altered mental status susan budnick, md. goals of this lecture… to provide a framework for...
TRANSCRIPT
Altered Mental StatusSusan Budnick, MD
Goals of this lecture…
To provide a framework for assessing patients when called for acute altered mental status in hospitalized patients
To learn how to begin diagnostic workup for patients that are acutely altered
How to manage basic issues that can cause patients to be altered in an acute setting
There are many causes of altered mental status…
And this list is not complete…
A useful mnemonic….AEIOU TIPS
A – Alcohol, Alzheimer’s
E – Endocrine, electrolytes
I – Infections, intoxications
O – Opiates, oxygen (hypoxia)
U - Uremia
T – Tumor, treatments
I – Insulin
P – Poisoning, psychosis (delirium)
S – Seizure, shock, stroke, SAH
Let’s talk about AMS…
Let’s go through some cases (5) and create a differential of the most likely causes for AMS in each patient.
Use a patient’s clinical history to guide your workup for AMS
Even if they cant give you a history!
What’s the most important thing to remember when assessing a patient with an acute change in mental status?
ABCs! Don’t forget the basics
Case 1: a 72 yo M admitted for COPD exacerbation You are on NF at UH and you get a call about a patient that was just
admitted earlier this evening. According to your signout, the patient is a 72 yo M with a PMHx of COPD, HTN, and poorly controlled DM that was admitted for a presumed COPD exacerbation. The nurse calls and states that during the 9pm vital checks, the patient seemed lethargic and wasn’t answering questions appropriately.
What do you want before you hang up the phone? Vitals: 95, 135/84, 37.2, 20, 92% on 4L O2 by NC
Top differential while walking to the room? Hypercapnic respiratory failure, acute on chronic respiratory acidosis hypoglycemia iatrogenic/medication Electrolyte abnormality since labs might still be pending
Case 1: a 72 yo M cont’d… Next move?
Evaluate the patient
Reasonable labs
FSBG
ABG if any signs of respiratory distress
Renal panel (check electrolytes, calculate an AG)
CBC
The FSBG shows a glucose of 36
What’s next?
Ask the nurse to give an amp of D50
See how much and what type of insulin he received
Case 1: a 72 yo M cont’d… What does an amp of d50 do to a pt’s BG?
It’s hard to say to since we aren’t a static system.
50cc of 50% D50 = 25g dextrose
It should raise our BG for at least a short period of time
Case 1: a 72 yo M cont’d… Follow through… What else will you have to do before this issue is
solved?
Look to see how much insulin the patient got and is scheduled to get
What if the repeat BG after 30 minutes is 50?
Repeat the hypoglycemia protocol!
If the patient got a large bolus of insulin, they could need a D5 drip or another amp D50 before this issue is resolved.
Case 2- 36 yo F with abdominal pain It’s your first day on the Dworken service and you are just learning about
your new night float admits. J.R. is a 36 yo F with a PMHx of Crohn’s s/p colectomy and a total of 9 intra-abdominal surgeries that was admitted yesterday with increased abdominal pain concerning for a Crohn’s flare. When you saw her while prerounding at 6:45 am, she seemed tired and slow to answer questions but you had just woken her up and she was still appropriately answering you. At that time, her vitals were stable and her physical exam was unremarkable other than a tender, but non-surgical appearing abdomen. Morning labs were still pending.
You get called during rounds by the nurse at 9am who is concerned that the patient seems “out of it” and would like a doctor to come assess her.
Top differential on the way to the room?
Sepsis 2/2 intra-abdominal process
Iatrogenic – medication related
Less likely things- PE? Syncope?
Case 2- 36 yo F w abdominal pain cont’d… First move?
Get fresh vitals- 37.1, 78, 108/74, 7, 86% on room air
Next?
Start some oxygen by NC
Look at current inpatient medication list
IV steroids
Lisinopril 10mg
IV dilaudid 2mg Q4H
IV morphine 4mg Q2H
Case 2- 36 yo F w abdominal pain cont’d…
Decision time… more data or a plan?
Naloxone 0.4mg IV push
The patient wakes up and is no longer lethargic and is complaining of pain
Follow through…
Patient may need more naloxone – it is short acting and may need to be redosed in 30 minutes or so
Decrease the amount of pain medications she is getting!
Communicate with the team including the nurses about how to proceed.
Case 3 – 84 yo M admitted for chest pain Your patient M.R. is an 84 yo M with a PMHx of CAD s/p PCI and stent
placement in 2014, BPH, and HTN that was admitted 1 day ago for chest pain rule out. In the ED, a foley catheter as placed for urinary retention thought to be secondary to BPH. All of his cardiac workup has been negative. He was kept over a long holiday weekend for PT/OT assessment on Monday for social concerns at home. On the morning of his planned discharge to SNF, you find him during prerounds more confused than usual. He is answering questions appropriately but only oriented to his own name. According to the overnight nurse, he was a little confused last night when getting his evening meds but she thought he looked “ok”
The nurse asks, “what do you want me to do?”
Top differential diagnosis before answering her? Sepsis, UTI PE Medication related/iatrogenic Hypotension/decreased cerebral perfusion 2/2 to ACS?
Case 3 – 84 yo M cont’d… First move? More data…
Get vitals – 37.3, 68, 114/86, 14, 96% on RA
Exam: In NAD, Oriented to name only, RRR, good pulses, clear lungs and no focal neuro findings…
Labs- morning renal panel, FSBG, CBC are already pending. Ask RN to get UA and culture
What’s next? Look at the medication list:
Aspirin 81mg
Clopidogrel 75mg
Metoprolol 25mg BID
Lisinopril 20mg
Melatonin 3mg
Finasteride 5mg
Tamsulosin 0.4mg
Morphine 4mg IV Q6H PRN chest pain – but he hasn’t received it in the last day
Case 3 – 84 yo M cont’d…
Case 4- 87 yo F admitted for HFrEF and severe AS
You admit an 87 yo F with a PMHx of severe aortic stenosis and valvular HFrEF (EF 25%, 3 recent hospitalizations for ADHF) that was admitted for TAVR workup. Other PMHx includes recurrent UTIs, HLD, and type 2 DM (last HbA1c 7.2%). The patient completed TAVR workup including her coronary angiogram and LHC negative for any ischemic disease. She is now awaiting TAVR scheduled 4 days from now.
When you see her this morning, she is less animated than usual. Although she awakens when you touch her arm, she is not oriented to time or place and quickly falls back asleep. You talk to the evening nurse that says she was awake all night and agitated. She was calling out and trying to get out of bed without assistance.
Later on rounds, she is more alert but only oriented to her name. While presenting to the attending, you list Altered Mental Status on her problem list. She asks for your differential diagnosis…
Case 4- 87 yo F cont’d… Differential Diagnosis?
Delirium
Hypoglyemia
UTI, sepsis
DVT, PE
Other cause of sepsis – HCAP?
Iatrogenic- medications
First move? Get vitals – 37.5, 86, 108/68, 97% on 2L O2 by NC (improved
since admission with diuresis)
Order some labs FSBG (ASAP), renal panel, CBC (morning labs pending), ABG, UA and
culture
Case 4- 87 yo F cont’d…
What’s next? Exam: Alert, oriented to name only, No focal neurologic
findings, RRR, AS murmur unchanged, good distal pulses, crackles to mid lung fields, 1+ pitting edema, JVP at 10cm.
Labs show: BG: 92
Renal panel: 136/3.8/106/23/8/0.74<86
CBC: 9.8>13.1/36.0<264
7.38/42/78
UA with no nitrites, leuk esterase, no sugar, protein or RBCs
Case 4- 87 yo F cont’d…
Medications: Metoprolol 25mg BID Simvastatin 20mg Lisinopril 5mg daily Lasix 40mg PO BID Mild sliding scale insulin Heparin SQ 5000 units TID (you made sure she has been
getting this since admission)
Anything else you could consider?
CXR
Case 4- 87 yo F cont’d…
Case 4- 87 yo F cont’d…
Decision time. Patient sounds volume overloaded – needs diuresis
For the AMS?
No clear etiology at this time but patient is HDS and dangerous etiologies are ruled out or much less likely.
Diagnoses still in the differential? Most likely ? Delirium (a diagnosis of exclusion)
PE. Why is this much less likely?
How to treat… Minimize sedating medications, family and frequent reorientation, remove
lines if not necessary, sleep hygiene (consider adding melatonin if sundowning), etc.
Case 5: 52 yo M admitted for AMS
M.K. is a 52 yo M with a PMHx of COPD, HTN and cirrhosis 2/2 hep C (never underwent treatment, active IVDU) that was admitted to UH 2 days ago for altered mental status. A diagnostic and therapeutic paracentesis showed no evidence of SBP. The patient was not compliant with his home medications and became progressively more altered until family brought him back to the hospital.
Now the nurse is calling you saying that he seems more altered than he did yesterday when she took care of him. He only wakes up to sternal rub and hasn’t been awake enough to take any oral medications all day.
Case 5: 52 yo M, cont’d… You talk to the nurse for a history…
No falls
He isn’t taking any opioids
No fevers, BP is at baseline, not tachycardic (but on a beta blocker)
CT on admission negative
Differential diagnosis for AMS in this patient?
Hepatic encephalopathy
Sepsis- SBP vs. endocarditis vs. aspiration PNA vs. UTI
DVT, PE- hypercoagulable state
CVA- septic emboli (recent IVDU)
Iatrogenic – look at med list
GI bleed
Case 5: 52 yo M cont’d…
First move? Get vitals: 37.3, 67, 97/62, 95% on RA
Examine patient:
Neuro: Alert to sternal rub, can say name, DOB but confused when asked questions, quickly falls back asleep, moving all extremities, no obvious CN deficits (but exam difficult), + asterixis
Cardiac: RRR, no MRGs
Pulm: CTAB but not following commands and taking deep breaths
Abdomen: Distended, dull to percussion, non-tender, no guarding, rigidity
Extremities: +2 peripheral edema to the knee, good distal pulses
Case 5: 52 yo M cont’d…
Medications:
Nadolol 40mg
Spironolactone 100mg
Lasix PO 40mg BID
Lactulose 30mg BID
Daily MTV
Duonebs Q6H prn
Fluticasone + Salmeterol (Advair)
Case 5: 52 yo M cont’d…
Labs?
FSBG: 89
ABG: 7.35/43/92
Renal panel: 133/4.3/106/25/8/1.2<90
CBC: 8.5>11.5/32.1<148
UA: Negative for nitrites, LE, RBCs, trace proteins
Blood cultures from admission (2 days ago) are negative
Ammonia?
Not something we clinically follow. Used for diagnosis rather than following improvements, deterioration of clinical status.
Returning to the differential diagnosis?
Hepatic encephalopathy
Sepsis- SBP vs. endocarditis vs. aspiration PNA vs. UTI
DVT, PE- hypercoagulable state
CVA- septic emboli (recent IVDU)
Iatrogenic
GI bleed
Most likely Dx?
What about the other diagnoses?
Case 5: 52 yo M cont’d…
Decision time…
Place an NG and lactulose Q2H until patient wakes up
Follow through…
Liver patients are often critically ill, even if they are on the floor
Check back early and often!
If not improving, consider a paracentesis to rule out SBP, etc.
Reconsider your differential!
Key points…
Think through your patient’s unique clinical history to narrow the ddx for AMS
Always remember the basics when assessing an altered patient -> ABCs
Code whites and BATs exist for a reason
Many etiologies that are life threatening can be ruled out quickly if needed
FSBG, vitals, ABG, UA, stat head CT if warranted
Clinical history is still important – even if the patient can’t provide it
Look at medications the pt is getting (!!), talk to nurses/techs that might know the pts baseline
Call family if needed. They are often very helpful!