altered level of consciousness emergency department evaluation
TRANSCRIPT
Altered Level of Consciousness
Altered Level of Consciousness
Emergency Department Evaluation
Emergency Department Evaluation
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DefinitionsDefinitions
Dementia chronic, slowly progressive decline in memory. Sensorium usually clear (in contrast to delirium)- patient oriented unless late stages of dementia
Delirium can be superimposed on dementia- need corroborating history of baseline mental status
Delirium Acute confusional state- transient disorder with impairment of attention and cognition
Focus of this talk
Dementia chronic, slowly progressive decline in memory. Sensorium usually clear (in contrast to delirium)- patient oriented unless late stages of dementia
Delirium can be superimposed on dementia- need corroborating history of baseline mental status
Delirium Acute confusional state- transient disorder with impairment of attention and cognition
Focus of this talk
Why is it important?Why is it important?
Delirium accounts for 10-15% of admissions to acute-care hospitals (though may not be primary diagnosis)
Many causes of delirium may be fatal if not reversed/treated: CNS infection, severe hypoglycemia, DTs, thyroid storm, TCA o/d, etc
Delirium accounts for 10-15% of admissions to acute-care hospitals (though may not be primary diagnosis)
Many causes of delirium may be fatal if not reversed/treated: CNS infection, severe hypoglycemia, DTs, thyroid storm, TCA o/d, etc
Key Components of Delirium
Key Components of Delirium
Acute onset (hours-days) Fluctuating LOC
ex; falling asleep during interview. Waxing/waning confusion
Changes in cognition memory, language, organization, attention (may ask you to repeat questions, etc), disorientation to time/place/person
Sleep disturbances Emotional lability, sometimes agitation Perceptual disturbances
hallucinations (visual>auditory), delusions Neurologic signs
gait changes, tremor, asterixis, myoclonus
Acute onset (hours-days) Fluctuating LOC
ex; falling asleep during interview. Waxing/waning confusion
Changes in cognition memory, language, organization, attention (may ask you to repeat questions, etc), disorientation to time/place/person
Sleep disturbances Emotional lability, sometimes agitation Perceptual disturbances
hallucinations (visual>auditory), delusions Neurologic signs
gait changes, tremor, asterixis, myoclonus
DSM-IV CriteriaDSM-IV Criteria Disturbance of consciousness (i.e., reduced clarity of awareness about
the environment) with reduced ability to focus, sustain, or shift attention. A change in cognition (e.g., memory deficit, disorientation, language
disturbance) or development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of a day.
Evidence from the history, physical examination, or laboratory findings indicate that the disturbance is caused by direct physiologic consequences of a general medical condition.
Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, D.C., American Psychiatric Association, 2000:143. Copyright 2000, American Psychiatric Association.
Disturbance of consciousness (i.e., reduced clarity of awareness about the environment) with reduced ability to focus, sustain, or shift attention.
A change in cognition (e.g., memory deficit, disorientation, language disturbance) or development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of a day.
Evidence from the history, physical examination, or laboratory findings indicate that the disturbance is caused by direct physiologic consequences of a general medical condition.
Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, D.C., American Psychiatric Association, 2000:143. Copyright 2000, American Psychiatric Association.
Differentiating Delirium from Dementia and
Psychiatric Psychosis
Differentiating Delirium from Dementia and
Psychiatric PsychosisCharacteristic
Delirium Dementia Psychiatric
Onset Over days Insidious Sudden
Course over 24hr
Fluctuating Stable Stable
Consciousness
Reduced Alert Alert
Attention Disordered Normal +/-Disordered
Cognition Disordered Impaired +/-Impaired
Orientation Impaired Often impaired
+/-Impaired
Hallucinations
Visual>Auditory
Often absent Auditory>Visual
Delusions Transient Usually absent
Sustained
Movements Asterixis, tremor
Often absent Absent
Adapted from Tintinalli, J., et al. Emergency Medicine: A Comprehensive Study. 2004.
HistoryHistory Course/Onset What functions affected
Memory, mood, perception, orientation, speech, etc
Get corroborating history from family, friends, caregivers: Key to diagnosis! Baseline function Medications PMH Drug use hx H/o psych d/o or prior similar presentations >50 y.o. w/o prior psych hx- thing organic
Course/Onset What functions affected
Memory, mood, perception, orientation, speech, etc
Get corroborating history from family, friends, caregivers: Key to diagnosis! Baseline function Medications PMH Drug use hx H/o psych d/o or prior similar presentations >50 y.o. w/o prior psych hx- thing organic
Physical ExamPhysical Exam General Appearance
kempt, disheveled, etc
Eyes Icterus Pupilary constriction (Narcotics), dilation (anti-
cholinergics, cocaine/meth, hallucinogen), asymmetry (CNS insult)
Papilledema
Smell ETOH, fruity (DKA), musty (fetor hepatis)
Look Asterixis, tremulousnous/agitation (w/d benzo or ETOH) Hidden sources of infection (decubitus ulcers,
cellulitis in hidden areas) - do full skin survey (undress and roll patient)
Subtle signs of head trauma hemotympanum, Battle sign, Raccoon’s eyes,
otorhinorrhea
General Appearance kempt, disheveled, etc
Eyes Icterus Pupilary constriction (Narcotics), dilation (anti-
cholinergics, cocaine/meth, hallucinogen), asymmetry (CNS insult)
Papilledema
Smell ETOH, fruity (DKA), musty (fetor hepatis)
Look Asterixis, tremulousnous/agitation (w/d benzo or ETOH) Hidden sources of infection (decubitus ulcers,
cellulitis in hidden areas) - do full skin survey (undress and roll patient)
Subtle signs of head trauma hemotympanum, Battle sign, Raccoon’s eyes,
otorhinorrhea
Physical ExamPhysical Exam Vital Signs as Clue Blood pressure
Hypertension (HTN emergency, preeclampsia, elevated ICP especially if also bradycardic, stimulant o/d, DTs)
Hypotension (sepsis, various o/d’s, dehydration, etc) Heart Rate
Tachycardia (fever, sepsis, dehydration, thyroid storm, o/d of stimulant, anticholinergics, theophylline, TCA, ASA)
Bradycardia (elevated ICP, asphyxia, o/d AV-node blockers)
Respiratory Rate Tachypnea (DKA, sepsis, ASA o/d, stimulant o/d) Bradypnea (narcotic/sedative o/d, CNS insult)
Temperature Fever (infection, thyroid storm, heatstroke, aspirin
toxicity, extreme adrenergic overflow of some drug o/d’s or DT’s)
Hypothermia (infection, thyroid/adrenal insufficiency, exposure)
Vital Signs as Clue Blood pressure
Hypertension (HTN emergency, preeclampsia, elevated ICP especially if also bradycardic, stimulant o/d, DTs)
Hypotension (sepsis, various o/d’s, dehydration, etc) Heart Rate
Tachycardia (fever, sepsis, dehydration, thyroid storm, o/d of stimulant, anticholinergics, theophylline, TCA, ASA)
Bradycardia (elevated ICP, asphyxia, o/d AV-node blockers)
Respiratory Rate Tachypnea (DKA, sepsis, ASA o/d, stimulant o/d) Bradypnea (narcotic/sedative o/d, CNS insult)
Temperature Fever (infection, thyroid storm, heatstroke, aspirin
toxicity, extreme adrenergic overflow of some drug o/d’s or DT’s)
Hypothermia (infection, thyroid/adrenal insufficiency, exposure)
Brief Neurologic/MMSE Brief Neurologic/MMSE Often limited due to patient’s inability to cooperate
MMSE Orientation (5): year, season, date, day, month Orientation (5): state, county, town, hospital, floor
Registration (3): Name 3 objects (patient repeats) Attention/Calculation (5): Serial 7’s or “WORLD” backwards
Recall (3): Recall 3 objects named previously Language (2): Name a pencil and watch Repetition (1): “No ifs, ands, or buts” Complex Commands (6): Follow 3 stage verbal command, follow printed commands: “Close eyes”, “Write a sentence”, “Copy design” (intersecting pentagons)
Score of <24 abnormal
Often limited due to patient’s inability to cooperate
MMSE Orientation (5): year, season, date, day, month Orientation (5): state, county, town, hospital, floor
Registration (3): Name 3 objects (patient repeats) Attention/Calculation (5): Serial 7’s or “WORLD” backwards
Recall (3): Recall 3 objects named previously Language (2): Name a pencil and watch Repetition (1): “No ifs, ands, or buts” Complex Commands (6): Follow 3 stage verbal command, follow printed commands: “Close eyes”, “Write a sentence”, “Copy design” (intersecting pentagons)
Score of <24 abnormal
CausesCauses
4 General Categories Primary Intracranial
Bleed, infection, tumor
Systemic Disease Affecting CNS Renal, cardiac, pulmonary, infectious, etc
Exogenous Toxins Environmental exposures, medications, drugs/etoh
Drug/ETOH withdrawal
4 General Categories Primary Intracranial
Bleed, infection, tumor
Systemic Disease Affecting CNS Renal, cardiac, pulmonary, infectious, etc
Exogenous Toxins Environmental exposures, medications, drugs/etoh
Drug/ETOH withdrawal
Mnemonic: I WATCH DEATH
Mnemonic: I WATCH DEATH
I - Infection W - Withdrawal A - Acute metabolic (acidosis, alkalosis, lytes,
liver/renal failure)
T - Trauma C - CNS pathology (bleed, infxn, CVA, seizure,tumor,
vasculitis)
H - Hypoxia (anemia, CO poisoning, resp/CV failure) D - Deficiencies (B12, folate, thiamine, niacin) E - Endocrinopathies (adrenal, pancreatic, thyroid,
parathyroid)
A - Acute Vascular (HTN encephalopathy, CVA, arrhythmia, shock)
T - Toxins/Drugs H - Heavy Metals (lead, manganese, mercury)
I - Infection W - Withdrawal A - Acute metabolic (acidosis, alkalosis, lytes,
liver/renal failure)
T - Trauma C - CNS pathology (bleed, infxn, CVA, seizure,tumor,
vasculitis)
H - Hypoxia (anemia, CO poisoning, resp/CV failure) D - Deficiencies (B12, folate, thiamine, niacin) E - Endocrinopathies (adrenal, pancreatic, thyroid,
parathyroid)
A - Acute Vascular (HTN encephalopathy, CVA, arrhythmia, shock)
T - Toxins/Drugs H - Heavy Metals (lead, manganese, mercury)
Work-upWork-up Guided by history/exam findings/vitals
CBC, comp panel Serum ammonia/coags (if suspect liver dz) B12, folate levels (more helpful for inpt team) ABG w/ carboxyhemoglobin level (if suspect CO-
poisoning). Also will uncover hypercarbia.
Infectious w/u (UA, CXR, Bld Cx, LP) UTOX, ASA/Tylenol/ETOH levels Endocrine (bedside CBG, TSH, calcium/phos levels,
cortisol level)
CT (brain, abdomen, chest depending on suspected source) EKG (arrhythmia, o/d’s, MI)
Guided by history/exam findings/vitals CBC, comp panel Serum ammonia/coags (if suspect liver dz) B12, folate levels (more helpful for inpt team) ABG w/ carboxyhemoglobin level (if suspect CO-
poisoning). Also will uncover hypercarbia.
Infectious w/u (UA, CXR, Bld Cx, LP) UTOX, ASA/Tylenol/ETOH levels Endocrine (bedside CBG, TSH, calcium/phos levels,
cortisol level)
CT (brain, abdomen, chest depending on suspected source) EKG (arrhythmia, o/d’s, MI)
Emergency Department Interventions
Emergency Department Interventions
Treat suspected underlying cause (infection, withdrawal, o/d, CVA, etc)
Low threshold for RSI (inability to protect airway, coma, poor gag): treat easily reversible causes first (ex: hypoglycemia, narcotic o/d responsive to narcan, etc)
Calm acute agitation with sedatives and neuroleptics to control behavior, facilitate procedures, protect staff, prevent rhabdo
Chemical restraint preferable to physical restraints
Treat suspected underlying cause (infection, withdrawal, o/d, CVA, etc)
Low threshold for RSI (inability to protect airway, coma, poor gag): treat easily reversible causes first (ex: hypoglycemia, narcotic o/d responsive to narcan, etc)
Calm acute agitation with sedatives and neuroleptics to control behavior, facilitate procedures, protect staff, prevent rhabdo
Chemical restraint preferable to physical restraints
Medications- Sedatives & Neuroleptics
Medications- Sedatives & Neuroleptics
Lorazepam (Ativan) Midazolam (Versed) Haloperidol (Haldol) Droperidol - (Inapsine) not available in ER
Ziprasidone (Geodon) - injectable Risperidone (Risperdal) - dissolvable
Olanzapine (Zyprexa) - dissolvable
Lorazepam (Ativan) Midazolam (Versed) Haloperidol (Haldol) Droperidol - (Inapsine) not available in ER
Ziprasidone (Geodon) - injectable Risperidone (Risperdal) - dissolvable
Olanzapine (Zyprexa) - dissolvable
AtivanAtivan Benzo of choice in ED PO/SL/IM/IV Can be mixed with neuroleptic in syringe
Short onset, relatively long duration Preferred over neuroleptic in treating toxic effects of stimulants
Adult dose (doses for EtOH w/d much higher) 0.5-2mg PO/SL 2-4mg IM 1-2mg IV
Caution: try to avoid when EtOH on-board as risk for respiratory suppression sig higher
Benzo of choice in ED PO/SL/IM/IV Can be mixed with neuroleptic in syringe
Short onset, relatively long duration Preferred over neuroleptic in treating toxic effects of stimulants
Adult dose (doses for EtOH w/d much higher) 0.5-2mg PO/SL 2-4mg IM 1-2mg IV
Caution: try to avoid when EtOH on-board as risk for respiratory suppression sig higher
MidazolamMidazolam
Benzo with rapid onset, brief duration
Sometimes used by paramedics Useful for rapid sedation of dangerously agitated patients
NOT recommended when EtOH involved - increased risk of respiratory depression
Adult dose 1 - 5 mg IM/IV
Benzo with rapid onset, brief duration
Sometimes used by paramedics Useful for rapid sedation of dangerously agitated patients
NOT recommended when EtOH involved - increased risk of respiratory depression
Adult dose 1 - 5 mg IM/IV
Neuroleptic AgentsNeuroleptic Agents
Haloperidol (Haldol) Drug of choice for acute severe agitation, psychosis, delirium, & for severe agitation w/EtOH on board
Can be mixed in syringe w/lorazepam and diphenhydramine (often included for dystonic rxn)
Dose 1-5mg PO 2-5mg IV/IM (5mg usual dose) - IV only in ICU at CCRMC
Cautions: hypotension, can lower seizure threshold, QT prolongation (IV form)
Haloperidol (Haldol) Drug of choice for acute severe agitation, psychosis, delirium, & for severe agitation w/EtOH on board
Can be mixed in syringe w/lorazepam and diphenhydramine (often included for dystonic rxn)
Dose 1-5mg PO 2-5mg IV/IM (5mg usual dose) - IV only in ICU at CCRMC
Cautions: hypotension, can lower seizure threshold, QT prolongation (IV form)
Neuroleptic AgentsNeuroleptic Agents
Droperidol (Inapsine) Rarely used Faster acting and more sedating then Haldol
More likely to cause hypotension Greater risk of QT prolongation/Torsades Check ECG/QT interval before administering
Adult Dose: 0.625-5mg IV/IM (5mg usual dose)
Droperidol (Inapsine) Rarely used Faster acting and more sedating then Haldol
More likely to cause hypotension Greater risk of QT prolongation/Torsades Check ECG/QT interval before administering
Adult Dose: 0.625-5mg IV/IM (5mg usual dose)
Neuroleptic Agents-less common for ED useNeuroleptic Agents-
less common for ED use Ziprasidone (Geodon)
Less likely to cause severe dystonic reactions
Adult dose: 10 - 20 mg IM
Risperidone (Risperdal) & Olanzapine (Zyprexa) Often used for sundowning in dementia Both available in rapidly dissolving PO form
Ziprasidone (Geodon) Less likely to cause severe dystonic reactions
Adult dose: 10 - 20 mg IM
Risperidone (Risperdal) & Olanzapine (Zyprexa) Often used for sundowning in dementia Both available in rapidly dissolving PO form
Antidotes- “Coma Cocktail”
Antidotes- “Coma Cocktail”
Oxygen Thiamine (100mg IV/IM) Glucose (50ml of D50W IV push) Naloxone (2-10mg SC/IM/IV or via ETT)
Flumazenil very controversial- may induce refractory seizures in setting of long-term use or mixed o/d with seizure inducing agents like TCA
Oxygen Thiamine (100mg IV/IM) Glucose (50ml of D50W IV push) Naloxone (2-10mg SC/IM/IV or via ETT)
Flumazenil very controversial- may induce refractory seizures in setting of long-term use or mixed o/d with seizure inducing agents like TCA
PITFALLSPITFALLS
Assuming ETOH “just drunk”- higher incidence of intracranial process
Assuming psych process Assuming dementia in old person Not getting corroborating in a patient who can’t tell you hx/sx’s, etc
Missing hidden sources of infection by not undressing/rolling patient
Assuming ETOH “just drunk”- higher incidence of intracranial process
Assuming psych process Assuming dementia in old person Not getting corroborating in a patient who can’t tell you hx/sx’s, etc
Missing hidden sources of infection by not undressing/rolling patient
SourcesSources Gerstein,P. Delirium, Dementia, and Amnesia.http://emedicine.medscape.
com/article/793247-overview. Accessed February 15, 2010.
Gleason, O. Delirium. American Family Physician. March 1,2003.
Huff,J. Altered Mental Status and Coma. In: Tintinalli JE, Krome RL, Ruiz E, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004: 1390-7.
Gerstein,P. Delirium, Dementia, and Amnesia.http://emedicine.medscape.
com/article/793247-overview. Accessed February 15, 2010.
Gleason, O. Delirium. American Family Physician. March 1,2003.
Huff,J. Altered Mental Status and Coma. In: Tintinalli JE, Krome RL, Ruiz E, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004: 1390-7.
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