altered level of consciousness - continuing … · 2006-12-07 · altered level of consciousness...
Post on 01-Sep-2018
229 Views
Preview:
TRANSCRIPT
ALTERED LEVEL OF CONSCIOUSNESS
Barry Simon M.D.Chairman, Department of Emergency MedicineHighland General HospitalAlameda County Medical CenterOakland California
UCSF Topics in Emergency Medicine - 2006
We will cover…
Terminology & definitionsTerminology & definitionsDeveloping a thorough differentialDeveloping a thorough differentialIdentifying the delirious patientIdentifying the delirious patientA variety of challenging casesA variety of challenging casesFocused H&P highlightsFocused H&P highlightsKey lab and imaging studiesKey lab and imaging studiesAvoiding errorsAvoiding errors
Scope / Spectrum2002 data from a University 2002 data from a University
HospitalHospital
ALOC pts - 5% of the ED volume
64% got admitted
28% neuologic 21% toxicologic14% trauma 14% psychiatric10% infectious 5% endocrine / metabolic3% pulmonary 3% oncologic
Altered Mental Status
Approach
Functional (psychogenic)•
Organic•
Toxic / metabolic (diffuse disease), infectious•
Structural (focal disease)•
Dementia•
{Delirium
Bottom Line
Psychiatric / functional Psychiatric / functional Pt gets labeled /Pt gets labeled / treatable but not reversibletreatable but not reversible
Delirium Delirium 80% reversible and up to 15% mortality80% reversible and up to 15% mortality
Dementia Dementia 20% reversible20% reversible
Delirium
Organic DiseaseAcute onset with a wildly fluctuating course.•
Difficulty focusing, easily distracted.•
Disorganized thinking, rambling, hard to
follow.
•
Altered level of consciousness.•
Visual hallucinations are common.•
Abnormal vital signs.•
Dementia
Organic Disease
Insidious, gradual onset.•
Normal alertness and attentiveness.•
Disorientation is the baseline.•
No hallucinations.•
Vital signs - normal.•
Acute Psychosis
Functional Disease
Abrupt onset with a stable course.•
Normal level of consciousness.•
Auditory hallucinations.•
Orientation usually normal.•
Vital signs may be elevated.•
Let’s Review
Wildly fluctuating Wildly fluctuating coursecourseAuditory Auditory hallucinationshallucinationsDisorientedDisoriented
Normal LOCNormal LOC
Abnormal Vital SignsAbnormal Vital Signs
Delirium
Psychosis
Delirium
Psychosis
Both
Levels of Consciousness Nomenclature - terminology
Traditional Descriptive (AVPU)•
Alert Awake and Aware•
Lethargy Responds to verbal stim•
Stupor Responds to painful stim•
Coma Unresponsive •
The Naked Man
History
32 year old male was found running nude in a field
near a school. He was well known to the police and
the medical community as an alcohol and speed
abuser. While being booked by the police he fell off a
bench, hit his head and became unconscious. No
other acute history was available.
•
ALOC - Naked ManPhysical
BP 70/ p HR 200 RR 16 T 41.6 C (106.9 F)•
Comatose - unresponsive to painful stimuli•
HEENT - small contusion on his forehead. Pupils
were 4 mm and sluggishly reactive to light. He had a
decreased gag reflex, and equivocal plantar reflexes
bilaterally. The rest of his exam was WNL.
•
ALOC - Naked ManFollow up
Despite aggressive resuscitative efforts the patient
expired several hours later. All ED studies were
unhelpful in making a diagnosis.
•
The differential was broad (toxins, hypothalamic
dysfunction, such as tumors, bleeds, CNS infections).
•
A thorough head-to-toe exam would have
keyed-in the examiner to the diagnosis.
•
*
ALOC - Naked Man
Postmortem diagnosis:
Thyrotoxicosis•
DDX - Altered ConsciousnessAEIOU TIPS
A. Alcohols T. Trauma, Tox, temp, Thyroid
E. Endocrine, ‘lytes’ I. Infections
I. Insulin (diabetes) P. Psychiatric
O. Oxygen, Opiates S. SAH, Seizures
U. Uremia
, ASA
Start from the head and work down
DDX - Altered Consciousness
Central nervous system•
Bleeds (traum a and nontraum a)•
In farcts•
In fect ions•
Seizures•
Conversion react ion / psych•
DDX - Altered ConsciousnessMouth: Toxins / Meds
Alcohols OpiatesAnticholinergics PhenothiazinesAnticonvulsants SalicylatesBarbiturates Sedative HypnoticsCarbon Monoxide SSRI’sCyanide SympathomimeticsHallucinogens Tricyclic antidepressantsHeavy Metals
Cocaine delirium and sudden death.•
Gamma hydroxybutyrate (GHB) = (GBH) •
Grievous bodily harm.•
An anesthetic with euphoric and sexual
enhancement properties.
Short acting benzodiazepines - Rohypnol •
(Roofies, Ruffies, Love Drug)•
Special Case Toxins
DDX - Altered Consciousness
Neck and ChestNeck•
Thyroid & parathyroid disease•
Chest•
Hypoxia•
Hypercarbia•
Emboli•
DDX - Altered Consciousness
Abdomen Liver•
Hepat ic encephalopathy•
Wern icke’s syndrom e•
• Pancreatic disease• Adrenal insufficiency• Renal disease: electrolyte and metabolic
disorders
Heat Stroke Heat Stroke –– think of while getting rectal tempthink of while getting rectal tempHypothermia Hypothermia –– rectal temprectal tempSepsisSepsisVasculitisVasculitis –– may consider as part of renal may consider as part of renal causescausesHyperviscosityHyperviscosity –– ALOC as it affects the CNSALOC as it affects the CNS
DDX - Altered Consciousness
Skin – Other??
To Tube or not to Tube
History
14 year old girl found down near a bus stop near her
school.
•
No one came with the girl to the hospital, so initially,
there was no other history available.
•
ALOC - Tube?
Physical exam
Gurgling respirations.•
BP - 98/ 74 HR - 110 RR - 10 Pulse ox 89% RA.•
HEENT - PERRL 3 mm sluggish - disconjugate gaze
++AOB.
•
Neck, chest, abdomen, extremities - all WNL.•
ALOC - Tube?Physical exam - continued
Neurologic•
Comatose - responds appropriately to deep
painful stimuli
•
Poor gag reflex, moves all 4 extremities equally to
painful stimuli
•
DTR’s 1-2+ equal•
Plantar reflexes equivocal•
ALOC - Tube?Medical decison making (for coding purposes only)
Possibly all secondary to alcohol ingestion in a young
girl, but airway control was needed. The glucose was
119 mg / dl. No response to 2 mg of narcan.
•
Prior to CT she would need RSI.......however•
*
ALOC - Tube?
Outcome
She woke up after 3 doses of 0.2 mg (total of 0.6mg)
of flumazenil to the point of spontaneously talking
(although she was dysarthric). Her blood alcohol was
190mg / dl.
•
FLUMAZENIL
Benzodiazepine competitive antagonistDose 0.2 - 2.5 mg •
Duration 40-60 min•
Controversial in:•
Mixed ingestions•
Chronic benzodiazepine users•
Patients with seizure disorders•
Altered Mental Status
History SourcesPatientPatient Pill bottlesPill bottles
MedicsMedics Hospital & Psych Hospital & Psych recordsrecords
RelativesRelatives FriendsFriends
Medic alert tagMedic alert tag Personal physicianPersonal physician
WalletWallet PocketsPockets
Altered Mental Status
Physical exam
Respiratory rate and pattern•
Heart rate and rhythm•
Blood pressure•
Rectal temperature•
-Vital Signs
Altered Mental Status
Physical Exam - General
Head - signs of trauma•
Breath odor - alcohol, fruity, almond, garlic, onion, +•
Neck - thyroid, scar, meningismus•
Altered Mental Status
Physical Exam - General
Chest - breath sounds, murmurs, rhythm•
Abdomen - organomegaly, ascites, peritonitis•
Skin - jaundice, petechiae, moisture, temperature,
color, needle tracks, spider angiomatas
•
Altered Mental StatusNeurologic exam
General observations•
Autism s•
Yawning•
Hiccups•
Swallowing•
Respiratory patterns•
Posturing•
Spontaneous movementsSpontaneous movementsPurposeful movementsPurposeful movementsResponse to painful stimuliResponse to painful stimuliToneTone
Altered Level of Consciousness
Motor Exam
Neurologic Exam
Eyes•
Ears•
M en tal Status Exam•
Keys
Altered level of consciousnessThe eye exam
Pupils•
Funduscopic exam•
Eye movements•
Eyelids•
Caloric Testing
Cold Water < 30 0 C
Normal - deviation away with nystagmus
Cerebral dysfunction - tonic deviation to one side
Brainstem dysfunction - no response
• Mini-mental status exam
• Confusion assessment method (CAM)
Altered Mental Status
Confusion Assessment Method
To diagnose delirium:
1) Acute onset with fluctuating course•
2) Inattention - difficulty focusing •
and
1) Disorganized thinking
or
•
2) Altered level of consciousness•
Diagnosis in < ten minutes
Bedside studies
History and physical•
Glucometer / dextrostick - dextrose•
Pulse oximetry •
ABG’s - Hypoxia / Hypercarbia / acidosis •. Istat
Rapid diagnostic studies
Bedside studies - interventions
Urinalysis•
Infection, hyperglycemia, dehydration•
Breathalyzer•
Electrocardiogram / rhythm strip•
Narcan, thiamine•
Flumazenil, physostigmine•
Physostigmine
Reversible inhibitor of acetylcholinesterase•
Used to RX, or DX severe anticholinergic syndrome•
Useful in GHB ingestion?•
DO NOT use in tricyclic overdoses•
Dose - 0.5 mg slow IVP up to a total of 2 mg•
Keep atropine nearby•
Altered Level of Consciousness
Additional studies to consider
‘Lytes, BUN, Cr, osmolality, calcium•
Complete blood count•
Carboxyhemoglobin •
Lumbar puncture•
Altered Level of Consciousness
Directed drug screen •
Thyroid function tests•
Head CT scan •
Peritoneal tap•
...and more studies to consider
Osmolar Man
HistoryAn 18 year old male calls 911 for a severe headache.
Upon arrival he refuses to let the medics in his home
and they leave. Thirty minutes later his mother calls
911 and the medics arrive to find a comatose male.
His mother explains that he is diabetic and frequently
forgets to take his insulin. The medics transport and
administer 25 gms of dextrose en route.
•
ALOC - Osmolar Man
Physical
BP 170/ 70 HR 92 RR 14•
Comatose male who appears otherwise healthy. Skin
is moist, pupils are PERRL at 6 mm, neurologic exam
is non-focal except for bilateral upgoing toes. The
general exam is otherwise normal.
•
ALOC - Osmolar man
Blood glucose on his pre-hospital dextrose
blood was 19 mg/dl. A second bolus of
dextrose did not change his mental status.
•
Early labs
Do we ever really need a second amp of glucose?•
ALOC - Osmolar Man
Follow-up
Repeat exam noted an unmeasurable amount of
anisocoria unnoticed before. CT scan found a large
subdural with midline shift; the patient was taken to
the OR and did well.
•
*
A 28 year old man was brought unconscious to the
emergency department. Fifteen minutes earlier, with
slurred speech, he had instructed a taxi driver to take
him to the hospital. He passed out before arriving at
the hospital.
•
A ‘Taxi ing’ Case
History
ALOC - Taxi manPhysical
BP 130/ 90 HR 100 RR 40•
Most of the physical exam was within normal limits.
On neurologic exam: Pupils were PERRL at 3 mm,
DTR’s were 3+ and equal, plantar reflexes were both
extensor and he had intermittent bilateral
decerebrate posturing.
•
*
ALOC - Taxi man
Follow up
Hypoglycemia commonly presents with focal
neurologic findings that can mimic structural lesions.
It is obviously important not to skip the basics. This
patient’s blood glucose was 20 mg/ dl and he awoke
after receiving 25 grams of dextrose.
•
Mid Term Review
Odor of breath Odor of breath ––arsenicarsenicAbsent pupil Absent pupil response to lightresponse to lightAverage inc. in BS Average inc. in BS after 1 amp D50after 1 amp D50Flumazenil is avoided Flumazenil is avoided in which patients?in which patients?
GarlicGarlic
Structural defect
130 mg/dl
Mixed ingestions
ALOC - SUMMARY
Take back to the ER points
Assume the patient is delirious•
DDX - start from the head and work your
way down
•
Think like a detective•
The eyes, ears, and mental status are keys•
● Don’t be afraid of flumazenil or physostigmine
Common Errors
Failure to consider the basics (glucose, oxygen,
thiamine)
•
Treatment delay during the evaluation•
Failure to re-examine at frequent intervals•
Incomplete differential ddx
Not So - Funny Man?
History
911 called for a pt. exhibiting bizarre behavior. No
similar past history. Friends stated he had been
acting funny, agitated, and not sleeping for several
days. No hx of drug use but the family had
suspicions. No other significant past or present
history.
•
Not So - Funny Man?Physical examHyper-alert and agitated. Talking very fast but not
making much sense.
•
BP 160/ 110 HR 124 RR 18 T 101 F•
HEENT - PERRL 5 mm Mucous membranes - moist •
No distinctive breath odor•
Skin - warm and dry•
Rest of the exam was WNL•
Not So - Funny Man?Confusion assessment exam
++ Acute onset with a fluctuating course.•
++Inattentive - could not focus on the questions.•
+Disorganized thinking - speech / subject was hard
to follow.
•
+- ALOC - hyperalert.•
Not So - Funny Man?
ED differential and course
Tox, CNS infection, thyroid disease.•
Blood glucose was 97 mg/dl. •
Tox was positive for amphetamine.•
To tap or not to tap?•
Sleeping Beauty
History
A 20 year old woman is found unconscious in her
room two hours after a fight with her parents. She
was well prior to the incident. She has a history of
‘emotional’ problems and occasional migraine
headaches. Medications include Tylenol and
Vicodin for her headaches
•
ALOC - Sleeping BeautyPhysical
BP 108/ 64 HR 68 RR 12•
The general PE was within normal limits. When left
alone she appeared to be sleeping. Pupils were
PERRL at 3mm. There was no response to painful
stimuli but there was some resistance to passive
elevation of her eyelids. Cold calorics elicited tonic
deviation of the eyes with no nystagmus.
•
ALOC - Sleeping BeautyFollow up
The history and physical suggested light coma or
simulated coma. However, caloric testing indicated
organic cerebral dysfunction. The patient remained
stable and gradually awakened over 48 hours. She
admitted to ingesting a handful of phenobarbital.
•
Pathophysiology of Coma
Structural causesBilateral cortical disease.•
Suppression of the Reticular Activating System.•
Supratentorial lesions•
Infratentorial lesions•
Intrinsic brainstem lesions•
Brainstem torque•
top related