ALTERED LEVEL OF CONSCIOUSNESS

Inclusion criteria: Patients who are disoriented, weak, dizzy, confused, suffered a syncopal episode, or are unconscious.  In these guidelines, hypoglycemia is defined as a POC glucose analysis of:
Adult:  less than 80 mg/dL (non-diabetic), OR less than 110 mg/dL or symptomatic (diabetic);
Pediatric:  less than 70 mg/dL (non-diabetic), OR less than 70 mg/dL or symptomatic (diabetic).
NOTE: Known diabetics may be symptomatic at a higher POC glucose level.

NOTE:  Never administer dextrose to a patient who is NOT  hypoglycemic. If the patient’s level of consciousness is altered, and a POC glucose analysis is normal, search for alternative causes.  Additional information is available at the bottom of these guidelines. Refer to NEONATAL Guidelines for newborn care.

SPECIAL NOTE: The use of naloxone should be restricted to patients suspected of opioid narcotic overdose AND hypoventilation and/or hypoxia, AND pinpoint pupils. Its use outside of these indications may cause undesirable narcotic withdrawal.

Basic Level

  1. Assess and support ABCs. If trauma is suspected, refer to the SPINAL MOTION RESTRICTION Policy to immobilize the spine & refer to the TRAUMA Guidelines.
  2. If there is no evidence of trauma, place the patient in a position of comfort or in the left lateral position. If there is evidence of shock, place the patient supine with the feet elevated and closely monitor the airway.
  3. Administer oxygen, as needed, to maintain SpO2 of at least 94%.
  4. If hyperthermia is suspected, monitor the patient’s temperature frequently. Be prepared to cool the patient aggressively, but do not cause shivering.
  5. Perform a POC glucose analysis.
    1. If the adult patient is hypoglycemic but responsive AND able to protect his or her airway, administer 1 tube (15 g) oral glucose SL. (Pediatric patient 1 to 13 years old: administer ¼ - ½ tube SL.)
    2. If symptoms persist after 10 minutes, administer a second tube (15 g) of oral glucose SL. (Pediatric patient 1 to 13 years old: administer ¼ - ½ tube SL.)

Advanced Level

  1. Consider establishing IV access at a TKO rate or use a saline lock. If the patient is hypotensive, treat according to SHOCK Guidelines.
  2. 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:

At least 14 years of age (or over 50 kg)

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

1 year to 13 years of age

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

Less than 1 year of age

  • 10% dextrose 5 mL/kg IVP/IO (waste 40 mL of D50; replace with 40 mL Normal Saline).
  • Contact BioTel.
  • Newborn under 1 month of age: administer only 2 mL/kg.

 

 

. . . IV or IO access cannot be obtained, administer:

At least 14 years of age

  • Glucagon 1 mg IM, IN or SQ.
  • May repeat once after 20 min.

1 year to 13 years of age

  • Glucagon 1 mg IM, IN, or SQ.
  • May repeat once after 20 min.

Less than 1 year of age

  • Glucagon 0.5 mg IM, IN, or SQ.
  • May repeat once after 20 min.
  1. All patients treated under these guidelines must have continuous cardiac monitoring. If a dysrhythmia develops, treat accordingly under its specific guidelines. Patients with continued altered mentation should also have ETCO2 monitoring.
  2. If there is evidence of opioid narcotic use, with altered mental status, hypoventilation and/or hypoxia, AND pinpoint pupils, administer:

Adult

  • Naloxone 0.4 mg every 5 minutes via IN or SLOW IVP or IO until the respiratory rate improves and the patient can maintain a SpO2 of at least 94%, OR until 2 mg have been given.

Pediatric

  • Naloxone 0.1 mg/kg via IN or SLOW IV Push or IO (maximum single dose 0.4 mg) until the respiratory rate improves and the patient can maintain a SpO2 of at least 94%, OR until 2 mg have been given.
If unable to establish IV access or if IN administration is not possible, administer the naloxone IM.
  1. 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.
  2. If altered mental status with bradycardia is caused by beta-blocker toxicity, administer:

Adult

  • Glucagon 1 mg – 2 mg IVP/IO over 2 to 5 min, OR 1 mg IM or IN. • May repeat once after 20 minutes.

Pediatric

  • Glucagon 0.5 mg (under age 1 yr) or 1 mg (at least one year of age) IV/IO, IM, or IN. • May repeat once after 20 minutes.
  1. If altered mental status with bradycardia is caused by calcium-channel blocker toxicity, administer:

Adult

  • Calcium chloride, 10 – 15 mg/kg slow IVP/IO. (optional medication)

Pediatric

  • Contact BioTel for authorization and dosing (risk of phlebitis). (optional medication)
  1. For patients with excited delirium, refer to EXCITED DELIRIUM Guidelines.
  2. Monitor vital signs and attempt to transport.
  3. For additional patient care considerations (e.g. other drug toxicities) not covered under standing orders, consult BioTel.

Notes: