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
- Assess and support ABCs. If trauma is suspected, refer to the SPINAL MOTION RESTRICTION Policy to immobilize the spine & refer to the TRAUMA Guidelines.
- 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.
- Administer oxygen, as needed, to maintain SpO2 of at least 94%.
- If hyperthermia is suspected, monitor the patient’s temperature frequently. Be prepared to cool the patient aggressively, but do not cause shivering.
- Perform a POC glucose analysis.
- 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.)
- 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
- Consider establishing IV access at a TKO rate or use a saline lock. If the patient is hypotensive, treat according to SHOCK Guidelines.
- 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).
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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.
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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.
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. . . 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.
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1 year to 13 years of age
- Glucagon 1 mg IM, IN, or SQ.
- May repeat once after 20 min.
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Less than 1 year of age
- Glucagon 0.5 mg IM, IN, or SQ.
- May repeat once after 20 min.
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- 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.
- 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.
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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.
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If unable to establish IV access or if IN administration is not possible, administer the naloxone IM. |
- 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.
- 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.
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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.
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- 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)
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Pediatric
- Contact BioTel for authorization and dosing (risk of phlebitis). (optional medication)
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- For patients with excited delirium, refer to EXCITED DELIRIUM Guidelines.
- Monitor vital signs and attempt to transport.
- For additional patient care considerations (e.g. other drug toxicities) not covered under standing orders, consult BioTel.
Notes:
- If the patient becomes alert and oriented after glucose/glucagon administration, do NOT administer naloxone.
- If the patient does not respond to glucose/glucagon & naloxone, consider other causes of altered LOC.
- Do not attempt to restore full consciousness in patients with evidence of narcotic use. Titrate naloxone administration to restore adequate ventilatory status, or to a SpO2 of at least 94%.
- Transport any patient taking any medication combination that includes glipizide (Glucotrol®) or other sulfonylureas (Dymelor® [acetohexamide], Diabinese® [chlorpropamide], Orinase® [tolbutamide], or Tolinase® [tolazamide]) if hypoglycemia is present in the field, as these agents are cleared very slowly from the bloodstream and necessitate physician evaluation.