Episode 197 - Altered Mental Status - The Next 30 Minutes

(electronic music) - Medic-43, district one, engine 51, response, cardiac arrest. (upbeat music) (engine revving) (screaming) (upbeat music) - Hello everybody, welcome again to another edition of the MCHD Paramedic Podcast. This is Dr. Casey Patrick and joining us is our regular guest, Dr. Mike Deepas-Quali. And we are gonna continue with our next 30-minute series that was based off serial killers. So we talked about the serial killers a couple years ago. Everybody seemed to really like those episodes when we think about what kills people with chest pain and shortness of breath, ultra-mental status, trauma, abdominal pain. And then a lot of medics across the service came to us and said, "Hey, what happens in the ER "when we bring you a chest pain?" Or a trauma patient. And today we're gonna hit on what happens for that first 30 minutes or so when we get a serial killer patient with ultra-mental status. And we're not starting with anxiety. We're not starting with chronic non-emergent conditions. We're starting in the ED with the serial killers in mind as well. So how does our approach differ? What labs do we order? How do we initiate the workup after EMS handoff? That's what we're gonna hit on today. But before we get into the next 30 minutes, let's do a quick review. So take the listeners through, when people call with ultra-mental status, what things kill them emergently? What do we want to MCHD medics thinking about on the way to that Delta Ereco call where that patient's confused? And we know they're really sick. - Yeah, so I think the important breakdown is to think about how long they've been confused. It was a sudden set of confusion where they completely fine five minutes ago. And then now they're completely unresponsive or confused. Or has this been something that's been gradual? Mom's been getting more confused over the last couple of days and that sort of thing kind of helps guide. Well, you start thinking about it first, but the big ticket items I think we need to think about whenever we're on scene with someone that's confused are stroke. I mean, I think everyone goes there first, a sudden onset of confusion. If it's real sudden, you could think about a hemorrhagic stroke. Seasures, maybe the patient's post-dictal. Oftentimes people will have sinkable episodes that look like seizures or they had an actual seizure now they're confused afterwards. So that's definitely something to think about. And that leads right into diabetic emergency. If someone is confused, anyone that's had a seizure should definitely have their blood sugar checked right away as well. 'Cause it could be related to their diabetes if they have that. You could also think about talks. You wanna think about other reasons people are confused. They could be on some depressed medication. They could have been on some stimulant medication. It's then resulted in hemorrhagic strokes. So there's all sorts of different things to think about. And I think the big differentiator is kind of the time course because if someone's been confused for a while or getting more confused, then you start to think about sepsis and other kind of systemic stuff. Why if someone would be confused, maybe some liver reasons or ammonia level, that sort of thing. So time course is key. Acuity is key. Vodal signs are vital. You know, age is always gonna play a role. You know what patients are at risk for, varies by age. You know, notice your surroundings when you're in folks homes. We don't have that advantage in the emergency department. And I know that that's kind of a common, you know, to take a look for pill bottles and prepare a perinealia and other things that could give you clues. Those are really vital for us as emergency physicians. And then, you know, if you can get some information from family or from bystanders, that's always key that may be lost for us in the emergency department. Those folks don't always come to the hospital. And so, you know, an allergic history, a surgical history, a recent hospitalization, something there may absolutely hold the key and that may be available for the medic on the scene, but for the emergency physician trying to take over, they may not show up. And we assume that's gonna happen, but it doesn't always. So stroke, seizure, substances or talks, blood sugar, sepsis or infection. I believe we left sepsis for last there for a good reason, because the time course there is often more indolent or subacute, not as acute as the others. So let's roll into the individual ones. Stroke is one for me at your little newer at doing emergency medicine than I am. This is one of the biggest 180s that I've experienced as an emergency physician over the last 20 years. What I do for stroke now in the ED could not look more different than what it did 20 years ago when I learned how to take care of strokes. 80% of them are a schematic. You mentioned the hemorrhagic versions, which are often very acute confusion. 20% fall into the ICH or the hemorrhagic stroke category. If you've listened to the podcast for a long time, you heard Dr. Dixon back when he was here talk about you were acutely normal and now you're acutely abnormal. It's a stroke until proven otherwise. If I heard him say that once, I heard him say that. Azillion times as a stroke crusader that he was, when I took care of strokes in 2006, we sent them to the CT scanner like we do now, not quite as quickly, and we got a non-contrast head CT. And then we crossed our fingers and hoped for the best, really, really advanced medicine. It's amazing how stroke care has changed in 20 years. How does it look now when an altered, acutely altered, maybe facial droop, throwing some arm weakness. When they show up to your ED and you're gonna take care of that patient, nothing happens slowly, right? - No, it's a whole system of care, right? They get called stroke right from the front or EMS even calls a head, more ready for them. A lot of places, you get the patients weight and move them right to the CT scanner right from the EMS gurney, get the imaging done right away. We're getting CTs of the head still, but we're also getting CTAs of the head and neck. It's kind of the whole package there to look for stroke. The main part of that head CT is to look for bleeding. If the patients in the acute window and would be a candidate for thrombolytics, we just have to make sure they're having a brain bleed 'cause giving thrombolytics to that patient would not be advisable. But that's the main part. And I think there is some confusion in the EMS side of things that the main reason to get the head CT is to make sure that there's no intercranial bleeding going on. And as long as that looks clear, that doesn't rule out stroke or a rule in ischemic stroke. That's just to make sure there's no bleeding. Once we've established that, we moved on the pathway if the patient is candidate. And then the CTA imaging, that's contrasted imaging to look at the vasculature in the neck and in the brain is looking for large vessel occlusions. I know people probably heard a lot about that. And basically what we're looking for is trying to see if in those larger vessels in the neck and the brain, if we can actually see where the clot actually is, where the blockage is. Now, these patients will often have very high NIH scores and have a lot of debility. They'll have a lot of symptoms, what I mean. So someone with a left pinky finger that's numb or maybe the left side of my face is a little bit different feeling than the right. That's not a large vessel occlusion. We're talking people with total hemiparallysis or a really bad a phase that that sort of thing. And that large vessel occlusion matters because not only can we see it, it's not distal and too small for imaging to see. It's also retrievable. And so that's where the decision tree branches from the first part that you mentioned was is the patient having a hemorrhagic stroke because if they are, then there is no thrombolytic to be given, right? That would be bad. And there is no large vessel occlusion or no large vessel clot to go and retrieve. Oftentimes those patients, while very, very sick, they become a little bit less urgent from a procedural standpoint, blood pressure control, then becomes very vital if they have anti-quagulants on board, the hemorrhagic stroke folks get reversal. Medical management really becomes the key in those folks. They don't often go get acute neurosurgery. Now there's always variations there and age and location and different things can drive that. But for the most part, a hemorrhagic stroke is medically managed. Neurosurgeons are involved in those decisions, but typically it's a medical management course. Now, if you have a large middle cerebral artery clot that you can see on that CT and geography of the head, then we're talking about neurointerventionalists and can you go for indivascular retrieval? And can we basically catheterize the brain and pull that clot out? And some of those recoveries and some of those just massive impacts that that procedure has and has had in my career are really some of the more amazing cases that I've seen. And when I think about the evolution of medicine over my career, which sounds really old, it's not that long ago. It's an amazing technology. And the system of care is important. And where we fall in EMS is even more important because notification and recognition of these patients because you mentioned the NIH scale and that's the NIH stroke scale that we use in the hospital, which is a little complex for EMS. It's a multi-step question, take the patient through face and speech and motor and sensory, engage and vision. I'm not gonna reside it. I don't think I can get it exactly right. But the higher it is, some of the hard part for me is a emergency physician. It's the higher it is, the harder it is to administer the test properly because the patient can't cooperate. And so when you get that NIH stroke scale in the 20s, you can't really communicate with a patient very often. And so a lot of these really altered, really sick patients that in the past I believe were delayed. And I've had some of these, even intubated patients recently, for me that were acutely altered, intubated to the respiratory failure. And then we take them to CT scan. And now we get CTAs when I didn't early in my career, they did have M1 and M2 lesions. And they were operable. And it's not quite as simple as the NIH stroke scale is eight. And I can communicate with the patient and they're a little aphasic. So these really dense, really high NIH stroke scales. And then that's another issue for their neurointerventionless because the higher the stroke scale is, the higher the risk is for them. But that's where we really take risk benefit into account. And if you think about yourself as a patient, if you're that dense, you want to give it a Hail Mary? Yeah. That's actually a really good point about how debilitating are the symptoms that you're experiencing. Because if you just think about more, say you don't see an LVO kind of more run of the mill stroke, someone's certainly within the time window for thrombolytics and they would qualify. But their NIH is low. It's one, it's two. Maybe they just have a little bit of numbness on one side. The thrombolytics are not without risk. And so that really becomes a really important informed decision to make with the patient at the bedside. It's not as simple as you're having a stroke. You're in the window. You qualify. Here you go. Because there is risk to that medication. And it certainly can cause bleeding. And so if I can't move one side of my body, I'm well way more apt to say you'd love to do it. I would want that. But if it's something non debilitating, if I just have some numbness on one side, I may pause and consider it a little bit more as to whether I want to get that medication. And so I have those discussions with patients all the time. And I think that as the emergency physician, we can really influence that decision greatly. And so there is a lot of back and forth and risk and benefit discussion. But if I feel strongly, hey, you have a lot of symptoms and you may benefit from this, we should probably do it. We proceed. And otherwise, if the symptoms are less debilitating and the patients are willing to discuss it with us, we may not proceed. So this is why sometimes in the emergency department, you may call stroke alert. And we may go through the whole process. And the patient still may not wind up getting a thrombolytic. And that's really where the difficulty comes in our world is trying to decide who qualifies for what, based on really it's a risk stratification decision. And when we think about individual retrieval, there is a risk for stroke with that procedure or risk for damage from puncture, pseudanurism, vascular injury. And there definitely is a risk with thrombolytic of bleeding. The idea to liece the thrombus is great. But that also puts you at risk for spontaneous bleeding elsewhere. So if there's no large vessel occlusion, but we still suspect stroke, then we often give thrombolytic alone or thrombolytic of choice these days is TNK or TNEC place. The advantages there are single, basically, IV push, single dose. There's no drip involved. That's a relatively new development, ultiplace or TPA is what some folks I still catch myself saying TPA when I mean TNK. So, ultiplace, TPA, old, required, and drip, new TNK or TNEC place. One of the things I wanted to hit on here when we think about is Scheme Extrokes and our protocols here at MCHD is just not to get too aggressive with blood pressure management. When we're thinking of Scheme Extrokes as possible, that's one thing, especially I find with younger folks, whether that's physicians or nurses, like hey, the blood pressure is really, really high. And actually the neurologist approach and the neuro-interventionist approach and those patients are to allow that blood pressure to be high, permissive, high-pertensive situations which can increase or I guess maintain collateral flow is the thought there. So something that oftentimes like, well, we're okay, we don't have to treat that blood pressure 190 and in fact if we do, you may actually make the patient worse. Now remember, I'm talking about a Scheme Extroke here, not hemorrhagic where the approach is much different medically and blood pressure lowering is the key. So we can go on about this one forever. That's just an insight into the large vessel occlusion versus the smaller strokes. And then when we think about thrombolysis versus endovascular retrieval where our decision tree branches go, let's talk about seizures because this is probably one when we think about strokes that oftentimes gets confused the most. Is seizure because they can look alike, especially if we see them after the fact, you may think, well, I see the seizure, Doc, that's easy. But we don't always see it. We may just find the confused person. So looking and asking about clues or key, some of the things that are gonna really point us down the seizure pathway in the emergency department, post-dictal state is very important. If someone has a sinkable episode, they come to and are at their baseline, seizures are often not. Tongue biting is key, especially lateral tongue bites. Past history of seizure, don't forget that one. Remember a patient when I was training that I gave TPA to, it was a place at the time. One of the first patients I gave, I'll tell you what it was, a younger guy. He had a very dense hemiparesis. And we were actually kind of excited about getting to give it. Yeah, we're gonna help this guy and his friend rocks and he goes, "Robbie, what are you doing?" He had another seizure. Oh, dang it. And so that's Todd's paralysis. That's hemiparesis weakness after a seizure episode. So I got to see that in real time and we turned off the TPA drip. Thankfully he didn't have any bleeding issues there. What about your seizure workup? So this is one I believe that sometimes, I can get pretty close to discharging the patients off the stretcher with seizures. And I get the cross-eyed look from the medics. Like aren't you gonna do more? That's all you're gonna do. They're cleaning the stretcher and the patients got their discharge paperwork. Talk about how seizure workups work or us in the ED. I think it just depends a lot on history, right? As with everything else we've talked about and we do an emergency medicine, the history is king. So if a patient comes by EMS and they've had a seizure, but they have a history of seizures and the history from EMS is, well, he didn't take his seizure medicine this morning. Well, then we're almost essentially done. We know what's going on. The patient has epilepsy. They unfortunately didn't have their medicine this morning. We should give them their medicine and then as long as they're okay and back to baseline mentation, they can probably go home and follow up. That's why history is so important in these cases. Number one cause of seizure is misdose of seizure medication. Now if it's a lifetime first seizure, that's where it gets a little bit more of a thought process involved. We have to think more about why they had seizure to do a little bit more investigating. I think that requires labs and probably a head CT if it's first time seizure, rule out a brain mass or some sort of brain bleeding or electrolyte disturbance. But once those are done and look okay, everybody kind of gets one a little bit. So I don't send people home on seizure medications. I will give them neurology follow up for first lifetime seizure, especially if they're younger to fall up in the office. But really what it comes down to is identifying if there's an obvious cause of seizure or if this is just a seizure that the patient had and whether they had a history of that or not. Very high percentage of folks out there have a seizure. A much higher percentage have a seizure than have epilepsy. Good point to hit on the fact that epilepsy from a diagnostic standpoint is unprovoked seizures that occur repeatedly over time. The neurologist may have a much more elegant way of saying that. But the learning point is just because you have a seizure doesn't mean you're gonna have another one. In fact, you're highly likely not to have another one. And it surely doesn't mean that you have epilepsy. The other thing to remember from an emergency department, emergency physician standpoint is we really concentrate on whether that seizure was provoked or unprovoked. So many of the seizures that we see, unfortunately are substance use related and withdrawal related and those folks don't need a million dollar workup. They need to either be bridged through their withdrawal. Benzo-Dazapine withdrawal, alcohol withdrawal, that's deadly and they need to be treated for those things. But even things, and we talked about this on the podcast before, Tramadol, is one of those medicines you guys hear about used in the ER. It's a medicine that I absolutely hate. And there's lots of mechanism reasons why. But one of the big reasons is even at therapeutic, what we would assume are therapeutic doses. In other words, I gave you the Tramadol for your back pain at the right dose from, looked it up on Google and I gave you the right dose. It can still provoke seizure. And there's good evidence that a lot of first time seizures, upwards of seven to 10% of them out there, overall are related to Tramadol use. And so you don't need any EEG, you don't need an MRI. If your seizure is provoked, just remove the provocation. And Israeli the key stimulants are a big one. Stimulant use can cause seizures. You don't need an MRI for that. You need to stop using methamphetamines. That's a pretty easy fix. One of the last pieces that come into our decision tree and that really I tend to focus on a lot from a risk standpoint is driving instructions for seizure history. It's a big deal. They don't need to drive until they've been worked up. I don't generally clear people to drive. the ER, I don't know how you approach that. Medically, legally, there's a lot of discussion there. I just try to make it clear that you shouldn't drive until you've been cleared. What the state does with driver's licenses and things like that, that's outside of our purview, we just need to mention it because if we don't, that's a big risk for the patient and the public. - Yeah, I mean, I've had people say, so you were saying I can't drive. I'm like, well, I'm saying you shouldn't drive. I'm not gonna call the police and see what you're doing tomorrow, but I'm telling you, you should get the work up and you should refrain from driving until that. - So we just, we hit on some talks in there, so we can move on from seizures into talks, just so common in the day today. And oftentimes, what, when you really look at the serial killers, and you know this from your practice on the truck, patients, hopefully sometimes have one thing, but they often can have more than one. It can be a seizure from a toxicology cause. It can be, you mentioned earlier, an intercerebral hemorrhage from excess stimulant use and exceedingly high blood pressure. So, you know, one of these can always lead to the other or have overlay. Talks and seizures go hand in hand. You gotta use your clues and use your eyes and ears and what's around you. Don't forget, don't forget the EKG. Don't forget to get the patient on the monitor and look around. We reviewed the case yesterday and we see this in the literature. But when we look at missed or delayed onset of compressions, you know, the most common cause there is seizure. So, make sure for both seizure and talks, we're getting a monitor on cause VF can look a lot like both. And then, okay, it's not VF, it's something else. That EKG is really important in talks cases too. Wide complex plus ultra mental status and ingestion. We always want to think about my card. Our protocols used to read here if there was a TCA overdose. Give by car, but why is that? Because TCA have sodium channel blocking properties and that protocol is maybe out there in your EMS service right now. And we had a medic about seven or eight years ago walking to my office and she had an EKG and it was wide and looked ugly and she said, I wanted to give this by car. I said, well, why didn't you? She said, well, it was a Benadryl overdose. I said, well, okay, go for it. She was like, look at the protocol. So I pulled it out and it said for TCA overdose. And so if you read our MCHD protocols now, for any suspected overdose, if you see wide complex, we're going to assume sodium channel blockade. And that may be a TCA, it may be Amitriptaline or Eleville, but it also may be Benadryl. There's lots of others. I thought that was a really solid example. We've talked about it on here before of a medic-driven protocol change during the service. There's some really bad actors when it comes to talks. I don't believe all talks is necessarily created equal. I don't want to offend the talks colleges out there, but there are some ingestions where we work through it and I don't get any raise and heart rate or armpit sweat. But there are some that when I hear that are coming, I get really nervous and think about calling in all the reinforcements. What are some of those for you? I put some notes on here of mine. I don't know if mine are yours. But if someone has a well-beautiful overdone that always gets me uncomfortable, especially the extended release. Anything extended release, well-breaching, a lot of the combo side drugs where we have anxiety depression or lithium. Olythium. Oof. Cardiotoxins, I don't like. Oh, yeah, big beta blocker overdose. Big subchannel blocker. Yeah, or did Jackson is not any fun. But those are some of the ones where we may be more concerned and the thing about the extended release ones, especially extended release, well-buterin, is on that list or the extended release, even depacote, is they can look really normal initially. And that's where you can get fooled from an EMS standpoint. If someone takes a large amount of most any drug, we should be prepared for the crash. And if you see ER or XR, you don't have to know what drug it is, but anytime you see extended release, ERXR on that prescription bottle, pads on, prep for airway compromised. Think about your bicarbs right in your holster. All of those things that you might need for a crashing tox patient, good access, good report to the hospital, because I have seen those patients, I know you have to, that look really, really good. And then they crash. And why is that? Because the drug is designed to not release at once. It's an extended release formulation. That's the point. And when you take that in large quantities, you may be fooled up front. And as that release happens, then the crash occurs. Whereas it's not exactly the same as if you, have a large overdose of methamphetamine or heroin or fentanyl, like that's not gonna happen two hours later. I had a patient just a couple of nights ago that was in for a reported ingestion of a large amount of binzos. And three hours later, he was-- - It showed itself. - No, he was talking just like me and you. So sometimes we know that did the ingestion actually happen or not. And in his case, if he had taken a large amount of Xanax as he said, at three hours, I'm not saying it's 100%, but it's pretty unlikely he's still chatting it up. Extended release, totally different ball game. And he absolutely could be chatting it up in three hours later, being a rest. So those are a big ones. Talks to the drones are important. We look for talk to drones just like y'all do. With mixed meds and mixed polysubstance, don't put all your eggs in any toxic drone basket. They're clues and they should guide you, but just because the pupils are X, Y or Z doesn't mean that it's not an opiate or doesn't mean that it is an opiate. And especially with all the synthetics that are out there now, seems like there's a new one every time we turn around. So in the end, the antidote for opiate overdose is oxygen. - Oxygen management. - Oxygen and adjunct is naloxone. Please, please, please. We don't titrate naloxone to awake. There's no indication for that. We titrate naloxone to respiratory drive. I think you said it pretty good in our discussion yesterday at lunch if a tox patient is awake. - Oh, I'm happy. - You did a good. - A tox patient is awake, but make them asleep. And if they're asleep, keep them asleep. - Yeah, there's, I mean, we just want to maintain oxygenation and respiratory drive. What about sedatives, alcohol? Those are some of the ones that are pretty straightforward. It's really supportive care. We can metabolize. Cardiotoxins on the other hand, those get a lot more dicey. Sometimes really high doses of multiple pressers. Very, very high doses of Norepinephrine, epinephrine, even get into things like phasopressin and methaline blue and all kinds of things that are outside of my will house. But really, vasoplegic when it comes to cardio toxin overdose. And we're really thinking about the most common one there. Calcium channel blockers and beta blockers. Now, when you get into some of those drugs, you also have extended release pieces there. And there are some weird ones in there. Propanolol was one that actually has sodium channel blockade and can widen the QRS. So don't be afraid. If you see that widen QRS, you're like, well, that's a beta blocker. It's not a sodium channel blocker. Propanol actually is. So don't overthink it. If you see a widen QRS and ingestion, an MCHD anyways, protocol specific. Give the by-carb. What about-- You're not going to hurt anybody with a dose of by-carb. There's nobody who even if they didn't need it all of a sudden. Oh, no, you gave-- it just give it because of the benefit of way outweighs the risk there. And that's why our protocol reads, "Suspected injection, ingestion," excuse me, and "wide complex QRS." You don't have to know the drug. It could be a drug that you don't even think is a sodium channel blocker. Don't rely on your brain. Don't rely on the history. Give the by-carb. Because if it is the case that sodium channel blocker is involved, how do you fix it? You give lots of sodium. It's not even a complicated mechanism there. In talks, it is a zillion degrees outside right now. It's used in summer. Beautiful. Don't forget exposure. And here we don't have a whole lot of hypothermia. That definitely can cause you to be altered. We trained in Indiana. So we saw some hypothermia there in the winter time. Here in Greater Houston, it's more altered mental status from heat stroke. And that's the key indicator for heat stroke. So quick mention for heat stroke. If you're altered and your temperature's greater than 105, then please rapidly cool those patients. We did a cold water immersion yesterday. So pretty-- it's that time of year. Pretty amazing time sensitive therapy that we've had great success with here. It's only 170, right? Yeah. I mean, the humidity's not that bad. Houston summer is rough. So cold water, immersion, and heat stroke, and thinking about that as a source for your altermentation is definitely on that list. Now moving on to the one that you probably think about very first thing for EMT school is how hypoglycemia. And probably the one we see on this list the most common. Oftentimes these patients don't even make it to us in the ER. So if I run into your house and you're preparing for your paramedic oral scenarios here at MCHD, and we scream at your alter mental status, you see blood glucose. That should be the first thing. I'm not going to run into your house in Texas. I'll get shot. But it's just a-- it should be a reflexive thing. And hypoglycemia, like you say, can cause seizure as well. Now, if the patients are awake and orring it after that seizure, it's probably not hypoglycemia. But during that episode, it's an important piece. don't overthink it. It should be reflexive. Check the blood glucose. For us in the ER, when we receive these patients so often, if you think about it from our standpoint, they're already awake because the treatment's done. They got dextrose. Well, if you want to combine things, if you're having insulin overdose, and when EMS is called out, you find their blood sugar is 20 and you give them some D10 or D50 or whatever you carry. And by the time you get them to us, their blood sugar is 100. But then the story is I took on my land, as well. Then now we're going to be sitting here starting an insulin or sorry, a dextrose drip to try to combat those long lasting effects from insulin. So there can like Dr. Patrick said, there could be more than one thing going on. And sometimes those when you talk about insulin overdose, sometimes that's not even intentional. It may not even be an intentional situation. It may be a patient who's progression of their dementia has some infectious process. You're an attract infection or pneumonia. They just not had good PO intake. I mean, people take insulin or oral opogocymix. They take those on a schedule and you know, they take 20 of lantus at night and don't eat. That's too much lantus. So that's technically an insulin overdose and it's not even intentional at all. And I'd say that's probably the most common thing that we see is I took my insulin and I didn't eat for whatever reason. And sometimes you have to track down on the secondary piece and that why didn't you eat? But the key for us is emergency positions is what's the length of action of that medication, whether it's oral or you know, sub Q insulin, because that's going to determine our discharge or not. So if it's a shorter acting insulin, like you know, kind of the most common one using the ER's regular insulin, if it's shorter acting, maybe give them a sandwich, maybe the EMS dose of IV dextrose, all done, wrap that up pretty quick because no one you watch them. It depends on the type. And if I don't know the type, then I'm more cautious. So you know, if it's an to your point, if it's lantus, which is a longer, a much longer acting insulin, I just start the sugar drip and emit them to the hospital because I know that it's, I can't wait that out in the ED. If it's a large, like if it's an intentional insulin overdose and it's a very large amount, then I'm starting to sugar drip and emitting them. If it's a shorter acting agent or maybe an oral agent, I may, you know, check every hour, feed them. I like to see, you know, no downward trends, but it really depends a lot on, you know, what type of insulin it is. I use a poison control and toxicology input just like y'all do in the field. If it's a complicated situation or maybe in, you know, a newer insulin that I'm not familiar with, I reach out for help on those and just, you know, typically no offense to any toxic colleges or boys in control, folks that are listening out there, they take calls over the phone. So just like when we take calls over the phone, they are very conservative. They can't see the patients and I don't blame them. So if I call them, I know I'm probably going to be looking at six hours because very rarely do they observe anything for less than that. It depends to, especially there are some diabetes medications that come in pills that can last 24 hours and reduce blood sugar. So those wind up being a whole days worth of observation and admission, depending on what it is. And when they're oral, the other piece that comes into play and some with the sub-Q versions, renal function is really important for us because it may be that dose of, you know, some of the older medications like a glipiside or a gliboride, those can be renaly cleared. And if they are and their creatinine was one two weeks ago and is 2.2 today, that same dose is going to be much more potent for that patient and be much more likely to cause hypogocymic episodes in hypogocymia. We probably should mention just indecrinden general. It reminds me to think about things like the thyroid and other electrode abnormalities like calcium and sodium. So really lots of indecrint things can cause ultra-middle status, not just sugar. It goes in an indecrinden group. But we're thinking about looking for hypo natremia, hypogocymia, hypercalcemia. You know, those are also on that list as well. You really want to go to sleep. You can start talking about sodium management. Should be macoma. Oh, yeah. Well, I always had to tell myself about thyroid because I tend to forget about it. Mixed dimacoma is hypo thyroidism to the max. And it's a rare complication from hypothyroidism. But it's one that's pretty easy to fix with IV-T4. And so it's one that we really have to think about. And oftentimes it occurs in combination with talks, with infection, with exposure, heat, or cold can be precipitators there. So there are some other ones that are less common in there that we have to think about. I was getting at sodium replacement. And the ultimate sleep aid in the end in the emergency department, we gently lower and gently raise sodium levels, probably out of overblown fears. But you know, you look for things like diuretics on med lists. That's really a common thing we look for in sodium abnormalities. Because most of the time diuretics are there. And it's oh, that's why they have a natremia, low sodium. High sodium is most commonly, I think, am I, or act as dehydration, really severe dehydration. Excessive alcohol use can affect sodium a lot. So those are some of the things that we look for and think about. Yes, beer, Potomania, or whatever you come up with these words. Yeah, no, we have to have fancy words in medicine to sound smart when it just, I drank way too much beer. I could just use the language that I had my whole life instead of learning a new one. I just drank beer and didn't eat food. Yeah. And rolling into the last piece that really complicates everything we talked about in our emergency department workup is infection. Because infection on top of really all of these things can cause, you know, we think about seizure. If you have meningitis or encephalitis, that can cause a seizure. So CNS specific infections in my, in my practice, I don't, I mean, I don't know how you divide it, but I tend to think about an alter patient. If it's more subacute, I'm really going down the infection pathway because that's pretty emergent. And especially if we're talking about meningitis or encephalitis, that IV antibiotic is vital. But I separated into into systemic and central and I try to think about central infection first, in other words, central nervous system infection. So that's where meningitis and encephalitis fall for me. meningitis being infection of the lining of the brain, the meninges and cephalitis being infection of the brain tissue itself. We look for things like, you know, fever is important. Fever is not always there with any infection. Injusmas and a common exam finding to look for that, like everything else is not always there. When, when it is, it's going to push you over. So those, those are important for us as emergency visions cause diagnostically, lumbar puncture comes into play and you want that sooner rather than later, you want antibiotics sooner rather than later. Nowadays, we're given steroids to meningitis patients. That one's gone a little bit circularly in my career, but adults and pets getting, getting steroids and antibiotics with, with the lumbar puncture and with imaging to make sure there's no masses there. What about, what about sepsis in general? Cause that's kind of, that's probably the most common. I do a lot of thinking about looking for meningitis and encephalitis and I do a lot of finding of other more subacute infections. Where else can we get in trouble there? What are we looking for? I can get in trouble anywhere. I mean, obviously urine is an obvious sore, especially for older population, intradominal. If things start coming positive for publicly sepsis, white counts up and the history makes sense for it and patient has fever and I have an identified a source. I get to patient completely naked to a complete skin exam cause you never know, could be sacral wound, could be foignets. It could be anywhere that you have skin or part of you is infected, feet exam for sure and diabetic patients, especially. You really have to go look in sometimes and you know, it's easy if they give you a urine sample and it's grossly infected. Well, that's probably the case. But things can certainly get more complicated than that. You know, the complete physical exam, you know, honestly, the more we talk about this, you know, the theme here is that history and exam is what matters. And the biggest piece that EMS brings is the history because, you know, I think over the last 30 minutes what we've talked about is patients present the history is what you have been these patients into immediately based on the first five minutes of history that you get from EMS. It kind of helps rule in and rule out or guide the thought processes to what's going on based on story. Cause you know, like you said, if the story is, mom was just talking to us and now she's on response in the bathroom. That's probably not meningitis. Well, the other thing to think about and I know y'all see this in the field when you bring these patients into the ER with sepsis alerts and so much of what guides our sepsis therapy today and I'm not going to get on the soap box of, you know, early fluids and pressers and some of the the CMS sepsis guidance, whether it's good or it's bad, there's lots you can read out there. What really happens is if a patient comes in and we suspect infection, they're going to get a large crystalloid ball is and they're going to get early broad spectrum antibiotics. That's just the way that it is. And you can fight the details there and there definitely is some room to fight. But what's so and you may say to yourself, well, what's it matter? Doc, if everybody's getting with a heart rate of 101 is getting roseff and fluids, what's it matter what we do on the truck? And you're 100% spot on in that history and physical being so crucial. Why is that because the antibiotics and fluids aren't source control? And source control is what really matters and that is where is that infection and is there something that needs to be drained or cut out? And are we on the right? antibiotic to augment that source control. And so you mentioned 40As for those that don't know 40As gangrene is a feared soft tissue infection in the growing region and the reason why it's so feared is because if we don't look in the growing reason and get that patient totally undressed, then we miss 40As or we may miss it for 12 hours. And the difference in source control for something like 40As gangrene, it's cousin elsewhere is necrotizing fasciitis. Really it's just 40As gangrene is the necrotizing fasciitis of the growing. That's really easy to diagnose when you look for it. But if the patient's bundled up, if it's wintertime or they're in a hallway bed or they're in the waiting room, then those things are harder to diagnose. And if you're not thinking about necrotizing fasciitis or something like 40As gangrene, then that 12 hour delay, I don't care how much 30CC per kilo you give, you can give all the row sephan in the world, sephapine, zosen, that source control is vodled. As surgeon needs to cut out that infected dead tissue so it doesn't spread. One things I've heard too is, you know, how could you miss that dog wouldn't the patient just tell you my, my ingotal area is all swollen and red and tender and it hurts. And yeah, maybe or maybe they're confused because this whole chat's on an ultra mental status and they can't talk at all. Or maybe it's a patient that has diabetes and has peripheral neuropathy and can't feel their feet, but they have a big wound on the heel of their foot that's grossly infected and giving them osteomyelitis and subsequent sepsis. Like they just, they have no idea and you won't either unless you look. I don't know, they've got some alcohol and bored and they've, they've dipped into the tox ultra mental status realm. They've got some polypharmacy with opiates. Maybe they got early dementia. They don't always tell you, maybe they're out in the middle of the hallway bed and they don't want to tell you that their groin is infected. I can remember a patient. That's what care of 20, 20 years ago with 40 A's and she was very modest and she was very embarrassed and she was on immunosuppressants for a liver transplant and she was in tears at what, you know, she felt like it had happened to her and she was embarrassed by it because it was, it went in her and she had necrotizing, necrotizing fasciata. So the groin, she had 40 A's, but she didn't want to tell the male doc out in, we were in ambulance triage at Wischer. So we had curtains that didn't really close and it was a very public place and she was just human, no more no less. And she wasn't even altered and it took us about a half an hour to get to, you know, hey, let me show you what's really wrong. So hopefully this is given you some insight into what we think about when ultra mental status patients arrive in the ER, but it also, I think the moral of the story when we talk about all of these conditions, history and physical or key and that has to start with y'all in the truck and EMS because so many of the things that you see on the scene will never be able to see. And if you look at the feet or you look at the groin or you find the fentanyl patches on the back of the patient, you've improved their care and you've provided a safety net for us as emergency physician. So take home points always expose the patient. fentanyl patches can't be found unless you look for needs gangrene is a visual diagnosis, say, a lot of us ulcers to cubitous ulcers, a QD, a QD, a QD is really important if the patient has dwindled downhill for a week, it is highly unlikely to be a stroke that really needs to move us into infection or acute on chronic talks type situations. The windows for TNK and we didn't really talk about this in the in the stroke part, but I think it's worse mentioning the close, the windows for TNK and indivascular therapy are really evolving. So don't discount the acuity of the ultra mental status if you're slightly outside of the last window you learned because that done, but it window was gone from three to four and a half and I'll bet you it continues to expand 24 hours for endovascular therapy is sort of where we've been, but we're finding that with perfusion scanning, their salads able to issue past 24 hours, we can still go after some of those large vessel occlusion strokes. So just know if that patient is acutely altered, we need to investigate stroke and I tend to let the experts guide me on whether or not we're in a window or out of a window for really anything. Like you said, recurrent seizure patients, they can be very quick in and out if we know what's going on. The exam there and the history is key. Think about talks, danger meds, anything XR or ER, cardio toxins, be very, very wary and make sure if you can get us the insulin type in those diabetic patients that are hypoglossemic, that's really important because it guides our timing. Anything you want to add before we wrap it up? The big thing on talks, honestly, if I could add was if you can bring the pill bottles with you, with whatever pills were left, that way we can do account, we can see exactly what the medication was, extend release or not, the drug concentration, that sort of thing. But the take home message again is, and I think we've said this before, the diagnostic momentum starts when EMS brings a patient to the ER and says, here's what's going on. And that gets the wheels turned in my head and we start down a pathway that you guys set. So, history and physical exam is one of the single most important thing you can do. Do it well, do it every time, do it consistently, don't skip steps. You're not going to see something that you don't look for and you surely can't see through close. So I would, I wouldn't let that be the closing, closing shot. I'm going to add something here if you're interested in coming to work for us at MCHD and hopefully you are energetic, patient forward, ready to work hard and practice good, clinical, pre-hospital medicine, paramedicjobs.org. Check us out, come work for us. If you want to leave us a reviews, wherever you like, watch, listen to podcasts, leave us a review, leave us some feedback, suggestions, all those things are great if you're watching on YouTube. Thanks. And as always, we'll be back again with another episode soon. This podcast was brought to you by the Montgomery County Hospital of District, Texas production and editing by Andrew Adams. Questions or comments which are always welcome to be sent to podcast at mchd-tx.org. Make sure to subscribe and love to keep updated to all our future castes. 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