Central Nervous System

2-2-a. Altered Mental Status

1) Check respiratory status and POX.

2) Check blood glucose: if < 70 mg/dl treat as directed in Hypoglycemia SO

3) If blood glucose ≥ 70 mg/dl and POX < 94% on supplemental O2, or respiratory rate ≤ 6 per minute, then support respiration as needed.

4) If the patient seems to be over sedated administer naloxone 0.4 – 2 mg intranasal “IN”/IV/IO. May repeat doses as needed, titrating initially, then larger doses until respiratory status improved.

5) If the history and physical exam suggest a probable fentanyl or carfentanyl overdose, consider giving higher dose of naloxone, until a total dose of ≥ 8 + mg has been given.

6) When giving naloxone IN, you must use the 1 mg/ml (stronger concentration) vials or the special new 4 mg per nostril / 0.1 ml nasal mister device.

7) If patient is not improved and no IV is available, give naloxone 2 mg IM

2-2-b. Excited Delirium Syndrome / Severe Agitation

Patients with excited delirium or severe agitation are so agitated and uncontrollable that they pose a danger to themselves and others. There is a very high risk for sudden cardiac arrest, so sedation is urgent. Scene safety and safety while transporting is essential. Consider getting police to help ensure the safety of the medics and patient. Treatment:

1) Midazolam 10 mg IN. You must use the higher concentration (5 mg/ml) when giving this medication IN. Administer half the dose into each nostril using a mucosal atomizer device. May repeat dose x 1 after 15 minutes, if needed.

2) Establish IV with NS at TKO rate.

3) Place patient on cardiac monitor.

4) Place POX and continuous wave capnography “ETCO2”.

5) Check glucose and treat as needed.

6) Check temperature. Patient is at high risk for severe hyperthermia. Cool patient as needed.

7) If needed, administer Midazolam 2 mg IV. May repeat every 2 minutes for a total of 6 mg (this is in addition to the initial IN midazolam).

8) Contact base station so they can prepare for receiving this patient and also if needed for additional medication orders.

9) Be prepared to support airway and breathing with O2 [see 1-4. Oxygen Administration]

10) If midazolam for IV is unavailable, substitute with:

• a) Diazepam 5 mg IV for an initial dose. Repeat every 2 minutes up to a maximum of 3 doses (15 mg total IV dose). Call for further orders if additional sedation is still needed. OR USE

• b) Lorazepam 2 mg IV for an initial dose. Repeat every 2 minutes up to a maximum of 3 doses (6 mg total IV dose). Call for further orders if additional sedation is still needed.

2-2-c. Seizures and Status Epilepticus

Continuous generalized seizures or repeated seizures without return to consciousness.

1) Administer O2 [see 1-4. Oxygen Administration]

2) Check blood glucose [see 2-6 Metabolic]

3) If seizure has lasted more than 5 minutes since it began, administer Midazolam 10 mg IN or IM. You must use midazolam 5 mg/ml (stronger concentration) when administering by the IN route. Administer half the total dose in each nostril using a mucosal atomizer device.

If midazolam is not available, go directly to the next paragraph to start the IV and give diazepam IV without any delay.

4) If seizure activity does not stop in 2 minutes, establish IV with NS at TKO rate. Administer Diazepam 5 mg slow IV push. This dose of IV diazepam may be repeated once if seizure activity does not stop after an additional 2 minutes.

If seizure continues more than 5 minutes after the 2nd diazepam IV dose, call for further orders.

5) Monitor oxygenation and be prepared to support airway.

6) If diazepam for IV use is unavailable, substitute with one of these:

a) Lorazepam 2 mg IV for an initial dose. If seizure activity does not stop in 2 minutes, repeat dose once. If seizure continues more than 5 minutes after the 2nd lorazepam dose call the base station physician for further orders. OR USE

b) Midazolam 2 mg IV for an initial dose. If seizure activity does not stop in 2 minutes, repeat once. If seizure continues more than 5 minutes after the 2nd midazolam dose call the base station physician for further orders.

7) Monitor respiratory status and support as needed. Avoid intubation if POX can be maintained above 90% with supplemental O2.

2-2-d. Stroke

1) If a stroke or Cerebral Vascular Accident / CVA is suspected, find specific new focal neuro deficits, use the LA Prehospital Stroke Scale/ LAPSS and get information from family / caregivers. Try for minimal scene time and bring a family member or another reliable historian in the ambulance, if possible. Go to the closest hospital appropriate for CVAs.

2) Check glucose, start IV and cardiac monitor.

3) Get the time of onset of the event, or a best estimate of this event time from family members, or the time the patient was last seen to be normal.

4) The MICT or the EMT should do a brief early communication for any possible stroke, and if the physical exam indicates this, include the attention getting phrase “Stroke Code: LAPSS Positive” with the above information.

5) The MICT on arrival in the hospital ED will state that they have a patient with “Stroke Code: LAPSS Positive” to encourage quick evaluation.