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Altered Level of Consciousness


Inclusion Criteria: Patients who are disoriented, weak, dizzy, confused, suffered a syncopal episode or are unconscious. In this guideline, hypoglycemia is defined as a blood glucose analysis (BGA)
Adult: less than 80 mg/dL (non-diabetic), OR less than 110 mg/dL (diabetic)
Pediatric: less than 60 mg/dL (non-diabetic) OR less than 90 mg/dL (diabetic)
Known diabetics may be symptomatic at higher BGA.


NOTE: Medics should transport patients taking any medication combination that includes glipizide (Glucotrol®) or other sulfonylureas (Dymelor® [acetohexamide], Diabinese® [chlorpropamide], Orinase® [tolbutamide], Tolinase® [tolazamide]) if hypoglycemia is present in the field.


          Basic Level

  1. Assess and support ABCs. If medics suspect trauma, immobilize the spine and refer to the Trauma guideline.
  2. Place the patient in a position of comfort or in the left lateral position. If evidence of shock, place the patient supine with the feet elevated and monitor airway closely.
  3. Administer oxygen as needed to maintain SpO2 of at least 96%.
  4. If medics suspect hyperthermia, monitor patient’s temperature frequently. Be prepared to cool patient aggressively but do not allow shivering.
  5. Perform fingerstick blood glucose analysis (BGA). If the patient is hypoglycemic AND can protect his or her airway, administer 1 tube oral glucose SL. If symptoms persist after 10 minutes, administer a second tube of oral glucose SL.


    Advanced Level

  6. Consider establishing IV access at a TKO rate or use a saline lock. If the patient is hypotensive, treat according to Shock guidelines.
  7. If the patient is hypoglycemic AND . . .

    . . . the level of consciousness does not improve with oral glucose, or if oral glucose could not be given, administer:

    Over age 12 years

    • 50% dextrose, 50 mL (25 grams) IV push
    • If symptoms and/or hypoglycemia persist after 10 minutes, administer an additional 25 grams

    1month to 12 years

    • 2 mL/kg 25% dextrose IVP or IO (waste 25 mL of D50; replace with 25 mL NS)
    • If symptoms and/or hypoglycemia persist after 10 minutes, administer an additional 2 mL/kg IV push

    1month to 12 years

    • 5 mL/kg 10% dextrose IVP or IO (waste 40 mL of D50; replace with 40 mL NS)


    . . . IV or IO access cannot be obtained, administer: (dose my be repeated in 45 minutes)

    Over age 12 years

    • glucagon 1 mg IM, IN, or SQ

    1 year to 12 years

    • glucagon 1 mg IM, IN, or SQ

    Less than 1 Year

    • glucagon 0.5 mg IM, IN, or SQ


  8. All patients treated under these guidelines must have continuous cardiac monitoring. If a dysrhythmia develops, treat under its specific guidelines. Patients with continued altered mentation should also have EtCO2 monitoring.


  9. If the patient is not hypoglycemic but there is evidence of narcotic use, administer

    Adult

    • naloxone 0.4 mg every 5 minutes via IN or SLOW IV push until the respiratory rate improves and the patient can maintain a pulse oximetry reading of 96% OR until 2 mg given

    Pediatric

    • naloxone 0.1 mg/kg via IN or SLOW IV push or IO (max single dose 0.4 mg) until the respiratory rate improves and the patient can maintain a pulse oximetry reading of 96% OR until 2 mg given
    If unable to establish IV access or if IN administration is not possible, administer the naloxone IM.


  10. If the respiratory rate or oxygen saturation does not improve with a full naloxone dose, secure and monitor the patient’s airway with an advanced airway, discontinue naloxone use, and proceed in the algorithm.


  11. If altered mental status or bradycardia caused by beta-blocker toxicity:

    Adult

    • Glucagon 1 mg - 5 mg IVP over 2-5 min or 1 mg IM

    Pediatric

    • Requires BioTel authorization


  12. If altered mental status or bradycardia caused by calcium-channel blocker toxicity:

    Adult

    • Calcium chloride, 10 - 15 mg/kg slow IVP (optional medication)

    Pediatric

    • Requires BioTel authorization


  13. For patients suffering from excited delirium, apply restraint according to the Restraint of Patient Policy and administer:

    Adult

    • Diazepam, 2.5 mg – 5 mg slow IVP to a maximum of 10 mg
    • Midazolam, 2.5 mg - 5 mg slow IVP (Max 5 mg) or intranasal (Max 10 mg)

    Pediatric

    • Pediatric sedation requires BioTel authorization
    NOTE: Individual departments may carry only one of these medications; They are not required to carry both.

  14. Monitor vital signs and transport

  15. For additional patient care considerations not covered under standing orders, consult BioTel.

Notes:

  • If patient becomes alert and oriented after glucose/glucagon administration, do NOT give naloxone.
  • If patient does not respond to glucose/glucagon and naloxone, consider other possible causes of altered LOC.
  • Do not attempt to restore full consciousness in patients with evidence of narcotic use. Titrate naloxone use to adequacy of ventilatory status.

 

 
 

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