Clinical Findings

Neuro: Confused, lethargic, obtunded, stuporous, or comatose.

Resp: Depressed (likely opioid OD), Cheyne-Stokes breathing (likely CVA), Kussmaul's respirations or fruity odor on breath (likely DKA), apneustic (likely brainstem injury), odor of alcohol (likely intoxication), sweet almond odor (likely cyanide exposure).

CV: Increased BP and decreased HR (likely increased ICP), hypotension (likely sepsis, MI, OD, internal bleeding), dysrhythmias.

Skin: Cool and moist (likely hypoglycemia, vasovagal response, MI, shock), warm and flushed (likely spinal injury, hyperglycemia, sepsis).

GI/GU:Nausea and vomiting, incontinence.

MS: Weakness, fatigue, abnormal flexion or extension, trauma.

Collaborative Management

• Place in lateral-lying position and suction airway as needed.
• Assess pupils and establish baseline GCS score.
• Assess for neurological deficits (e.g., slurred speech, facial droop, or weakness or numbness on one side of the body).
• Obtain STAT bedside blood glucose level.
• Review MAR and labs for causes of AMS.
• Administer or assist with STAT medication as ordered: