altered mental status ndafp 2018 - compatibility mode · – stuporous/comatose = icu stepwise...
TRANSCRIPT
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Altered Mental Status
Austin Smith, M.D.
Adjoint Assistant Professor of Emergency Medicine
Department of Emergency Medicine
Vanderbilt University School of Medicine
Nashville, TN
Attending Physician
Intermountain Park City Hospital and Heber Valley Hospital
Park City, Utah
Disclosures
• The views and opinions expressed in this presentation are those of the
author and solely the author and do not necessarily reflect the official
policy or position of Vanderbilt University, Vanderbilt University Medical
Center, Vanderbilt University School of Medicine, Intermountain
Healthcare, Intermountain Park City Hospital, Intermountain Heber Valley
Hospital, or any of their affiliates or agencies.
Disclosures
• Grant Support
– Supported by an educational grant from McGraw Hill Education that is
not relevant to this presentation
Disclosures
• Off label uses
Disclosures Disclosures
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Outline
• Scope of Lecture
• Definition
• Challenges
Scope
• Acute and subacute changes in mental status
Scope
• Acute and subacute changes in mental status
• Acute and subacute changes are more likely to
be precipitated by a life-threatening illness
Definition
• Any change in a patient’s baseline mental
status
Definition
• Any change in a patient’s baseline mental
status
– A VERY broad definition
Definition
• Any change in a patient’s baseline mental
status
– A VERY broad definition
– A difficult chief complaint in many ways
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Challenges
• The scope is extremely broad
Challenges
• The scope is extremely broad
• Patient is poor historian
Challenges
• The scope is extremely broad
• Patient is poor historian
• Physical exam often not helpful
Challenges
• The scope is extremely broad
• Patient is poor historian
• Physical exam often not helpful
• Labs and imaging often not helpful
Challenges
• The scope is extremely broad
• Patient is poor historian
• Physical exam often not helpful
• Labs and imaging often not helpful
• May be nothing or life threatening!
Challenges
• The scope is extremely broad
• Patient is poor historian
• Physical exam often not helpful
• Labs and imaging often not helpful
• May be nothing or life threatening!
• So many terms/scales
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Definitions
• Coma: unresponsive to any stimuli
Definitions
• Coma: unresponsive to any stimuli
• Stupor: only arouse with vigorous and
continuous stimuli
Definitions
• Coma: unresponsive to any stimuli
• Stupor: only arouse with vigorous and
continuous stimuli
• Delirium: acute disturbance of consciousness
accompanied by an acute loss of cognition
(but not better explained by dementia)
Definitions
• What is delirium and how do you assess it?
Delirium
• Hypoactive Delirium
– Appear drowsy or somnolent
– Subtle and often missed!
Delirium
• Hypoactive Delirium
– Appear drowsy or somnolent
– Subtle and often missed!
• Hyperactive Delirium
– Obvious presentation
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Delirium
• Hypoactive Delirium
– Appear drowsy or somnolent
– Subtle and often missed!
• Hyperactive Delirium
– Obvious presentation
• Mixed-Type Delirium
– Presents with both features
Delirium
Delirium
http://eddelirium.org
Delirium
Delirium Dementia
• Gradual and associated with gradual loss of
cognition
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A Stepwise Approach
Stepwise Approach
• Severity
– ”ABCs and 5 S’s”
Stepwise Approach
• Severity
– ”ABCs and 5 S’s”
– The 5 S’s:
1. Sugar
2. Stroke
3. Sepsis
4. Seizure
5. Sonorous Respirations (Opiate Intoxication)
Stepwise Approach
• Severity
– “ABCs and 5 S’s”
• Stabilize
– Address vital signs and combativeness
Agitation Stepwise Approach
• Severity
– “ABCs and 5 S’s”
• Stabilize
– Address vital signs and combativeness
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Stepwise Approach
• Severity
– “ABCs and 5 S’s”
• Stabilize
– Address vital signs and combativeness
• History and Physical
• Differential Diagnosis
• Labs/Imaging
• Disposition
Stepwise Approach
• History
Stepwise Approach
• History
– Best obtained from someone else
Stepwise Approach
• History
– Best obtained from someone else
– Timing: Acute is worse, abrupt may suggest stroke
Stepwise Approach
• History
– Best obtained from someone else
– Timing: Acute is worse, abrupt may suggest stroke
Stepwise Approach
• History
– Best obtained from someone else
– Timing
– Associated Symptoms: Recent seizures, recent
neurologic complaints, recent infectious
symptoms
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Stepwise Approach
• History
– Best obtained from someone else
– Timing
– Associated Symptoms
– Medications: Needs to be obtained first-hand,
look for recent
changes/additions/discontinuations
Stepwise Approach
Stepwise Approach
• History
– Best obtained from someone else
– Timing
– Associated Symptoms
– Medications:
• Antibiomania? Clarithromycin/Fluroquinolones
• Metronidazole encephalopathy
Stepwise Approach
• History
– Best obtained from someone else
– Timing
– Associated Symptoms
– Medications
– Social History:
• Many elderly patients are abusers of sedative hypnotics
• Also consider physical abuse
Stepwise Approach
• Physical Exam
– Complete neurologic exam
• Right parietal lobe infarcts can cause AMS without any
focal findings
• Aphasia can be confused with AMS
• Gait: Wernicke’s?
– If suspected, consider thiamine administration 500mg IV
before gluocse
Stepwise Approach
• Physical Exam
– Complete neurologic exam
• Right parietal lobe infarcts can cause AMS without any
focal findings
• Aphasia can be confused with AMS
• Gait: Wernicke’s?
• Tone: Serotonin syndrome, malignant hyperthermia,
NMS
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Stepwise Approach
• Physical Exam
– Complete neurologic exam
– Ocular Exam
Stepwise ApproachOcular Exam
Mydriasis Sympathomimetic
Anticholinergic
Miosis Opiate
Pontine Stroke
Horizontal Nystagmus Drug Intoxication
Peripheral Nervous System Lesion[81]
Vertical Nystagmus Central Nervous System Lesion [81]
Wernicke’s encephalopathy
Rotary Nystagmus Drug Intoxication
Central Nervous System Lesion
Exophthalmos Grave’s Disease (Hyperthyroid)
Ophthalmoplegia Wernicke’s Encephalopathy
Increased Intracranial Pressure
Proptosis Retrobulbar hematoma
Orbital Cellulitis
Scleral Icterus Hepatic Failure
Gaze Deviation Seizure
Oculogyric Crisis
Visual Field Deficit Central retinal artery occlusion
Occipital Lobe Infarct
Stepwise Approach
• Physical Exam
– Complete neurologic exam
– Ocular Exam
– GU Exam
• Fournier’s Gangrene, Prostatitis, GI bleed
Stepwise Approach
• Physical Exam
– Complete neurologic exam
– Ocular Exam
– GU Exam
– Skin Exam
• Findings of liver disease, infection, drug patches
Stepwise Approach
• Differential Diagnosis
Breather
• Differential Diagnosis
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Breather Breather
Stepwise Approach
• Differential Diagnosis in 5 Categories
1. Vital Sign Abnormalities
2. Toxic/Metabolic
3. Structural
4. Infectious
5. Psychiatric
Stepwise Approach
Stepwise Approach
• Differential Diagnosis in 5 Categories
1. Vital Sign Abnormalities
2. Toxic/Metabolic
3. Structural
4. Infectious
5. Psychiatric
Stepwise Approach
• Vital Sign Abnormalities
– Should be considered life threatening as they are
causing end organ dysfunction of the brain
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Stepwise Approach
• Vital Sign Abnormalities
– Should be considered life threatening as they are
causing end organ dysfunction of the brain
– Address before moving on
Stepwise Approach
• Toxins
– Prescription AND OTC medications
– Environmental Toxins (CO, Jimson weed,
marijuana gummy bears)
– Withdrawal
Stepwise Approach
• Metabolic
– Glucose
• Hypoglycemia can mimic anything
• DKA/HHS
Stepwise Approach
• Metabolic
– Sodium
Stepwise Approach
• Metabolic
– Sodium
• The most common electrolyte disorder
Stepwise Approach
• Metabolic
– Sodium
• The most common electrolyte disorder
• Most common cause in outpatients is thiazide use
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Stepwise Approach
• Metabolic
– Sodium
• The most common electrolyte disorder
• Most common cause in outpatients is thiazide use
• Usually not the cause unless < 120 mEq/L
Stepwise Approach
• Metabolic
– Calcium
• Most common cause in outpatients is primary
hyperparathyroidism
• Most common cause in inpatients is malignancy
Stepwise Approach
• Metabolic
– BUN
• When > 100mg/dL, mental status changes may develop
and uremia is likely present
Stepwise Approach
• Metabolic
– Hyperthyroid
• Tachycardia, mania, sweating
• Thyroid Storm
Stepwise Approach
• Metabolic
– Hyperthyroid
• Tachycardia, mania
• Thyroid Storm
– Hypothyroid
• Lethargy, dry skin, enlarged thyroid, irritability, cold
sensitivity, etc.
• Myxedema coma: most severe complication-
multisystem organ failure
Stepwise Approach
• Metabolic
– Adrenal Insufficiency
• Often missed early
• Dark Skin Pigmentation
• Hyponatremia with Hyperkalemia
• Cardiovascular Collapse
• Sepsis not responding to treatment
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Stepwise Approach
• Metabolic
– Hepatic
• Hepatic encephalopathy
• Cerebral Edema
• High risk of ICH
Stepwise Approach
• Infectious
– Systemic
• SOFA score has shown that AMS is an independent
predictor of ICU stay and hospital mortality
Stepwise Approach
• Infectious
– Systemic
• SOFA score has shown that AMS is an independent
predictor of ICU stay and hospital mortality
– Neurologic
• Meningitis, Encephalitis
• Anti-NMDA Encephalitis
Stepwise Approach
• Neurologic
– Intracranial hemorrhage
– Traumatic hemorrhage
– Locked-in Syndrome
– Non-Convulsive Status Epilepticus
Stepwise Approach
• Psychiatric
– A diagnosis of exclusion
Stepwise Approach
• Psychiatric
– A diagnosis of exclusion
– 20% have a medical problem causing or
exacerbating their psychiatric condition
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Stepwise Approach
• Psychiatric
– A diagnosis of exclusion
– 20% have a medical problem causing or
exacerbating their psychiatric condition
– Psychiatric patients have a high rate of medical
comorbidities
• Largely undiagnosed and untreated
Stepwise Approach
• Psychiatric
– Atypical presentations of common medical
problems are common
– Changes in vision appear to be most predictive of
a medical illness causing, or at least contributing
to, their symptoms
Stepwise Approach Stepwise Approach
• Labs
Stepwise Approach
• Labs
– Most should have a CBC/BMP
Stepwise Approach
• Labs
– Most should have a CBC/BMP
– Urinalysis
• Yes, but be careful
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Stepwise Approach
• Labs
– Most should have a CBC/BMP
– Urinalysis
• Yes, but be careful
• Asymptomatic bacteriuria is common and overtreated
Stepwise Approach
• Labs
– Most should have a CBC/BMP
– Urinalysis
• Yes, but be careful
• Asymptomatic bacteriuria is common and overtreated
• Bacteria can be in the urine with a systemic infection
Stepwise Approach
• Labs
– Toxicologic Screen
• Serum ETOH/APAP/ASA levels
Stepwise Approach
• Labs
– Toxicologic Screen
• Serum ETOH/APAP/ASA levels
• Consider serum osmolality too
Stepwise Approach
• Labs
– Toxicologic Screen
• Serum ETOH/APAP/ASA levels
• Consider serum osmolality too
• Urine Drug Screen?
– Prone to false positives, not particularly sensitive, and rely on
multiple factors for detection
Stepwise Approach
• Labs
– LP?
• If you think about it, you should probably do it
• Save CSF
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Stepwise Approach
• Imaging
Stepwise Approach
• Imaging
– CXR
• Hypoxia, fever, cough, respiratory symptoms
• Free air?
Stepwise Approach
• Imaging
– EEG
1. No cause
2. Any history of seizure or seizing before arrival
Stepwise Approach
• Imaging
– EEG
1. No cause
2. Any history of seizure or seizing before arrival
– Incidence in patients with AMS is 8-30%
Stepwise Approach
• Imaging
– Noncontrast Head CT
• Routine in AMS?
– Controversial, but if impaired level of consciousness, consider
– Always if concerned or trauma, deficit, anticoagulants
Stepwise Approach
• Imaging
– CT Angiography
• Excellent for stenosis, aneurysms, dissections
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Stepwise Approach
• Imaging
– MRI
• If no cause is found, MRI can be helpful, particularly for
strokes and tumor
Stepwise Approach
• Disposition
– Stuporous/Comatose = ICU
Stepwise Approach
• Disposition
– Stuporous/Comatose = ICU
– Stroke = Stroke unit (improved mortality and
outcomes)
Stepwise Approach
• Disposition
– Stuporous/Comatose = ICU
– Stroke = Stroke unit (improved mortality and
outcomes)
– Poisoning = Discuss with toxicologist
Stepwise Approach
• Disposition
– No cause, but resolved = observation vs discharge
home (but great followup/supervision plan
needed)
• However, missed delirium in elderly patients carries a
higher mortality rate
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