Altered Mental Status and Coma

Brian Nelson

Case No. 1

A 21 yo BF presents to the Baltimore City Hospital E.D. in the summer of ‘78.

Her family states she is having a bad headache and needs her “Quiet World” tablets

Case continues

No history other than an Ambulance took her to another hospital earlier that day when a neighbor heard her screaming and called EMS

At the other hospital an exam and CBC were said to be normal and she was discharged

General Exam

Patient grossly delirious, oriented to name only

BP 125/70, P 76, RR 24, T 100.2 orally HEENT: PERRL, fundi difficult to evauate

because of roaming eyes, grossly normal Neck: Very Stiff Chest: Loud wet rales throughout lung fields

Neurologic Exam

Able to follow only simplest comands, Cranial Nerves grossly intact, Cerebellar could not be tested, specific muslce group strength could not be tested, but patient moved all extremities and fought attempts to test range of motion. Reflexes, gait and Romberg could not be tested

Diagnostic workup

CXR: Complete opacification of left lung CBC: Hct 43, WBC 10.7 K, 75 segs, 17

bands, 7 lymphs ABGs on room air: 7.42/37/98 Lytes, BUN, glucose, Ca, PO4 all normal

Provisional Diagnosis?

Diagnosis and Dilemma

Provisonal Diagnosis: Pneumococcal Pneumonia with secondary meningitis

Plan? Allow that in 1978 the nearest CT scanner was 5 miles away (and slow first generation). Minimum time to get a head CT 3 hours

LP was performed

Opening pressure was 28 cm H2O

5 cc clear spinal fluid removed

5 minutes later the patient lost consciousness, dilated her left pupil and stopped breathing

Coma mnemonic for the brain impaired Doc A for alcoholism E for encephalopathy I for insulin O for opiates U for uremia T for trauma and environmental disturbance I for infection P for psychiatric S for syncope

Alcoholics have many reasons to be impaired Head trauma, hypothermia Infections: pneumonia, meningitis, sepsis Withdrawal: delerium tremens, post-ictal Metabolic: alcoholic ketoacidosis, lactic acidosis Brain atrophy, Wernicke’s, Korsakoff’s, lead

encephalopathy Toxic alcohols: methanol, isopropyl, ethylene glycol Liver failure, hypoxia

E for encephalopathy

Post-ictal Hypertensive Encephalopathy Intracerebral mass CVA - vasocclusive

• thrombosis• embolism• venous infarct

CVA- hemorrhagic• Intracerebral hemorrhage• Subarachnoid hemorrhage

I for insulin

Too little• Diabetic Ketoacidosis• Hyperosmolar Non-ketotic Coma

Too much• Hypoglycemia

O for opiates

Essentially any chemical including water

sedatives anticholinergics hallucinogens sympathomimetics

U for uremia

Hyper and hypo Na, hyper and hypo Ca, hyper and hypo Mg, hypophosphatemia

Hyper and hypo T4, Hyper and hypo adrenal, panhypopituitarism

Liver, renal, and exocrine pancreas failure, HYPERCARBIA HYPOXIA, HYPOXIA, HYPOXIA

T for trauma and environmental disturbance

Epidural, Subdural, Subarachnoid and intracerebral hemorrhage

Concussion and contusion Hypo and hyperthermia

I for infection

Meningitis Sepsis Brain abscess Encephalitis The weirdos: cerebral syphillis, malaria,

tuberculosis, cystocercosis, nagleria, cryptococcosis, toxoplasmosis, etc

P for psychiatric

Hysteria Malingering Catatonia

S is for syncope

Arrhythmias Infarction Hypovolemia Hemorrhage Vasodepressor syncope

Causes of Stupor or Coma in 500 patients Diffuse dysfunction 76%

Supratentorial lesions 20%

Subtentorial lesions 12%

Psychiatric 8%

Things that aren’t coma

Dementia Acute Confusional State (Delerium) Persistent Vegetative State Akinetic Mutism Locked in syndrome Psychogenic Unresponsiveness Brain death

When altered but not Coma, check components of consciousness

Wakefulness Attention Working Memory Perception Long-term Memory Motivation Cognition Purposeful motor response

Initial actions

Check SaO2 and pupils, support respiration and oxygenation, Narcan for suspected narcotics OD

Check BP and conjunctiva, treat shock and anemia

Glucometer, admin glucose if indicated

Two minute exam, Is it structural? History Pupillary reactions Oculocaloric respones Respiratory pattern Motor responses Skeletal tone

Should have 95% accuracy of structural vs diffuse dysfunction

Is it structural: History

Sudden vs. gradual onset PMH: particulary depression, Diabetes,

Drug user, medications prescribed or missing

Is it structural: pupillary reactions Metabolic: small reactive Diencephalic: small reactive Midbrain: midposition, fixed CN III: unilateral dilated Pons: pinpoint fixed Medulla: dilated, fixed Tox: narcotics -pinpoint reactive, hypoxic,

barbs - dilated and fixed

Oculocalorics

Brainstem intact: deviates to cold water

Brainstem damaged: anything else

Low brainstem: no response

COWS is backwards, patient must have live vestibule, no vestibular toxic drugs

Respiratory Pattern

Eupnea: diffuse dysfunction Cheynes-Stokes: Diencephalon Sustained hyperventilation: Midbrain Ataxic: Medullary

Motor Responses and tone

Diffuse: aversive reactions Early diencephalon: aversive &

cogwheeling Low diencephalon: flaccid or decorticate,

tone decreased Midbrain: flaccid or decerebrate Medulla: lower extremity flexion

Diffuse dysfunction

Pupils small and reactive Oculocalorics: tonic deviation Tone: normal No posturing, normal tone Normal breathing of Cheyne-Stokes

Psychogenic unresponsiveness

Eyelids flutter and close actively Pupils small and reactive Tone variable, bizarre posturing may be

present Optokinetic testing positive Oculocalorics: fast component present

Supratentorial Mass

Initially focal signs (the mass) Signs move rostral to caudal Signs point to one level at any time motor signs may be asymmetrical

Supratentorial herniation

Central

Uncal

Combined

Early diencephalic phase

Eupnea Pupils small and reactive conjugate deviation aversive motions cogwheeling (paratonia)

Late diencephalic

Cheyne-Stokes breathing Pupils small and reactive Conjugate deviation: easier less cortical

control Flaccid or decorticate

Mid-brain upper pons

Sustained hyperventilation pupils mid position, fixed irregular oculocalorics impaired, dysconjugate flaccid or decerbrate

Lower pons, upper medulla

Ataxic breathing pupils midposition fixed irregular No caloric response flaccid or L.E. flexion

Uncal herniation - early 3rd nerve Eupneic Dilate pupil, sluggish full or dysconjugate oculocalorics aversive movements, paratonia, Patient may be awake

Uncal herniation Late 3rd nerve

Sustained hyperventilation Dilated pupil, lid droops, Eye moves out and down Decorticate posturing

Subtentorial lesions

Pontine hemorrhage or infarction Tumors Cerebellar hemorrhage: if treated surgically before

coma ensues, patient may achieve normal neurolgic recovery

Signs point to one level and stay there Cranial nerve findings common Vertigo and nystagmus often prominent

Initial diagnostic eval: all patients Lytes, BUN, Glucose Measured osmolality ABGs and cooximetry Urinalysis

Selected studies for some patients

Imaging LP Endocrine, Liver function Cultures (blood, CSF) Toxicology ECG

Management

Oxygen, ventilation, airway protection Circulation Glucose and thiamine, narcan lower intercranial pressure Control seizures Treat infection Correct acid-base disturbances

Management

Correct electrolytes Correct body temperature Specific antidotes Control agitation

Oh yes, and our herniating lady

Patient was intubated and hyperventilated Mannitol was given Neurosurgeon was paged stat He placed an intraventricular drain, clear

CSF squirted across the room. . .

And she woke up

Patient was taken to angio suite where a 4 vessel revealed bilaterally greatly enlarged ventricles

Dye down the drain revealed a non-communicating hydrocephalus with block below the 4th ventricle

Subsequent records from the warehouse revealed that she had been admitted for 6 months at age 18 months

DX: Hydrocephalus residual from TB meningitis 18 yrs before Patient was given a Ventriculo-peritoneal

shunt, was doing well 6 months later

Lessons

Her neck wasn’t stiff and she wasn’t resisting ROM, she had paratonia

She had no focal findings because the lesions were bilateral and symmetrical

Neurosurgeons are handy

It’s better to be lucky than good

Case 2

37 yo M found down at place of business at 5 am On arrival to ED: Tachypneic, tachycardic,

hypertensive, diaphoretic and retching. Unresponsive to voice or pain. Pupils 2 mm bilaterally and unresponsive to light. Does not move extremities.

Pt paralyzed, intubated and sedated What are the possible diagnoses? How should we

work it up?

Case 2 possible Diagnoses

Mixed overdose with narcotic effect pupils possible but unlikely: narcan had no effect

Intracerebral hemorrhage with intraventricular extension leading to sudden central herniation

Primary pontine lesion, if onset were sudden, more likely a bleed than a stroke