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.

THE ENDTHE END

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