Altered Mental Status

David T. Matero, M.D.Assistant ProfessorEmergency MedicineUniversity of Colorado DenverAltered Mental StatusOverviewAltered mental status: It Could Be [almost] Anything! requires a thorough work-upWhat 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?

Example63 yo female found down next to park bench. Bystander called EMS who are now moving patient from gurney onto bed.You ask for history: There is noneYou ask for ROS: There is noneYou 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 traumaShaken Baby SyndromeElectromagnetic, Physics, trauma, Radiation CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea waterDrowning/Near- drowningHeat exhaustion/prostrationHeat strokeEncephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposureElectrocution/lightning strikeHigh altitude cerebral edemaDecompression sicknessHigh altitude pulmonary edemaIatrogenic, Self Induced DisordersWater intoxicationHypothermic anesthesiaHyponatremia 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, pneumococcalTyphoid feverMeningitis, 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 syndromeTrichinella meningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisLegionaires diseaseListeria monocytogenes/listeriosisMeningitis, fungalRocky mountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleeping sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, CaliforniaEncephalitis, equine, VenezuelanEncephalitis, Japanese BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acuteFungus brain abscessLeptospirosis IctohemorrhagicaInfected 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 diseaseBrain stem 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 hyperbilirubinemiaMetabolic disordersMethemoglobinemia, HereditaryPorphyria, acute intermittentGlutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical DisordersEncephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHypercalcemiaHypercapnea HypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontine myelinolysis, centralDeficiency DisordersDehydration and feverDehydrationWernicke's encephalopathyMalnutrition/StarvationPellagra/niacin deficiencyMarchiafava-Bignami syndromeCongenital, Developmental DisordersNephrogenic diabetes insipidusHereditary, Familial, Genetic DisordersMELAS EncephalopathyVan Bogaert encephalitisUsage, 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, cardiacBrain stem herniation/peduncle/tonsilsFat embolismSuperior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolismCerebral hemorrhageCerebral vein thrombosis/phlebitisIntracerebral hemorrhageMyocardial infarction, acuteSubarachnoid hemorrhageTransient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosisCerebral/Venous sinus thrombophlebitisSuperior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexiaSleep deprivationVegetative, Autonomic, Endocrine DisordersCardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shockConvulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotensionOrthostatic hypotensionPost-ictal statusThyrotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignantMalignant hyperthermiaMyxedema comaMyxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart blockInappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, juvenileNarcolepsyPickwick's syndromeReference to Organ SystemShockCerebral edemaDisseminated intravascular coagulopathyHepatic encephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndromeBrain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremic encephalopathyEncephalopathyHyperviscosity 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/ToxicityDigitalis toxicity/poisoningHypoglycemia, diabetic/treatmentInsulin overdose/exogenousIntoxication/overdose syndromeSalicylate intoxication/overdoseTricyclic overdoseBarbiturate/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) poisoningCarbon monoxide 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 gas poisoningMethane gas poisoning/asphyxiaCarbon dioxide gas inhalation/asphyxiaOrgan Poisoning (Intoxication)Neuroleptic malignant syndromeFrom Vertebrobasilar migraine syndrome to Hyponatremia Its TOO MUCHYou 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 Readily the 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 wrongPatient 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: MetabolicB12 or thiamine deficiency, serotonin syndromeO: Hypoxemia (pulmonary, cardiac, anemia); high CO2V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MIE: Electrolytes and endocrineS: Seizures / status epilepticus, post-ictalT: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes )U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathyP: Psychiatric, porphyriaI: Infection (inflammatory-see vasculitis above)D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol)M: MetabolicB12 or thiamine deficiency, serotonin syndromeGlucose metabolism uses up even more thiamineSerotonin syndrome=serotonin toxicity and caused by various drugs, medicines and combinations thereof -increased heart rate, shivering, sweating, dilated pupils, myoclonus, as well as overresponsive reflexes

O: Hypoxemia (pulmonary, cardiac, anemia); high CO2Purely Hypoxic patient is anxious/agitated-PEPurely Hypercarbic patient is sleepy -Jet Insufflation in kids or bad COPDerV: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MIAll of these cause poor perfusion of the brain either focally or globally through local effects (CVA) or through loss of forward flow to brain (MI)E: Electrolytes and endocrineElectrolyte shifts can cause swelling in the brainHigh Na or Ca global depression (any electrolyte involved in ion-channel transmission in the brain can cause a problem)Hypoglycemia most common cause of endocrine-related MS depressionS: Seizures / status epilepticus, post-ictalPost-ictal state typically resolves in 20-40minutesNon-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 (lead, mercury, CO, toxidromes )Tumor causes compression or diffuse edemaHypothermia: Global depression of ion-channelsToxins: Wide range of responses depending on individual and their reserveLook 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)

U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathyElectrolyte AbnormalitiesUremia-Urea build-up AND electrolyte abnormalitiesHepatic Encephalopathy- elevated Ammonia (level should be high but poorly correlated with actual degree of AMS)P: Psychiatric, porphyriaCatatonia: 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 effectsI: Infection (inflammatory-see vasculitis above)Meningitis (A constant concern in all patient, esp at extremes of age)CerebritisD: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol)Learn and look for Toxidromes (withdrawal states are usually essentially opposite in symptoms)

In Summary: It ALL Boils Down to One of Two ThingsBoth cerebral hemispheres are depressedThe Reticular Activating System is not functioning.In Summary: It ALL Boils Down to One of Two ThingsBoth cerebral hemispheres are depressedThe Reticular Activating System is not functioning.Diffuse Process most ofthe cases arise from thisIn Summary: It ALL Boils Down to One of Two ThingsBoth cerebral hemispheres are depressedThe Reticular Activating System is not functioning.Diffuse Process most ofthe cases arise from this ? In Summary: It ALL Boils Down to One of Two ThingsBoth cerebral hemispheres are depressedThe Reticular Activating System is not functioning.Diffuse Process most ofthe cases arise from thisStroke, Seizure or Trauma to this regionApproach the Patient Covering Most Urgent Bases FirstABCsIntravenous access, oxygen therapy, cardiac monitoring with pulse oximetryAccu-check / glucose / thiamineCervical spine precautionsNaloxone

Approach the Patient Covering Most Urgent Bases FirstEKG / cardiac monitoringABG with carboxyhemoglobinCBC, electrolytes, Ca, MgDrug screen, EtOH, serum osmolarityUrinalysis Imaginglumbar punctureliver, thyroidApproach the Patient Covering Most Urgent Bases FirstEKG / cardiac monitoringABG with carboxyhemoglobinCBC, electrolytes, Ca, MgDrug screen, EtOH, serum osmolarityUrinalysis Imaginglumbar punctureliver, thyroidFrail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.

63 yo female found down next to park bench 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:101, 88/45, T- 35.6, 92% RA

63 yo female found down next to park bench -HEENT: PERRL, TMs clear, MM slightly dry-Neck: Supple, no JVD-Chest: no crepitus, atraumatic-GI: soft, BS present/normal; rectal no gross blood, NL tone-Extrem: UE and LE with no clubbing, cyanosis, edema pulses present except as noted in ABCs-Back: Atraumatic, no step-offs-Neuro: CN grossly intact, MAE, 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 lesionsWhat Was Abnormal?What Could It Mean?

What Was Abnormal?What Could It Mean?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:101, 88/45, T- 35.6, 92% RA

63 yo female found down next to park bench -HEENT: PERRL, TMs clear, MM slightly dry-Neck: Supple, no JVD-Chest: no crepitus, atraumatic-GI: soft, BS present/normal; rectal no gross blood, NL tone-Extrem: UE and LE with no clubbing, cyanosis, edema, pulses present except as noted in ABCs-Back: Atraumatic, no step-offs-Neuro: CN grossly intact, MAE, withdraws extrem to pain,no gross focal neurol def, reflexes symmetrical, does not answer Qs or follow commands, moaning -Skin: well perfused-GU: Perineum atraumatic, no discharge or lesionsPutting 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 PEX?

What could cause this state?

What is more likely now?M: MetabolicB12 or thiamine deficiency, serotonin syndromeO: Hypoxemia (pulmonary, cardiac, anemia); high CO2V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MIE: Electrolytes and endocrineS: Seizures / status epilepticus, post-ictalT: Tumor, trauma, temperature, toxins (lead, mercury, CO, toxidromes)U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathyP: Psychiatric, porphyriaI: Infection (inflammatory-see vasculitis above)D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol)What is more likely now?M: MetabolicB12 or thiamine deficiency, serotonin syndromeO: Hypoxemia (pulmonary, cardiac, anemia); high CO2V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MIE: Electrolytes and endocrineS: Seizures / status epilepticus, post-ictalT: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes )U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathyP: Psychiatric, porphyriaI: Infection (inflammatory-see vasculitis above)D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol)Next Step: Diagnostic StudiesPrioritize acute life threats firstGet high-yield, easy items first: Glc, EKGKeep modifying testing as DDX changes with resultsShotgun Approach (parallel processing)Is patient stable to go to imaging or to wait for lab result before making treatment decision?

How Do I Know What to Order?Balance these two things to determine what tests/priority:-Shotgun approach (intended to move things along quickly and cast wide net)-What youve learned from your H&P

LABS1414.1101 2617 1.110114.5 38014.4

41.9UA:Spec grav 1.026pH 6.0Ketones +Glucose Bile Blood +Bacteria ++WBC ++Nitrite +Leuk. Est +LFTs- NormalASA, APAP, Coags NormalLABS1414.1101 2617 1.110114.5 38014.4

41.9UA:Spec grav 1.026pH 6.0Ketones +Glucose Bile Blood +Bacteria ++WBC ++Nitrite +Leuk. Est +LFTs- NormalASA, APAP, Coags NormalDo We Know Whats Going On?We know the patient has a UTIIs this enough to explain the patients sepsis?Can we stop our work-up?Could the UTI be a red herring?

Do We Know Whats Going On?We know the patient has a UTIIs this enough to explain the patients sepsis? YESCan we stop our work-up?Could the UTI be a red herring?

Do We Know Whats Going On?We know the patient has a UTIIs this enough to explain the patients sepsis? YES Can we stop our work-up? NOCould the UTI be a red herring?

Do We Know Whats Going On?We know the patient has a UTIIs this enough to explain the patients sepsis? YES Can we stop our work-up? NOCould the UTI be a red herring? YES

What Else Should We Do?Pt does have Sepsis and a UTI, this could be Urosepsis. HOWEVER, it could also be something else (and there just happens to be a UTI)

What Else Should We Do?EKG MI, Intervals (Toxins), Other-CXR PNA (Sepsis), Edema, Trauma-Head CT Bleed, Swelling, Mass -Lumbar Puncture Bleed, Infection -Urine Drug Screen Drugs of Abuse -

What Else Should We Do?EKG MI, Intervals (Toxins), Other- NORMALCXR PNA (Sepsis), Edema, Trauma- NORMALHead CT Bleed, Swelling, Mass - NORMALLumbar Puncture Bleed, Infection - NORMALUrine Drug Screen Drugs of Abuse - NORMAL

We THINK We Know the CauseUrosepsis

We THINK We Know the CauseUrosepsisRe-Examine the patient and make sure nothing has changed and that the exam is consistent w DxDont become emotionally attached to a Dx, as the clinical picture can change and start looking like something else The only atypical presentation is a typical presentation

CONCLUSIONMaintain a wide differentialGet a Grip on the Diagnosis through systematic clue findingRemember: Its focal in the RAS, or diffuse in the Bilateral HemispheresRe-evaluate patient frequently and do frequent hypothesis-testing in your mind