altered mental status - pemcincinnati · altered mental status is usually caused by an underlying...
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Mental StatusAltered
Brad Sobolewski, MD, MEd
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Terminology
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ALTERED MENTAL STATUS…is due to an underlying
disease processis not a diagnosis in and of itself
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Coma A transient state of
complete unawareness and unresponsiveness
Lethargic Depressed consciousness resembling a deep
sleep from which a patient can be aroused but into which they immediately return
Obtunded = Stuporous Not totally asleep but demonstrates greatly
diminished responses to external stimuli
Normal GCS 15
Coma GCS 3
AMS GCS <15 but >3
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DELIRIUM Acute confusional state characterized by confusion, disordered speech and hallucinations
IRRITABILITY The state of being abnormally responsive to slight stimuli
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Differential Diagnosis
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A E I O U
T I P S
Alcohol Encephalopathy, Electrolytes Insulin, Intussusception Overdose Uremia
Trauma Infection Psychiatric Seizure, Shock, Stroke
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PRIMARY CNS DISORDERS Focally affect the brain by exerting external pressure (bleed/mass) or causing elevated ICP
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SYSTEMIC ABNORMALITIES 1. Alter neural activity through decreased availability of
substrates (hypotension, oxygen, glucose) 2. Altered intracellular metabolism (hypo/hyperthermia) 3. Introducing extraneous toxins (ingestions, liver/kidney failure) 4. Other conditions (lupus, Wilson’s)
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HYPOXIA Hypercapnia cerebral vasodilation and increased CBF
Hypocapnia cerebral vasoconstriction and decreased CBF
CBF can increase 2-fold during periods of hypoxia
O2 sat ≠ cerebral oxygen delivery
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HYPOXIA Mild symptoms Difficulties with complex learning tasksReductions in short-term memory
Moderate symptomsCognitive and motor disturbances
Severe symptomsFainting, coma, seizures, cessation of brain stem reflexes, and brain death
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HYPOGLYCEMIA Autonomic symptomsGlucose 40 - 70 mg/dL Sweating, weakness, tachycardia, tremor, and feelings of nervousness and/or hunger
Neuroglycopenia10 - 50 mg/dL Lethargy, irritability, confusion, uncharacteristic behavior, hypothermia, seizure and coma
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HYPOTHERMIA Mild 32-35°C (90-95°F)Peripheral signs Consciousness is typically preserved
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HYPOTHERMIA Moderate 28-32°C (82-90°F)Slurred speech, clumsy, agitated and impaired thinking Confusion and lethargy as core body temp drops
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HYPOTHERMIA Severe hypothermia ≤ 28°C (82°F)No more shivering - muscle rigidity and flushed skin Stupor then coma with fixed and dilated pupils
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HYPERTHERMIA Children with heat exposure and elevated body temperature (≥40°C [104°F]) with CNS abnormalities should be treated as victims of heat stroke
CNS symptoms
Impaired judgment, inappropriate behavior, delirium, hallucinations, ataxia, dysarthria, or coma
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INFECTIONS Lead to global CNS dysfunction
Meningitis, encephalitis, focal infections
Antibiotics and antivirals
M. pneumoniae, C. pneumoniae and EBV can cause severe impairment of mental status with or without meningoencephalitis
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Anticholinergics
Many drugs can cause AMS
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TOXINDROMES
Up To Date: Emergency department evaluation of acute onset psychosis in children
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PSYCHIATRIC CAUSES Unless there is a past history of the exact same behavior it is dangerous to assume that the cause of AMS is psych
Differential is broad
Medical > psych
If unsure do a workup
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PSYCHIATRIC CAUSES Acute onset psychosis • Disruption in thinking, accompanied by delusions or
hallucinations • Delusions false, fixed beliefs that cannot be resolved
through logical argument • Hallucinations false perceptions that have no basis in
external stimuli
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PSYCHIATRIC CAUSES Patients may feign unconsciousness
Catatonic patients preserve ability to maintain posture
‘Fakers’ usually: • Avoid hitting their face with a falling arm • Resist eyelid opening • Raise HR to auditory or painful stimuli • Intact DTR, oculovestibular and oculocephalic reflexes
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PSYCHIATRIC CAUSES Brief hallucinations can occur in “normal” situations: • Falling asleep and waking • Bereavement • Sleep deprivation • Caffeine
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Fleisher, Gary R. (2012-06-06). Textbook of Pediatric Emergency Medicine (Textbook of Pediatric Medicine (Fleisher)) (Kindle Locations 8463-8464). Lippincot (Wolters Kluwer Health). Kindle Edition.
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LIFE THREATENING CAUSES OF AMS Epidural hematoma Cerebral edema Bain neoplasms Cerebral infarctions CSF shunt malfunction Meningitis/encephalitis Toxic ingestions Hypotension Hypoxia Sepsis!
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Management
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Problem with ABCs?
Need meds or fluids now?
Meet any of the following criteria? • Intubated or apnea • CPR • Severe respiratory distress • SpO2 < 90% • Acute mental status changes • Unresponsive??
STS
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YOUR JOB Rapid cardiopulmonary assessment
Secondary survey with attention to pupils, GCS, mental status and signs of trauma
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A general approach to the assessment and management of
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glucoseoxygen Narcan labs
CT
LP
ABC IV
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Your assessment should include interventions needed to address ABC related problems
ABC
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AIRWAY Assess for potency and ability to maintain
Watch for deterioration
RSI for intubation
ABC
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BREATHING Ventilation may be impaired by declining respiratory drive or muscle dysfunction
Goal O2 sat >95%
Use ETCO2
Intubate those who cannot sustain adequate oxygenation or ventilation
ABC
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CIRCULATION Continuous EKG monitoring
Assess for perfusion and identify shock
IV for any patient with abnormal VS
ABC
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DISABILITY GCS - repeat as patient changes
Pupil exam
ABC
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Pupil response is the most direct “window to the brain”
Conditions affecting the brain diffusely spare pupils - except for opiates
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Will the result alter the approach to treatment?
Will it return in time to affect therapy positively?labs
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ISTAT +/- Accucheck
Renal panelOsmolality
AcetaminophenSalicylateEthanolUrine Drug Screen
ßhCG
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Ingestions are usually symptomatic by 4-6 hours except in acetaminophen ingestions
Sporer et al Am J Emerg Med, 1996: Retrospective review of 1820 patients with SI or AMS with suspected ingestion - 0.3% had toxic APAP levels not suggested by history, none required NAC
Chan et al Hum Exp Toxicol 1995: Retrospective review of 294 Chinese patients, 4/208 with suspected APAP poisoning had elevated but non-toxic levels
In the absence of history however, still get one
If elevated then repeat at 4 hours
ACETAMINOPHEN LEVEL
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Obtain in the unknown ingestion with AMS
Done nomogram no longer routinely used
Levels > 90-100 mg/dL are usually associated with severe toxicity
May need multiple determinations in massive ingestions or sustained release preparations
SALICYLATE LEVEL
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Elimination follows zero order kinetics
Rate varies 12-25 mg/dL/h - naive drinkers 10 mg/dL/h
Rough correlation between level and symptoms
Level <300 mg/dL in a comatose patient should prompt search for another cause
ETHANOL LEVEL
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Urine metabolites can be seen for 2-3 days
Blood 6-12 hours
Does a toxicology screen affect the management of a patient who has taken overdose?
Even if positive it rarely alters management Kellermann Ann Emerg Med, 1987 Kellermann Am J Emerg Med, 1988 Brett Arch Intern Med, 1988 Belson Pediatr Emerg Care, 1999 Sugarman Pediatr Emerg Care, 1997
Go ahead and order one, but don’t base your management on it
URINE DRUG SCREEN
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Can show block with digitalis or other cardioactive drugs
Diagnostic for serious TCA overdose with QRS widening (≥0.10 sec) & rightward shift of the terminal 40 ms of the frontal plane QRS complex vector (terminal R wave in aVR)
EKG
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QRS ≥100 msec
Terminal R wave >3 mmR/S ratio >0.7
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μ-opioid receptor competitive antagonist
Give in suspected opiate overdose
IV, IM, IN or SQ
Doesn’t save lives - just prevents procedures
Narcan
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OTHER ANTIDOTES Don’t give flumazenil for benzodiazepine OD - precipitates seizures
Physostigmine may transiently improve MS in anticholinergic ingestion
Diphenhydramine for phenothiazine dystonia
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If you suspect meningitis/encephalitis
Stable enough?
Is sedation necessary and safe?
LP
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Any acute coma of unknown etiology
Elevated ICP
Trauma
CSF shunt
Focal neuro findings
Unsupervised child
CT
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ANTIBIOTICS Little harm in giving ceftriaxone +/- vancomycin +/- acyclovir
Try to delay until after LP
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PHYSICAL RESTRAINTS Need regular reassessments and appropriate documentation
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CHEMICAL RESTRAINTS Diphenhydramine, hydroxyzine, lorazepam, midazolam, haloperidol, ziprasidone
PO meds can have similar onset to IM
Other interventions first
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Fleisher, Gary R. (2012-06-06). Textbook of Pediatric Emergency Medicine (Textbook of Pediatric Medicine (Fleisher)) (Kindle Locations 8463-8464). Lippincot (Wolters Kluwer Health). Kindle Edition.
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Take Home Points
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Altered mental status is usually caused by an
underlying disease process
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ABC > IV > glucose + labs > CT > LP
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Even with a past history of mental health illness acute onset psychosis
is more commonly associated with an underlying medical cause
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Mental StatusAltered