Table 5.

Initial Assessment and Management of a Patient with Altered Mental Status

	Assessment	Intervention
Airway	Is patient protecting his/her airway? Look for airway obstruction including foreign bodies	Extend neck, provide chin lift or jaw thrust. Suction oropharynx In cases of trauma, provide cervical spine immobilization. Nasopharyngeal airway Oropharyngeal airway if no gag Endotracheal intubation patient is not able to protect airway
Breathing	Is there respiratory distress? Is the patient hypoventilating? Is the patient cyanotic or hypoxic? Ascultate the chest	Provide high flow oxygen* Provide bag-valve mask ventilation if hypoventilating
Circulation	Check for pulse while getting blood pressure measurement Look for other signs of hypoperfusion (i.e. capillary refill, skin temperature). Place on electrocardographic monitor to look for dysrhythmias Look for obvious bleeding If hypotensive or signs hypoperfusion, consider bedside ultrasound**	Establish intravenous access Two large bore intravenous lines are needed in patients who are hemodynamically unstable. Fluid challenge with intravenous crystalloid if hypotensive or has other signs of hypoperfusion Stop hemorrhage if accessible
Disability	Examine pupils Assess responsiveness using a scale such as the GCS Check finger stick blood glucose Consider toxicologic causes (i.e. opioid overdose)	One amp (50cc) of D50 in hypoglycemia Nalaxone in suspected opioid overdose
Exposure	Expose the patient. Minimize heat loss in patients who are normothermic or hypothermic Look for transdermal drug patches (e.g. fentanyl) that could cause mental status changes Look for signs of infection	Remove drug patches

^*In patients who have chronic obstructive pulmonary disease, high flow oxygen may remove their respiratory drive especially in patients with chronic respiratory failure. Oxygen saturation should be titrated to the low 90s%.

^**Bedside ultrasounds are commonly used in emergency departments and intensive care units to rapidly rule out causes of hypotension such as cardiac tamponade and intrabdominal blood. The inferior vena cava can also be assessed using the bedside ultrasound to assess whether a patient is hypovolemic (dehydration, hemorrhage) or hypervolemic (heart failure).

GCS, Glasgow Coma Scale