Altered Mental Status Causes

Whether you have dealt with someone who is intoxicated or have come across someone who seems…off after hitting their head in a traffic accident, chances are you have had to assist someone presenting with an altered mental status.  In this Medical Monday, we are launching a series that specifically addresses different causes of why a person might have an altered mental status.  For the first part of the series, we will address stroke signs, symptoms, and treatments.  

Firstly, it is important to understand that there are two separate types of strokes (also known as cerebrovascular accidents).  They are as follows:

Ischemic Stroke – This is the most common type of stroke.  It is caused by a blockage either from fatty build up in the vessels blocking blood flow, or blockage from a clot that has formed.  To paint a simple picture as an example, imagine the brain as a small city in a mountainous area.  If a large avalanche is triggered and blocks the major pass or road into the city, all aspects of the city will suffer a major disruption if the blockage is not cleared.  The brain is no different.  If the patient does not receive the treatment that they need in a fairly small amount of time, it will be too late, and the patient will either end up with irreversible damage, or they will die.  As an interesting side note, heart attacks happen much the same way, just in a different part of the body. (The heart) 

Hemorrhagic Stroke – This type of stroke is less common.  In this type of stroke, a blood vessel in the brain has begun to leak, or it has ruptured causing the vessel to bleed into other areas of the brain.  The space between your cranium (the nugget holder) and the brain (the nugget) is very minimal.  With bleeding occurring from the vessel, pressure is created which essentially suffocates the brain cells.  Back to our small mountain city and the avalanche comparison.  Instead of the avalanche blocking the major road, the avalanche has fallen directly onto the small city smothering it.  It was taught in paramedic school that if a patient exclaims to you that they are having the absolute worst headache of their life, consider this type of stroke as a possible cause.      

Now that we know what the two different types of stroke are, we will discuss what kind of assessment that you can perform to assist with determining if the altered mental status patient is suffering from this condition.  It is called the BE FAST assessment.

B – Balance.  Does the patient have trouble maintaining their balance?

E – Eyes.  Does the patient have blurred vision in one or both eyes?

F – Facial Drooping.  If you observe facial drooping on either side of the patients face, you should request an EMS response.  

A – Arm Drift.  Direct the patient to hold both of their arms out in front of them and to keep their eyes closed.  Look for one arm that appears weaker, or that drifts.  

S – Speech.  Is the patient aphasic (unable to speak at all), or are they presenting with slurred speech or saying random words that have no order or make no sense?

T – Time.  It is critically important to note the time that you observed the person with ANY of the above symptoms, and ALSO make every attempt to find out what time it was that they were last seen normal.  This is so important because if the patient is having an ischemic stroke they only have 3 hours (in the vast majority of cases according to 2018 American Heart Association guidelines) to receive the drug (clot buster) used at the hospital to treat these patients.  

With all of that being said, most every single drunk person will exhibit one or more of the above traits.  While good common sense along with experience plays a strong role, it is very important to note that it is absolutely possible that a person who is intoxicated is ALSO experiencing a stroke.  It has been highlighted in the medical world that intoxicated patients who are actively having a stroke have delayed diagnoses and treatment.  If there seems more to the scene than someone just being drunk, I urge you to request an EMS response.  

Another medical condition I will address is a transient ischemic attack (TIA).  This is a medical event where a person may experience stroke like symptoms, but they resolve over a fairly quick amount of time.  If a person has experienced a TIA, the chance that they will eventually experience a full-on stroke increases significantly.  

Lastly we will cover Bell’s Palsy.  Bell’s Palsy is a condition where the facial nerve (one of your 12 cranial nerves) becomes compressed or inflamed which causes one side of the face to droop.  This condition obviously mimics a sign of a person having a stroke, however a person with bell’s palsy typically does not have a fast onset.  Also, in the case of a stroke there will likely be many more signs and symptoms that present with the patient.  

Key points to remember:

Stroke = Bad

Use the BE FAST mnemonic as an assessment guideline.  

Request EMS early on.

Note the time you found the patient and how they presented

Find out when they were last seen normal

If you believe that the patient is having a stroke, it is critical to get the patient to a hospital that has a stroke center capability!!

I hope that you learned something from this down and dirty stroke episode of Medical Monday.  If you have something to add, or if you have any questions or comments, please leave them below.  As always, I look forward to hearing from you.