Altered Mental Status Framework
Objective: Use one repeatable pass for altered mental status so you do not miss low sugar, airway trouble, overdose, stroke, sepsis, or trauma.
Why this matters
Altered mental status is a symptom, not a diagnosis. Low sugar, opioid overdose, stroke, the fog after a seizure, sepsis, and head injury can all look the same in a living room. Use one fast pass for causes you can treat. Do not lock onto the first story.
- You can check sugar, sat, pupils, medication bottles, and a bystander’s story. You do not have a CT scan or a toxicology screen.
- Fix what you can now. Open the airway, treat the sugar, and give naloxone for slow breathing. Restrict spinal motion if the story fits. Still transport for stroke, sepsis, or traumatic brain injury if those remain possible.
- Write down the last time they were seen normal. Bring the bottles. The emergency department cannot rebuild that history later.
Clinical sequence
- Check the airway, the sugar, and breathing first. Then look for stroke, seizure, and trauma. Keep the pass short. Do not turn it into a 20-minute interview.
- Check the sugar before you call this a psychiatric problem or intoxication.
- A one-sided deficit or a sudden worst headache still follows a stroke pathway, even if the person uses drugs. A sudden worst headache can also be a subarachnoid hemorrhage, bleeding around the brain. Do not drop that pathway because of drug use.
- If they want to refuse, check capacity, name the risks, and use a witness. Low sugar, low oxygen, and head injury can remove capacity. Do not accept a refusal from someone who cannot understand it.
First Pass (Always)
- Make the scene safe. Think about trauma, carbon monoxide, and other hazards.
- Open the airway and support breathing and circulation. People with altered mental status vomit and block the airway.
- Check the sugar early, per protocol.
- Check the sat and give oxygen when it is indicated. If they are breathing too slowly, use capnography when you have it. That is the exhaled carbon dioxide reading.
- Look at the pupils and the arms for injection marks. Look at medication bottles and medical-alert jewelry. Ask a bystander what is normal for this person.
- One-sided neurologic signs move you toward a stroke pathway. Do not skip that pathway.
- Fever, or a low temperature, plus an infection clue moves you toward sepsis. Do not stop at the first label.
AEIOU-TIPS Style Map
- Alcohol and acid-base problems.
- Epilepsy, electrolytes, and endocrine problems. Endocrine means a hormone problem.
- Insulin, meaning sugar that is too low or too high.
- Opioids and other overdose.
- Uremia, toxins that build up in kidney failure.
- Trauma and temperature.
- Infection.
- Psychiatric illness and poisoning.
- Stroke, shock, and bleeding around the brain.
Use the list to remind you of actions you can take now. It is not a hospital admission note. Do not let the list replace the airway check.
Key points
- Treat the reversible causes you are allowed to treat, such as sugar, naloxone, and oxygen, while you package the patient.
- Do not stop at “just drunk” without a primary survey and a sugar check.
- Head injury can be hidden. Look at the scalp and ask about falls.
- If you know their baseline, write it down. Dementia and a new change are not the same.
Common errors
- Giving naloxone for severe slow breathing before you have a plan to support the airway.
- Missing low sugar because the patient looks like they are waking from a seizure.
- Leaving a person on scene who cannot make an informed refusal.
- The scene is safe. Then check airway, breathing, and circulation. These patients vomit and block the airway.
- Check the sugar early.
- Look at the pupils, the bottles, and the medical alert. Ask what is normal for them.
- One-sided signs go to a stroke pathway. Fever or an infection clue goes to a sepsis pathway.
Practice
One-minute check
Your partner gives three altered patients. For each one, list your first five actions in order. Name one cause you will not dismiss as “just drunk.”
Then write 8–10 lines on a fictional call in Narrative Coach (never real PHI).
Related: Diabetic Emergencies, Naloxone, Stroke.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — AMS, glucose, naloxone, stroke, and sepsis are protocol pathways; this site does not pick your destination
- AHA 2025 Part 10: Special Circumstances — opioid-associated respiratory arrest: airway and CPR first; naloxone if it does not interrupt high-quality care
- ADA Standards of Care in Diabetes—2025 — treat symptomatic hypoglycemia; do not skip glucose because they “look drunk”
- 2026 AHA/ASA Acute Ischemic Stroke Guideline — last known well and a stroke-capable destination when one-sided signs are still possible
- Surviving Sepsis Campaign 2026 — prehospital screening and notification; antibiotics only if your system is built for them
- AEIOU-TIPS is a teaching mnemonic to prompt treatable causes — not a validated diagnostic score and not a reason to skip ABCs.
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.