Altered Mental Status · 6/1/2018 2 Overview •Altered mental status: It Could Be [almost] Anything! requires a thorough work-up •What is the differential for altered mental status?

6/1/2018

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Spokane County EMS

Altered Mental StatusSherlock Holmes Approach to the Cause

Dr. Douglas Presta

Objectives

• Recognize the importance of historical factors in diagnosing causes of Altered Mental Status(AMS)

• Articulate a differential diagnosis of AMS based on H&P findings

• Construct an approach to the diagnostic workup and management of a patient with AMS

• Describe initial management of many causes of AMS

• Discuss the disposition of a patient with AMS

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Overview

• Altered mental status: It Could Be [almost] Anything!requires a thorough work-up

• What is the differential for altered mental status?

• What is the type of problem that could cause it?

• What is the organ system(s) that could be involved?

Example

• 63 yo female found down next to park bench. Bystander called EMS.

• You ask for history: There is none

• You ask for Review of Systems: There is none

• You ask for PMH, Meds, Anything!: There is none

WELCOME TO EMERGENCY MEDICINE

What Could Be Wrong With Her?Tramua: Brain laceration/injuryConcussionDepressed skull fractureHead traumaBrain, contusionBrain injury, massiveDiffuse axonal injury/Acute brain traumaShakenBaby SyndromeElectromagnetic, Physics, trauma, Radiation CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea waterDrowning/Near- drowningHeatexhaustion/prostrationHeat strokeEncephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposureElectrocution/lightning strikeHighaltitude cerebral edemaDecompression sicknessHigh altitude pulmonary edemaIatrogenic, Self Induced DisordersWater intoxicationHypothermicanesthesiaHyponatremia correction, rapidSurgical, Procedure ComplicationAnesthesia, generalBrain surgeryInfectious Disorders (Specific Agent)Pneumonia, bacterialAIDS MeningoencephalitisEncephalitis, herpes simplexEncephalitis, secondary viralEncephalitis, viralMeningitis BacterialMeningitis, aseptic/viralMeningitis, HemophilusMeningitis, pneumococcalMeningococcal meningitisPneumonia/BronchopneumoniaPneumonia, acute lobarPneumonia, pneumococcalTyphoidfeverMeningitis, tuberculosisAmebic (Naegleria) meningoencephalitisBacterial overwhelming sepsisCandidiasis systemicChickenpox encephalitisEncephalitis, bacterial/cerebritisEncephalitis, Dawsons/inclusion bodyEncephalitis, Eastern equineEncephalitis, mumpsEncephalitis, Murray valleyEncephalitis, non-viralEncephalitis, St Louis BEncephalitis, Western equineGram negative (e coli) meningitisHistoplasmosis meningitisKunjin viral encephalitisLa Crosse viral encephalitisLegionella meningoencephalitisLeptospiral meningitisLeptospirosis/severe (Weils) typeListeria meningitisLyme meningoencephalitisMalaria, cerebralMeningitis, candidaMeningitis, Coxacki viralMeningitis, echo viralMeningitis, staphylococcus aureusMononucleosis encephalitisPlague meningitisPost-viral/infectious encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes syndromeRussian tick-bourne encephalitisToxic shock syndromeTrichinellameningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisLegionaires diseaseListeria monocytogenes/listeriosisMeningitis, fungalRockymountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleepingsickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, CaliforniaEncephalitis, equine, VenezuelanEncephalitis, Japanese BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acuteFungus brain abscessLeptospirosisIctohemorrhagicaInfected organ, AbscessesInfectionsAbscess, intracranialBacteremia/SepticemiaBrain abscessEmbolism, septic, cerebralEndocarditis, infectiveMeningoencephalitisPneumonia, aspirationSepsisSepsis, overwhelmingSeptic shockUrosepsis/septicemiaEncephalomyelitis, acuteEncephalopathy/secondary/toxic/sepsisNecrotizing fasciitis/mixedBrain stem encephalitisEncephalitisMeningitisPneumoniaGranulomatous, Inflammatory DisordersHemorrhagic pancreatitis, necrotizingPancreatitis/resp distress syndromeNeoplastic DisordersHypercalcemia of malignancyMetastatic brain diseaseBrainstem tumorBrain tumorFrontal lobe tumorMedulloblastomaMeningeal carcinomatosisParietal lobe tumorPrimary CNS lymphomaTemporal lobe tumorBrain tumor , malignant (astrocytoma)CraniopharyngiomaGlioblastoma multiformeInsulinoma/Islet cell tumorMeningiomaPontine gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune DisordersEncephalitis, hemorrhagic, acuteEncephalitis, post viralEncephalomyelitis, necrotizing hem. ac.Encephalomyelitis, post-infectiousStevens-Johnson syndromeTransfusion reaction, hemolyticLupus cerebritisPolyarteritis nodosaBehcet's syndromeHashimotos EncephalitisMetabolic, Storage DisordersHypoglycemia, reactive diabeticDiabetic ketoacidosis/comaHyperosmolar hyperglycemic coma, nonketNeonatal hyperbilirubinemiaMetabolicdisordersMethemoglobinemia, HereditaryPorphyria, acute intermittentGlutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical DisordersEncephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHypercalcemiaHypercapneaHypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontinemyelinolysis, centralDeficiency DisordersDehydration and feverDehydrationWernicke's encephalopathyMalnutrition/StarvationPellagra/niacin deficiencyMarchiafava-Bignami syndromeCongenital, Developmental DisordersNephrogenic diabetes insipidusHereditary, Familial, Genetic DisordersMELAS EncephalopathyVan BogaertencephalitisUsage, Degenerative, Necrosis, Age Related DisordersAlzheimer's syndromeDementia, Lewy-body typeMultiple sclerosisRelational, Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia, factitiousCatatoniaManic deleriumAnatomic, Foreign Body, Structural DisordersAcute subdural hematoma/hemorrhageBrain compressionEpidural hematomaIntracerebral hematomaIntraventricular brain hemorrhageSubdural hematomaTamponade, cardiacBrainstem herniation/peduncle/tonsilsFat embolismSuperior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolismCerebral hemorrhageCerebral vein thrombosis/phlebitisIntracerebral hemorrhageMyocardial infarction, acuteSubarachnoidhemorrhageTransient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosisCerebral/Venous sinus thrombophlebitisSuperior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexiaSleepdeprivationVegetative, Autonomic, Endocrine DisordersCardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shockConvulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotensionOrthostatic hypotensionPost-ictal statusThyrotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignantMalignant hyperthermiaMyxedemacomaMyxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart blockInappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, juvenileNarcolepsyPickwick's syndromeReference to Organ SystemShockCerebral edemaDisseminated intravascular coagulopathyHepaticencephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndromeBrain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremicencephalopathyEncephalopathyHyperviscosity syndromePernicious anemiaPontine lesion/disorderThrombotic thrombocytopenic purpuraCombined system disease/pernicious an.Fever Unknown OriginReversable Posterior Encephalopathy SyndromePathophysiologicSepsis encephalopathy/elderlyCardiac output reductionCerebral depressed functionsDrugsMedication/drugsBenzodiazepines Administration/ToxicitySedative drugs Administration/ToxicityDigitalistoxicity/poisoningHypoglycemia, diabetic/treatmentInsulin overdose/exogenousIntoxication/overdose syndromeSalicylate intoxication/overdoseTricyclicoverdoseBarbiturate/sedative abuse/dependentDrug induced Hypoglycemia.Oral hypoglycemic Administration/Toxicity/effectInsulin (Humulin/Novulin) Administration/ToxicityIsoniazid (INH/Nydrazid) Administration/ToxicityErgot toxicityIsoniazid hepatitisMilk-alkali syndromePoisoning (Specific Agent)Opiate overdose toxidromeKitchen gas/propane exposureAlcohol/Ethanol ingestion/intakeAlcohol amnestic disorderAlcohol induced hypoglycemiaAlcohol intoxication, acuteAlcohol seizure (rum fits)Cholinergic crisis toxidromeDelirium tremensInsecticide/organophosphate typeOverdose, drug/alcoholPoisoningSnakebite(neurotoxic/coral/cobra type)Snakebite (rattlesnake/pit viper type)Alcohol withdrawalHallucinogen abuseLead poisoning in childrenSmoke inhalationHeroin/morphine usage/addictionCyanide/Hydrogen cyanide exposure/poisoningVomiting CBW agent (Dm/Da/Dc) Weapon exposureArsine gas (Hydrogen arsenide) poisoningCarbonmonoxide poisoning/exposureDiethylene Glycol poisoningEthylene glycol [Antifreeze] ingestionInsecticide/pesticide poisoningIntentional poisoningIsopropyl alcohol ingestion/poisoningMustard gas exposure/poisoningNerve gas exposureAluminum toxicity/syndromeAmmonia exposure/inhalationHydrogen sulfide poisoning/inhalationInsecticide/chlorinated/non-ester's inhLead poisoningLead encephalopathyNitrogen narcotic actionCarbon disulfide inhalant/poisoningChlorine

i i M th i i / h i C b di id i h l ti / h i O P i i (I t i ti )N l ti li t d

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• From Vertebrobasilar migraine syndrome to Hyponatremia

• It’s TOO MUCH

• You need a clue:-EMS report-Cell phone (call family members)-Bystander account-PMH from meds, alert bracelet, wallet, PhysEx (e.g fistula)-Phys Exam for current physiological state of patient-Labs-Imaging

Physiologic Reserve Determines How Readilythe Patient Will Have AMS!

• Frail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.

• Young Healthy Patient: Likely to be something significant that has gone wrong

• Patient With Obvious Comorbidities: Other causes (than primary medical problem) will more readily alter this patient (less reserve!)

You May Get Frustrated at this Patient and Say (ddx):• M: Metabolic—B12 or thiamine deficiency, serotonin syndrome

• O: Hypoxemia (pulmonary, cardiac, anemia); high CO2

• V: Vascular causes—hypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MI

• E: Electrolytes and endocrine

• S: Seizures / status epilepticus, post-ictal

• T: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes)

• U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy

• P: Psychiatric, porphyria

• I: Infection (inflammatory-see vasculitis above)

• D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRI’s, BZD’s, barbiturates, alcohol)

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M: Metabolic—B12 or thiamine deficiency, serotonin syndrome

• Glucose metabolism– Low Blood glucose

– High Blood glucose

O: Hypoxemia (pulmonary, cardiac, anemia); high CO2

• Purely Hypoxic patient is anxious/agitated

• Purely Hypercarbic patient is sleepy

V: Vascular causes—hypertensive emergency, ischemic/hemorrhagic CVA,

vasculitis, MI

• All of these cause poor perfusion of the brain either Stroke(CVA) blocked flow or through loss of forward flow to brain Heart blocked(MI)

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E: Electrolytes

• Electrolyte shifts can cause swelling in the brain

• High Na or Ca global depression (any electrolyte involved in ion-channel transmission in the brain can cause a problem)

• High K+ increases refractory time of heart contraction

S: Seizures / status epilepticus, post-ictal

• Post-ictal state typically resolves in 20-40minutes

• Non-epileptiform seizures can be cause of depressed mental status

-No tonic-clonic activity

-Ultimately diagnosed with EEG

-Eye movement, hx, ’trial of Ativan’ may give clue

T: Tumor, trauma, temperature, toxins, toxidromes

• Tumor causes compression or diffuse edema• Hypothermia: Global depression of ion-channels• Toxins: Wide range of responses depending on

individual and their reserve• Look for Toxidromes- A symptom constellation

specific to a given toxin (e.g. Slurred speech, • B lateral-gaze nystagmus, cerebellar • deficits, altered mood is the toxidrome • for Ethanol)

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U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy

• Electrolyte Abnormalities

• Uremia-Urea build-up AND electrolyte abnormalities

• Hepatic Encephalopathy- elevated Ammonia (level should be high but poorly correlated with actual degree of AMS)

P: Psychiatric, porphyria

• Delerium, Dementia & Psychosis

• Catatonia: no focal neurological deficits but unresponsive (responds to Ativan!)

• Porphyria: A group of enzyme deficiencies in hematologic biosynthesis pathway that results in accumulation of Porphyrins (or precursors): Multiple s/sx including various MS effects

I: Infection (inflammatory-see vasculitisabove)

• Urinary Tract Infection- UTI

• Meningitis (A constant concern in all patient, esp at extremes of age)

• Cerebritis

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D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRI’s, BZD’s,

barbiturates, alcohol)

• Learn and look for Toxidromes (withdrawal states are usually essentially opposite in symptoms)

Approach the Patient Covering Most UrgentBases First

• ABCs

• Intravenous access, oxygen therapy, cardiac monitoring with pulse oximetry

• Accu-check / glucose / thiamine

• Cervical spine precautions

• Pupil reaction

Detailed History

• Can you tell me what you see different about patient today?

• Can you describe how they are different?

• When did this change start?

• Has it ever happened before (previous diagnosis)?

• Have there been any changes in her medicines recently (polypharmacy)?

• What do you think might have caused this?

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Approach the Patient Covering Most UrgentBases First

• EKG / cardiac monitoring

• ABG with carboxyhemoglobin

• CBC, electrolytes, Ca, Mg

• Drug screen, EtOH, serum osmolarity

• Urinalysis

• Imaging

• lumbar puncture

• liver, thyroid

Frail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.

Case 1

63 yo female found down next to park bench

• You have no information: You do a physical exam

-A: Breath sounds clear B/L, +gag, trachea midline, no pooling of secretions

-B: Spontaneous respirations

-C: Regular rhythm , tachycardia, Bilateral femoral pulses, diminished DP pulses (but present)

-VS: HR:101, B/P: 88/45, Temp- 99.1 f, O2 sat: 92% RA

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-HEENT: PERRL, Ears clear, Mucus Membranes slightly dry

-Neck: Supple, no JVD

-Chest: no crepitus, atraumatic

-GI: soft, BS present/normal; rectal no gross blood, NL tone

-Extrem: Legs wrapped over open sores, 2+ pitting edema, pulses present except as noted in ABCs

-Back: Atraumatic, no step-offs

-Neuro: CN grossly intact, withdraws to pain, no gross focal neurol deficits, reflexes symmetrical, does not answer Qs or follow commands, moaning

-Skin: well perfused

-GU: Perineum atraumatic, no discharge or lesions

What Was Abnormal?What Could It Mean?

Putting the Physical Exam Findings Together:

• Do you think this is a Global or a Focal Process?

• How would you summarize the state of the patient based on Physical Exam?

• What could cause this state?

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• You have no information: You do a Physical Exam

-A: Breath sounds CTAB, +gag, trachea midline, no pooling of secretions

-B: Spontaneous Respirations

-C: Regular rhythm , tachycardia, B Femoral pulses, diminished DP pulses (but present)

-VS HR: 101, 88/45, T- 99.1, 92% RA


-HEENT: PERRL, TMs clear, Mucus Membranes slightly dry-Neck: Supple, no JVD


-GI: soft, BS present/normal; rectal no gross blood, NL tone

-Extrem: : Legs wrapped over open sores, 2+ pitting edema, pulses present except as noted in ABCs


-Neuro: CN grossly intact, withdraws extrem to pain,no gross focal neurol def, reflexes symmetrical, does not answer Qs or follow commands, moaning

-Skin: well perfused


Case 2

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72 yo female found on the floor


-A: Breath sounds equal, +gag, trachea midline, pooling of secretions

-B: Snoring respirations 8- 10/ min

-C: Irregular rhythm , bradycardia, cool to the touch, excessive sweating



-HEENT: PERRL, Ears clear, drooling



-GI: soft, Bowel Sounds present/normal; rectal no gross blood

-Extrem: Cyanosis, edema, pulses present


-Neuro: CN grossly intact, withdraws to pain, no gross focal neurol deficits, reflexes symmetrical, does not answer Qs or follow commands, moaning

-Skin: motled apperance



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-A: Breath sounds equal, +gag, trachea midline, pooling of secretions

-B: Snoring respirations 8- 10/ min

-C: Irregular rhythm , bradycardia, cool to the touch, excessive sweating


What do you want to know now?

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Case 2

26 yo male found on the floor


-A: Breath sounds equal, no gag, trachea midline, pooling of secretions

-B: Snoring respirations 4/ min

-C: Irregular rhythm , bradycardia, cyanotic, cold to the touch



-HEENT: Pupils constricted, Ears clear, mouth dry




-Extrem: Cyanosis, no edema, pulses slow & weak but palpable


-Neuro: CN grossly intact, does not withdraw to pain, no gross focal neurol deficits, reflexes symmetrical

-Skin: cyanotic apperance


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-A: Breath sounds equal, no gag, trachea midline

-B: Snoring respirations 4/ min

-C: Irregular rhythm , bradycardia, cyanotic, cold to the touch


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-HEENT: Pupils constricted, Ears clear, mouth dry




-Extrem: Cyanosis, no edema, pulses slow & weak but palpable


-Neuro: CN grossly intact, does not withdraw to pain, no gross focal neurol deficits, reflexes symmetrical

-Skin: cyanotic apperance


Remember…

• …it’s okay if you do not diagnose the patient’s problem. It’s not okay if you fail to take care of what you are trained to take care of.

QUESTIONS????

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Post Test

1. All the below pneumonics are used to determine altered mental status except?

a) AEIOUTIPS

b) MOVESTUPID

c) MONA

d) AVPU

Post Test

2. The below medical conditions can cause altered mentation except?

a) Alcohol

b) Asthma

c) Seizure

d) Dementia

Post Test

3. Diabetes is a metabolic issue with problems with which hormone?

a) Glucose

b) Calcium

c) Potassium

d) Insulin

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Post Test

4. Glasgow Coma scale involves all except?

a) Ears

b) Verbal

c) Motor

d) Eyes

Post Test

5. All are priority assessments in altered mental status patients except?

a) Vitals

b) Temperature

c) Bowel sounds

d) Blood Glucose measurement

Special thanks to

Sheila Crow

Stitchin’ Dreams Embroidery

[email protected]

For providing our Secret Question prize

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Documents

Altered Mental Status · 6/1/2018 2 Overview •Altered mental status: It Could Be [almost] Anything! requires a thorough work-up •What is the differential for altered mental status?