Assessing Mental Status


EMS providers frequently encounter patients who are not alert and present with an altered mental status, meaning their level of brain function is in question. Various physical examination techniques are employed during the assessment to determine the level of cerebral function and integrity of the brainstem. It is important to understand the limitations of these techniques, as well as potential findings that may cause you to erroneously interpret, report and document the level of brain function. This information is often used to identify trends to determine if the patient's condition is deteriorating, remaining the same or improving.

Two structures are responsible for a conscious state: the ascending reticular activating system (ARAS) and the cerebral hemispheres. The ascending reticular activating system is not truly a single tangible anatomic structure; however, it is a network of nerve cells and fibers that extend from the spinal cord through the lower brainstem and continue upward toward the mesencephalon and thalamus. The impulses are then distributed throughout the cerebral cortex. The ARAS continuously receives sensory input that allows the body to remain in a wake or sleep state, remain aware of surroundings and respond appropriately while awake. The ARAS has an effect on both the autonomic nervous and motor systems, which in turn control the body's cardiovascular, respiratory and motor response to external stimuli.

Consciousness requires the patient to have an intact ARAS and at least one cerebral hemisphere. If either the ARAS or both cerebral hemispheres are affected by a particular condition and not functioning properly, the patient will not remain in a wake or alert state. Head injuries, severe cerebral hypoxia or anoxia, central nervous system-depressant drugs and electrolyte disturbances are only a few of the possible factors that would disrupt the function of the ARAS or both cerebral hemispheres and render the patient unconscious.

Several assessment techniques may be used during the physical exam to determine the brain's ability to receive, transmit, interpret and respond appropriately to an external stimulus applied to the body. One of the most common techniques is a painful stimulus applied to a patient who is not alert or not responding to verbal stimuli. The patient's response assists the examiner in determining the extent or level at which the brain is able to function. Continuous reassessment provides valuable input when considering a differential diagnosis; making a decision on providing more advanced emergency medical care; and determining whether your treatment is improving the patient's condition, if the patient is remaining stable or if the condition is deteriorating.

The mnemonic AVPU is universally used by EMS personnel at all levels to determine a patient's mental status. Historically, AVPU was used only to assess eye-opening to various stimuli; however, it has evolved to a more general interpretation of patient responses. A refers to alert. An alert patient opens his eyes spontaneously upon your arrival at his side. If the patient is alert, there is no reason to continue with the AVPU assessment. It would be prudent to determine if the patient was oriented to person, place and time.

If the patient does not have spontaneous eye-opening, V is the next step in the AVPU process, which is achieved by using a verbal stimulus in an attempt to get the patient to respond. Historically, the patient was asked specifically to "open your eyes" when applying the verbal stimulus. If eye-opening was attained, the patient was said to have responded to a verbal stimulus. Today, many emergency services providers ask the patient to "squeeze my fingers" or "wiggle your fingers" in place of the traditional eye-opening command. Again, if the patient responds to a verbal stimulus, there is no need to continue.

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The child needs to be seen by a psychiatrist. Only a doctor and a judge can decide these things.
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