after periods of physical exertion in warm or even moderate temperatures.

Heat Exhaustion. Heat exhaustion occurs when the body’s temperature rises and thermoregulatory responses are activated to compensate. Sweating is usually profuse, allowing heat loss through evaporation.

Heat exhaustion is an early sign that the body’s temperature-regulating mechanisms are becoming overwhelmed. Heat exhaustion is not always preceded by heat cramps. The patient’s temperature will be normal or slightly elevated. Over time, the patient loses fluid through sweating, which decreases blood volume. Blood flow to the skin increases in an effort to increase heat loss, thus reducing blood flow to the vital organs. Because less blood is available for the vital organs, the patient may begin to experience sign and symptoms of shock.

Without interventions, the patient’s condition will deteriorate for as long as the heat stress continues, and the body’s core temperature will continue to rise. The patient may vomit and begin to show changes in level of responsiveness. Without prompt intervention, heat exhaustion can quickly advance to heat stroke.

Heat Stroke. Heat stroke is the least common but most severe  heat-related illness. Often, it occurs when signs and symptoms of heat exhaustion are ignored. Heat stroke begins when the body’s thermoregulatory mechanisms are overwhelmed by heat stress and begin to stop functioning.

Sweating stops because the body’s fluid levels are low. When sweating stops, the body cannot actively cool itself effectively, and the body’s core temperature rises, usually above 40°C (104°F). It soon reaches a level at which the brain and other vital organs (i.e., the heart and kidneys) begin to fail. If the body is not cooled, heat stress can lead to seizures, coma, and death. Heat stroke is a serious medical emergency. You must recognize the signs and symptoms and provide treatment immediately.

Signs and Symptoms of Heat-Related Illness. The table below shows the signs and symptoms of heat stress.

Treatment for Heat-Related Illness. If recognized in its early stages, a heat-related illness can usually be reversed. Follow these treatment steps immediately (figure below):

Pouring water on a patient’s torso is more effective if there is a layer of cloth to keep the water in contact with the skin until it evaporates. Pour the water onto clothing, a towel, or another layer of cloth rather than directly onto the patient’s skin. Fanning the patient after pouring the water encourages evaporation (in addition to creating or increasing convective cooling). Note that other liquids may be used if water is not available: Beverages are often cool and available, for example. Even IV fluid can be used, so long as it is not necessary for rehydrating the patient.

Patients with heat-related illness should be given an electrolyte-replacement beverage or water. Electrolyte replacement is especially important for patients with heat cramps.

When caring for heat stroke, immerse as much of the patient’s body in cold water as possible with the resources available. If using a bucket, for example, the patient should immerse his or her hands and as much of the forearms as possible.

When treating a patient with heat cramps, the patient can usually resume activity once the cramps stop and there are no other signs or symptoms of illness. A patient with heat exhaustion or heat stroke should not resume normal activities on the same day.

A patient should be in the rapid transport category if he or she has heat stroke or any of the signs or symptoms listed in red above. If transportation is not yet on scene, cool the patient aggressively until it arrives. When transporting a patient with a heat-related illness, provide cooling en route as well. As a minimum, poor cool liquid onto the patient’s chest (with clothing or a towel over the skin as usual) and fan the patient to encourage evaporation. Keep the vehicle’s interior as cool as possible (e.g., turn up air conditioning).

Refusing water, vomiting, and a changing level of responsiveness are signs that the patient’s condition may be deteriorating. Such a patient should in the rapid transport category. If the patient vomits, stop giving oral fluids and position the patient in the recovery position. Ensure that the patient has a protected, patent airway. Keep the patient lying down and continue to cool the body as quickly as possible. Monitor the patient closely, and be prepared to perform rescue ventilations and/or CPR if required.

Cold Injuries (Hypothermia, Frostnip, Frostbite)

Cold-related illness may occur when the body’s heating mechanisms are overwhelmed by prolonged or extreme cold temperatures. They may also occur as localized superficial injuries (as when patches of skin are frozen by frostbite).

Hypothermia

Hypothermia occurs when the body core temperature decreases from a normal 37°C to 35°C or below. Hypothermia can be life threatening, especially when the core temperature drops below 28°C.

There are four distinct stages of cold stress. The signs and symptoms of each stage build upon the signs and symptoms of the previous stage.

  • Cold Stressed—Not Hypothermic:
    • Shivering
    • Normal mental status
    • Normal or near normal motor functions
  • Mild Hypothermia:
    • Vigorous shivering; complaining of the cold
    • Decreased motor and sensory function
    • Difficulty taking care of self
  • Moderate Hypothermia:
    • Weak and intermittent shivering, or shivering that later stops
    • Complaints about the cold
    • Lack of coordination or speech; confused or unusual behaviour
    • Impaired judgment
    • Apathy or a decreasing level of responsiveness
    • Unresponsiveness
  • Severe Hypothermia:
    • Cessation of shivering
    • Unresponsiveness
    • Stiffening of body tissues
    • Shallow or absent respirations
    • Weak or absent pulse

Severe hypothermia can cause bradycardia and bradypnea. If vital signs seem absent and you suspect hypothermia, check for signs of pulse and respiration for 60 seconds. If neither are detected, start CPR.

Treatment for Hypothermia. A patient with hypothermia (mild, moderate, or severe) is in the rapid transport category. Handle the patient gently and keep him or her in a horizontal position.

Place the patient in a hypothermia wrap immediately if his or her clothing is dry or damp, or if shelter or transport is less than 30 minutes way. If clothing is very wet and shelter or transport is less than 30 minutes away, wrap the patient without removing clothing.

If shelter or transport is more than 30 minutes away, seek protection from the wind and wet weather (create shelter if necessary) and then remove any wet clothing. Dry the patient by blotting (not rubbing) the skin, and then apply a hypothermia wrap. If the patient is responsive, allow him or her to sit up, and provide a warm, sugary, non-alcoholic beverage to drink, taking care to ensure that the patient does not choke and that the drink is not too hot.

Apply a hypothermia wrap by performing the following steps (figure below):

  1. Place a tarp or large piece of plastic (external  vapour barrier) on the ground.
  2. Place an insulation pad (or pads) on the tarp or  plastic.
  3. Place as much additional insulation as possible  on the pad (e.g., blankets or sleeping bags).
  4. Place a piece of plastic or foil sheet (internal  vapour barrier) on the insulation.
  5. Gently place the patient in the wrap, apply  warm water bottles or heating pads to the patient’s upper torso (if available), and close each layer.
  6. Cover the patient’s head and neck with whatever appropriate material is available (e.g., toque, heavy hat, hood, scarf, or small blanket).

Applying a hypothermia wrap.

If heat sources are not immediately available (e.g., if water must be heated before it can be poured into a hot-water bottle), you can open the wrap once the heat source is ready, place it on the patient’s upper torso, and close the wrap again.

Frostnip

Frostnip is a local, superficial condition that occurs when skin, usually on the face, is exposed to cold temperatures and begins to freeze. It is essentially a minor form of frostbite. If the tissues below the skin begin to freeze as well, frostnip will escalate to frostbite.

If a patient has frostnip, his or her skin may appear pale, and there may be pain or stinging in the area. Treat frostnip by warming the area against warm skin or in warm water (38–40°C).

Frostbite

Extremities (toes, feet, fingers, hands, ears, and nose) are particularly prone to frostbite. When frostbite occurs, the water inside and between the body’s cells begins to freeze and swell. Inside the body, the ice crystals and swelling begin to damage or destroy the body’s cells, blood vessels, and nerves.

Signs and symptoms of frostbite include:

  • Skin that appears white or waxy.
  • Skin that is cold and hard to the touch.
  • A lack of feeling in the affected area.

After the area is thawed, the patient may experience a burning sensation, redness, pain or tenderness, and blisters.

Frostbite may be classified as either superficial or deep. A patient with superficial frostbite may develop clear blisters after the affected area has thawed. Superficial frostbite may result in small amounts of tissue loss or no tissue loss at all. A patient with deep frostbite may develop dark, hemorrhagic blisters after the affected area has thawed. Deep frostbite is likely to result in tissue loss.

Treatment for Frostbite. When treating a patient for frostbite, handle the affected area gently. Do no rub the affected area or apply snow or ice (rubbing causes further damage to the frozen tissue).

Thaw the area only if you are certain that it will not freeze again: You may need to transport the patient to a warmer environment before providing care. Warm the affected area, preferably by submerging it in a container of warm water (38–40°C). Use a thermometer to check the temperature of the water if possible. If a thermometer is unavailable, carefully use your own hand to test the water; the water should feel warm but not uncomfortable. Keep the affected body part away from the bottom or sides of the container, and leave it in the water until it starts  to turn red and feels warm.

If a container of warm water is unavailable, frozen tissue may also be warmed through direct contact with warm skin from either the patient (e.g., arm pits) or responder (e.g., stomach).

If the patient is responsive and does not have gastrointestinal symptoms, rehydrate the patient (preferably with sugary, warm, non-alcoholic beverages). To treat the pain that thawing may cause, advise the patient to take an over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen.

Once the frozen area is thawed, refrain from breaking any blisters. Protect them with dry, sterile, non-adherent dressings. Place these dressings between the fingers or toes as well if they are affected. If possible, elevate the thawed area above the level of the patient’s heart. The patient should be assessed by a physician.

Head and Spinal Injuries

Overview

Injuries to the head and spine can damage both bone and soft tissue, including brain tissue and the spinal cord. This can result in paralysis, impaired mental function, and internal bleeding within the brain.

It is difficult to determine the extent of damage in head and spinal injuries. Signs and symptoms of a serious head and/or spine injury may be slow to develop, especially in the case of trauma to the brain. In most cases, the only way to assess the full extent of the damage is by having an X-ray or MRI scan conducted. Since you cannot know exactly how severe a head or spinal injury is, always provide initial care as if the injury is serious. Remember to treat head and/or spinal injuries before minor injuries such as lacerations, and to prioritise life-saving interventions over care for the spine.

Mechanisms of Injury for Head and Spinal Injuries

The mechanism of injury is often the best guide to determine whether someone has suffered a head or spinal injury. You should consider the possibility of a head and/ or spinal injury whenever the body is subjected to powerful blunt forces, extreme spinal motion (figures below), or when the cause of trauma is unknown:

  • A patient found unresponsive with an unknown cause.
  • Any fall from a height greater than approximately 1 metre.
  • Any motor vehicle collision.
  • Any injury in which a patient’s helmet is badly damaged or broken.
  • Any injury involving a severe blunt force to the head or trunk.
  • Any penetrating injury to the head, neck, or trunk.
  • Any head injury that occurs when a patient is diving.
  • Any incident involving electrocution (including lightning strikes).

Head Injuries

Skull Fractures. Because of the risk of brain trauma, skull fractures are very serious. The signs and symptoms of a skull fracture include:

  • Visible damage to the scalp.
  • Deformity of the skull or face.
  • Pain.
  • Swelling.
  • Fluid (clear or pinkish) coming from the nose, ears, mouth, or a head wound.
  • Unusual pupil size.
  • Bruising around the eyes.
  • Bruising behind the ears.

Orbit Fractures. Trauma to the face may result in a fracture of  the bones that form the orbits, or eye sockets (figure below). A patient with an orbit injury may complain of double or decreased vision. He or she may also experience numbness above the eyebrow or over the cheek, or massive discharge of fluid from the nose.

Fractures of the lower part of the orbit are most common. They can cause paralysis of the upward gaze: the patient’s eyes will not be able to follow your finger upward.

Place cold packs around the injured orbit to help reduce the swelling, without putting any pressure on the fracture site. A patient with an orbit fracture should be rapidly transported in a supine position, as surgery is usually necessary and permanent visual impairment is possible. Injuries that cause orbit fractures are often associated with concussions.

Objects Impaled in the Skull. If an object is impaled in the skull, leave it in place and stabilize it with bulky dressings. Dress the area around the wound with sterile gauze, but allow blood to drain. Avoid putting direct pressure on the head if you suspect a skull fracture.

If an object has penetrated the skull but is not visibly protruding (e.g., a bullet), cover the wound lightly with sterile dressings.

Brain Injuries. Brain damage can occur with an open or closed wound. The severity of the injury often depends on the mechanism of injury and the force involved. All head injuries should be considered serious. The signs and symptoms vary depending on the location and severity of the injury, but they may include:

  • Changes in level of responsiveness.
  • Paralysis or flaccidity of muscles (i.e., limp, lacking tone), usually on one side of the body.
  • Unequal facial movements and/or disturbances in vision or pupils.
  • Ringing in the ears or other disturbances in  hearing.
  • Limb rigidity.
  • Loss of balance.
  • Rapid, weak pulse.
  • High blood pressure with slow pulse.
  • Breathing problems.
  • Vomiting.
  • Incontinence.

Cushing’s reflex is the body’s natural response to an increase in intracranial pressure (for example, as a result of cerebral hematoma) and often indicates a serious head injury. The three characteristic signs of this response are often referred to collectively as Cushing’s triad). These signs are:

  1. A change in respiration (irregular and often deep).
  2. An increase in blood pressure (especially a widening of the gap between systolic and diastolic pressure).
  3. Bradycardia.

If the patient has a serious head injury, blood or cerebrospinal fluid (CSF) may drain from the ear. Cover the ear lightly with a sterile dressing without applying direct pressure. If CSF drains into the nose or mouth, airway management will be necessary.

Concussion. A concussion is an impact to the head or upper body that causes the brain to shake inside the skull. This shaking can cause the brain to collide with the bony structures that make up the skull’s inner shell, which sometimes causes swelling and/or bleeding, or to rotate within the skull, which can shear or tear the brain nerve fibres and sometimes stretch and damage the brain cells.

When the brain sustains an acceleration injury, there is usually damage at two points. The brain initially strikes the skull, called the coup effect, and then there is a second point of damage when the brain strikes the skull on the opposite side (the contrecoup effect).

A concussion can result from even a seemingly minor injury, and the signs and symptoms may not be immediately obvious (see table below). Concussions are evolving injuries, with the effects intensifying, dissipating, or changing unexpectedly in the days and weeks following the initial injury. Depending on the severity of the concussion, signs and symptoms can last for days, weeks, or even months. The majority of concussions, however, resolve in a short period of time. A patient does not have to have lost consciousness to have incurred a concussion. A patient who has had one concussion is at increased risk for future concussions.

Signs and symptoms of a concussion

Identifying signs and symptoms of a concussion in a child is more difficult than in an adult. It is particularly difficult for a young child or infant, since these patients may not be able to describe the symptoms. In addition to the standard signs of a concussion, a child or infant may exhibit the following signs:
• Disturbed sleeping and eating patterns
• Excessive crying
• Disinterest in activities or favourite toys

Children may also express simply “feeling off” or “not feeling right” following a physical impact. This is also a possible symptom of a concussion.

Anyone suspected of having a concussion should be examined by a physician as soon as possible. If a patient sustains a suspected concussion during an activity, he or she should cease all activity immediately and be monitored closely until he or she can be examined and evaluated by a physician. For example, athletes who have sustained a significant blow to the head should be removed from the activity immediately and not be allowed to return to the current game or practice regardless of whether they have signs and symptoms of a concussion. The player should not be left alone and should be monitored closely.

Cerebral Hematoma. The brain requires large amounts of oxygen and so contains many arteries and veins. When the brain is injured, there is a significant risk of internal bleeding from these blood vessels. Blood from a ruptured vessel in the brain can accumulate in the skull (figure below). Because there is very little empty space in the skull, the buildup of blood creates intracranial pressure (ICP), which can cause further damage to brain tissue. Depending on whether the damage is to an artery or a vein, bleeding in the skull can occur rapidly or slowly, sometimes even over a period of days. This bleeding will affect the brain, causing neurological effects such as changes in responsiveness.

There are four types of bleeding that can occur in the skull (figure below):

  1. Epidural Hematoma. An epidural hematoma is arterial bleeding that occurs between the skull and the dura mater. It usually results from a low-velocity blow to the head. The signs and symptoms appear quickly, and the
  2. patient usually presents with a brief loss of responsiveness, followed by regained responsiveness and then a rapid decline in responsiveness. As this decline occurs, the patient’s pupils may become sluggish, dilated, or non-reactive. Motor function may also be impaired on one side of the body, which will be the side opposite the injury.
  3. Subdural Hematoma. A subdural hematoma is venous bleeding in the subdural space resulting from a violent blow to the head. Neurological deficits may be obvious immediately after the blow, or they may develop up to days later. While the signs and symptoms of subdural hematoma may not appear immediately after the impact, other signs of trauma may be visible. As the pressure resulting from the bleeding increases, signs and symptoms will begin to appear. Possible symptoms include headaches, visual disturbances, personality changes, difficulty speaking, and deficits in motor function.
  4. Subarachnoid Hematoma. A subarachnoid hematoma is arterial bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. The subarachnoid space is the path through which the cerebrospinal fluid circulates, and it is responsible for protecting the brain from serious injuries. Subarachnoid hematomas may occur spontaneously from a ruptured cerebral aneurysm, or they may result from a head injury. Possible signs and symptoms include a severe headache with rapid onset, vomiting, seizures, confusion, and a lowered level of responsiveness.
  5. Intracerebral Hematoma. An intracerebral hematoma is caused by blunt or penetrating trauma that damages blood vessels in the brain itself. Often, there is more than one contusion, and they can enlarge over time. Specific neurological consequences depend on the location and size of the hematoma.

The four main types of cerebral hematomas.

Spinal Injuries

Injuries to the spine can fracture the vertebrae and sprain the ligaments; however, these injuries usually heal without complications. The greater concern with serious spinal injuries is that the vertebrae may shift, compressing, lacerating, or severing the spinal cord. This can cause temporary or permanent paralysis, or even death. The extent of the neural damage can depend on which area of the spinal cord is damaged.

Signs and symptoms that indicate a spinal injury may be immediately obvious or may have a delayed onset.

Signs and symptoms of spinal injuries include the following:

  • Changes in the level of responsiveness
  • Severe pain or pressure in the neck or back
  • Swelling in the injured area
  • Tingling or loss of sensation in the extremities
  • Partial or complete loss of movement of any
    body part
  • Unusual bumps or depressions on the neck
    or back
  • External hemorrhaging from the neck or back
  • Irregular or impaired breathing
  • Nausea or vomiting
  • Loss of balance
  • Incontinence
  • Specific changes in blood pressure and pulse

While signs and symptoms alone do not always suggest a spinal injury, they may do so in combination with the MOI. Regardless of the situation, spinal motion restriction (SMR) should be initiated for any patient with a suspected spinal injury. These patients should be in the rapid transport category.

Spinal Motion Restriction (SMR)

When a head and/or spinal injury is suspected, SMR should be considered before extricating or transporting a patient. Moving a patient with a suspected spinal injury may cause additional damage to the spine. SMR refers to any technique for limiting movement of the patient’s neck and/or spine. It may be done manually or with special equipment (e.g., a cervical soft collar or backboard).

See Chapter 18: Reaching, Positioning, and Extricating Patients for how to apply SMR.

Altitude Sickness

At higher altitudes, the lower atmospheric pressure results in less available oxygen in the air, resulting in hypoxemia (decreased oxygen saturation of the arterial blood). The risk increases as the patient moves higher, but high-altitude illness may occur at elevations as low as 2,500 metres above sea level.

The body gradually adapts physiologically to changes in altitude. Within the first 10 days, the body compensates by increasing its respiration and pulse rates.

Other adaptations may take place anywhere from 10 days to 6 weeks and include increased red blood cell production, increased capillarization (development of capillary networks), and a gradually decreasing resting heart rate.

Edema (accumulation of fluid in extravascular space) is a major factor contributing to high altitude illness. Edema formation usually occurs in two places:

  • In the brain (interstitial space): Primarily involved in acute mountain sickness (AMS) and high-altitude cerebral edema (HACE)
  • In the lungs (alveoli): Primarily involved in high-altitude pulmonary edema (HAPE)

The most common cause of death related to high altitude is HAPE. With all high-altitude illnesses, rapid recognition and treatment are crucial, as they can significantly reduce mortality.

The following table summarizes the signs, symptoms, and treatment for illnesses that result from high altitude:

Alcohol and Drug Overdose

See Chapter 32: Poisoning.

Shock

Pathophysiology of Shock

When vital organs such as the heart, lungs, brain, and kidneys do not receive oxygen-rich blood, their ability to function effectively is compromised. This triggers a series of responses that results in a combination of signs and symptoms known as shock. These responses are the body’s attempts to maintain adequate blood flow to the vital organs and prevent them from shutting down.

Shock is caused by one or more of the following problems:

  1. Cardiogenic Shock: The heart is not functioning effectively. When the heart is not functioning effectively, blood will not circulate properly even if the rest of the circulatory system is working normally. A patient in cardiac arrest, for example, will rapidly go into shock. This is referred to as ‘cardiogenic shock’.
  2. Obstructive Shock: Something physically prevents the heart from filling or emptying effectively. This may be caused by a pulmonary embolism for example, or a tension pneumothorax.
  3. Hypovolemic Shock: The quantity of blood circulating in the body is too low. A healthy body can compensate for some decrease in blood volume (up to 500 mL) without causing any stress to the body. To compensate for the lost volume, the body absorbs fluid from the kidneys, lungs, and intestines and immediately begins to manufacture new blood cells. When the blood lost is greater than the body’s ability to compensate, the patient will rapidly go into shock.
    • Hemorrhagic Shock. Occurring when the vascular system rapidly loses a large quantity of blood due to hemorrhaging.
    • Anaphylactic Shock. Occurs as a result of an extreme allergic reaction (anaphylaxis). It increases the permeability of the body’s blood vessels, allowing fluid to leech out of the circulatory system, thereby reducing the volume of circulating blood in the vascular system.
  4. Distributive Shock: The blood vessels are unable to constrict effectively. Normally, blood vessels control the flow of blood to different areas of the body by constricting and dilating to change the pressure of the blood. This process ensures that blood reaches the areas of the body that need it most. Injury, illness, toxins, and infection can all cause blood vessels to lose their ability to constrict, causing a drop in blood pressure. Although the actual volume of blood in the body does not change, the capacity of the vascular system itself increases as the vessels dilate, so the same volume of blood is under lower pressure.
    • Neurogenic Shock. A form of distributive shock that occurs when the nervous system loses its ability to control the constriction of the body’s blood vessels, causing them to dilate. This cause is usually an injury to the brain or spine.
    • Psychogenic Shock. A form of distributive shock that results from emotional stress. When a person receives upsetting news for example, the body’s blood vessels can dilate, allowing blood to pool in the extremities rather than circulating throughout the body. This effect is similar to that of neurogenic shock, but the cause is psychological rather than neurological in origin.
    • Septic Shock. A form of distributive shock that occurs as a result of severe infection. As the infection progresses, it releases toxins into the blood that cause the blood vessels to dilate, allowing blood to pool in the lowest part of the body.

Stages of Shock

A patient can go through three distinct stages of shock: compensated shock, decompensated shock, and irreversible shock.

Compensated Shock. When the body initially detects that perfusion is low, it attempts to restore normal circulation through a series of compensatory mechanisms. The blood vessels constrict, focusing blood towards vital organs and helping to sustain blood pressure. This reduces the amount of blood circulating to the less critical tissues in the extremities and skin, which causes the skin to become pale and cool. A patient’s capillary refill will slow during this stage of shock as less blood travels to the extremities. The heart beats more rapidly to increase blood flow. As a result, respiration must also increase so that the level of oxygen in the blood is not reduced. These changes in pulse and respiration can often be detected during the primary assessment, but there tends to be little change in blood pressure during the compensated stage. A patient in compensated shock may or may not be sweating, depending on the cause of shock and the individual patient’s reaction to it. The patient may be apprehensive or anxious.

Decompensated Shock. If the body’s compensatory mechanisms are unsuccessful, the body’s tissues begin to become hypoxic. At this stage, shock becomes life threatening, though immediate interventions may reverse the effects. Decreased oxygen flow to the brain can cause the patient to become confused, listless, or unresponsive, and the heart and other organs begin to work less effectively. Respiration will become slow, shallow, and irregular, and the pulse will become weak and rapid. Blood pressure will drop, and the body’s temperature will decrease. Cyanosis may occur around the lips and eyes due to the prolonged lack of oxygen, and the patient’s pupils will dilate. Diaphoresis (excessive sweating) and extreme thirst are common.

Irreversible Shock. Without intervention, decompensated shock progresses to irreversible shock. The body’s vascular system becomes unable to maintain its internal pressure, so blood pools in the extremities away from the vital organs. At this stage, the damage to the brain, heart, and other tissues is so extensive that the patient will not survive regardless of any interventions performed.

The effects of shock over time.

Care for Shock

Early recognition and care for serious injuries and conditions will minimize the effects of shock. Help the patient rest comfortably in the recovery or supine position. A supine position will help increase blood flow to the patient’s vital organs, especially the brain. Elevating the patient’s feet 20 to 30 cm can help improve blood flow to the head and torso. The supine position with feet elevated is sometimes referred to as the Trendelenburg position or shock position. This is not indicated if the patient has experienced trauma that is putting stress on the cardiovascular system or if the patient’s systolic blood pressure is over 100 mmHg.

Help the patient maintain a normal body temperature. This may involve controlling environmental factors, such as turning off air conditioning.

Avoid giving the patient anything to eat or drink, even if he or she is thirsty. The patient’s condition may be severe enough to require surgery, in which case it is better to have an empty stomach.

A patient presenting the signs and symptoms of shock should be rapidly transported to an advanced care facility, regardless of the cause. Because hypoxia is the underlying condition caused by shock, high-flow supplemental oxygen is indicated.

Seizures

A seizure is the result of abnormal electrical activity in the brain. It can cause temporary changes in movement, function, sensation, awareness, or behaviour. Seizures can occur when the normal functions of the brain are disrupted by injury, disease, fever, infection, metabolic disturbances, or conditions causing a decreased oxygen level.

Types of Seizures

Generalized Seizures. Generalized tonic-clonic seizures, also called grand mal seizures, are the most well-known type of seizure. They involve both hemispheres of the brain and usually result in loss of responsiveness. This type of seizure rarely lasts for more than a few minutes.

Before a generalized seizure occurs, the patient may experience an unusual sensation or feeling called an aura. An aura in this context can include a strange sound, taste, or smell, or an urgent need to get to safety. If the patient recognizes the aura, he or she may have time to sit or lie down and warn bystanders before the seizure occurs.

Generalized seizures usually last 1 to 3 minutes and can produce a wide range of signs and symptoms. When a seizure occurs, the patient loses responsiveness and can fall, causing injury. The patient may become rigid and then experience sudden, uncontrollable muscular contractions that can last several minutes. Breathing may become irregular and even stop temporarily. The patient may drool, and the eyes may roll upward. As the seizure subsides and the muscles relax, the patient may lose bladder or bowel control.

The four stages of generalized seizures are:

  1. Aura phase: The patient may sense something unusual (not all patients will experience an aura).
  2. Tonic phase: The patient appears unresponsive and experiences muscle rigidity.
  3. Clonic phase: The patient experiences uncontrollable muscular contractions (convulsions).
  4. Postictal phase: The patient displays diminished responsiveness with gradual recovery and confusion (he or she may feel confused and want to sleep).

Partial Seizures. Partial seizures can be simple or complex, and they are the most common type of seizure experienced by patients with epilepsy. They usually involve a small area of one hemisphere of the brain. A partial seizure can spread and become a generalized seizure. In simple partial seizures, the patient usually remains aware of his or her surroundings. Complex partial seizures usually last for 1 to 2 minutes, though they may last longer, and awareness is either impaired or lost while the patient remains responsive.

In simple partial seizures, there may be involuntary muscular contractions in one area of the body (e.g., the arm, leg, or face). Some patients cannot speak or move during a simple partial seizure, although they may remember everything that occurred. Simple partial seizures may produce a feeling of fear. They can also produce odd sensations such as strange smells or hearing voices. In rare occurrences, strong emotions such as anger or joy can be brought on by a seizure.

Complex partial seizures often begin with a blank stare followed by random facial movements (e.g., smacking the lips or chewing). The patient may appear dazed or be clumsy. The patient’s activities may be lacking in direction, and he or she may be unable to follow directions or answer questions. This type of seizure usually lasts for a few minutes but may last longer. The patient generally cannot remember what happened and may be very confused. Provide reassurance and calmly explain what happened.

Absence (Petit Mal) Seizures. Individuals may also experience an absence seizure, also known as a petit mal seizure. These are most common in children. During an absence seizure, there is brief, sudden loss of awareness that may be mistaken for daydreaming. There may be little to no movement, and the patient may appear to have a blank stare (though eye fluttering and chewing movements may also appear). This type of seizure is also referred to as a non-convulsive seizure, since the body remains relatively still during the episode. Most often, these seizures last for only a few seconds.

Febrile Seizures. Young children and infants may be at risk of febrile seizures, which are seizures brought on by a rapid increase in body temperature. They are most common in children under the age of 5 years.

Febrile seizures are often caused by ear, throat, or digestive system infections and are most likely to occur when a child or an infant runs a rectal temperature of over 39°C. A patient experiencing a febrile seizure may experience some or all of the following signs and symptoms:

  • Sudden rise in body temperature
  • Change in level of responsiveness
  • Rhythmic jerking of the head and limbs
  • Loss of bladder or bowel control
  • Confusion
  • Drowsiness
  • Rigidity
  • Holding the breath
  • Rolling the eyes upward

Status Epilepticus. Status epilepticus is a seizure that lasts longer than 5 minutes or a series of repeated seizures lasting longer than 5 minutes without a return to normal responsiveness between them. If you suspect that a patient is experiencing this type of seizure, the patient is in the rapid transport category, as this a serious medical emergency and can be fatal. If the seizure passes, place the patient on his or her side and suction the patient’s airway.

Epilepsy. Epilepsy is a term used to describe a group of neurological disorders in which the individual experiences recurrent seizures as the main symptom.

Most epileptic seizures last only a few seconds. People living with epilepsy can often control seizures with medication, and sometimes epilepsy can resolve with age. In more severe cases, the frequency of seizures may be reduced through curative surgical re-sectioning or implanted devices (e.g., a vagus-nerve stimulator). While some patients require lifelong medical therapy, sometimes medication may be reduced or even eliminated over time.

Care for Seizures

When treating a patient who is having a seizure, there are two main priorities: preventing injury and managing the airway.

To protect the patient from injury, move nearby objects away from the patient. Do not place anything in the patient’s mouth to prevent the patient from biting his or her tongue or cheek. It is rare that an actively seizing patient bites hard enough to cause significant bleeding, and this intended precaution may act as an airway obstruction instead.

Manage the patient’s airway by positioning the patient on his or her side, if possible; doing so will allow fluids to drain away from the mouth. Never put your fingers into the mouth of an actively seizing patient to clear the airway.

In some cases, the patient may be in the postictal phase by the time you arrive. Check to see if the patient was injured during the seizure. Offer comfort and reassurance, especially if the seizure occurred in public, as the patient may feel embarrassed or self-conscious. Keep bystanders well back to provide maximum privacy, and stay with the patient until he or she is fully responsive.

Transport Decision for Seizures

The patient will usually recover from a seizure in a few minutes. If you discover the patient has a history of seizures that are medically controlled, you may not need to escalate the patient to the rapid transport category.

However, the following cases indicate the patient is in the rapid transport category:

  • It is the patient’s first seizure.
  • You are uncertain about the cause of the
    seizure.
  • The patient presents with status epilepticus.
  • The seizure takes place in water.
  • The seizure is the result of trauma.
  • The patient is pregnant.
  • The patient is known to have diabetes.
  • The patient is a child or an infant.
  • The patient fails to regain responsiveness after
    the seizure.
  • The patient is an older adult who may have
    suffered a stroke.