1. Altered Mental Status (AMS)
University of Utah Medical Center
Division of Emergency Medicine
Student Orientation

2. Case 1 78 yo male CC: Unresponsive
HPI: Arrives by EMS who state he was found in bed this morning by his wife, unresponsive. Usual state of health last night. No complaints. No recent illnesses. No signs of trauma
PMHx: CAD, PAF, HTN, cholesterol

3. Case 1 All: PCN Meds: metoprolol, Lipitor, coumadin, nitro
Surg Hx: appendectomy, L inguinal hernia repair
Soc Hx: remote tobacco use, 2 drinks per evening, married, 3 children, retired police officer.
FHx: CAD, HTN

4. Case 1 Vitals: T 38 HR 56 RR 10 BP 210/100 SpO2 94% RA
HEENT: pupils sluggish, equal
Chest: CTA, heart RRR
Abd: soft NT/ND
Ext: scattered healing ecchymoses, 2+ pulses
Neuro: unresponsive, decerebrate posturing to painful stimulus

5. What’s going on? Diagnosis?
Hint: that’s your job

6. Altered Mental Status Up to 40% of geriatric population
Metabolic vs. structural
80% metabolic
Multifactorial
May have more than one etiology at a time
You need to be a (medical) detective
40% of geriatric population will experience an episode of AMS, 80% of the causes are metabolic. Often multifactorial, i.e. infection, medication use etc.
Naughton, Bruce et al. “Delerium and Other Cognitive Impairment in Older Adults in an Emergency Department: Ann of EM 1995(25):

7. Altered Mental Status Inattention Confusion Lethargy Stupor Coma
Intact mental status with misinterpretation of external stimuli
Lethargy
Wakefulness with depressed awareness of self and environment
Stupor
Unresponsiveness from which the pt. may be aroused with vigorous noxious stimuli w/o achieving the normal baseline
Coma
Unresponsiveness from which the patient cannot be aroused by verbal or physical stimuli
Be careful re: how you describe a patients mentation.

8. Mechanism Cerebral cortex disruption must be BIHEMISPHERIC
Diffuse axonal injury
Toxins (drugs, EtOH)
Metabolic toxins (ammonia, urea)
Deficiency of substrates (glucose, oxygen)
Infections
Focal lesions typically do not cause AMS

9. Mechanism Disruption of the Reticular Formation
A grouping of fibers that traverses the brainstem to the thalamus
Mediates state of wakefulness through continuous stimulation of the cerebral cortex
Interruption usually from structural lesions
Supratentorial pressure (mass effect)
Infratentorial pressure (compression of brainstem)
Intrinsic brainstem lesions (pontine hemorrhage)
Reticular Formation: It is a poorly-differentiated area of the brain stem, centered roughly in the pons. The ascending reticular activating system connects to areas in the thalamus, hypothalamus, and cortex, while the descending reticular activating system connects to the cerebellum and sensory nerves.

10. Midline Shift which leads to herniation

11. Differential Diagnosis
AEIOU TIPS
A - Alcohol (drugs), Ammonia
E - Electrolytes, endocrine, environment (too hot/too cold)
I - Insulin (meaning glucose. High-DKA, HHNK; low hypoglycemia)
O - Oxygen (hypoxia), Opiates
U - Uremia
T - Trauma, toxins
I - Infection (sepsis, meningitis)
P - Psychogenic, Porphyria
S - Stroke, SAH, Space occupying lesion, Shock

12. History Many patients with AMS are poor historians – where to look?
Wallet / belongings
Friends / family
Witnesses
EMS
Police (can go to scene)
Medical record
Need to know how quickly this came on, antecedent symptoms etc.

13. History PMHx Medicines Allergies Social History Psychiatric Hx
recent changes
account for pills
interactions
Allergies
Social History
EtoH
Drug use

14. Physical Exam Vitals Temp Heart rate Respiratory rate Blood pressure
SpO2
Glucose
Not really a vital sign but so important it should be

15. Physical Exam ABC’s Head to toe, detailed exam
Undress patient completely
Look everywhere
Signs of trauma
Sources of infection

16. Respiratory Patterns
Cheyne-Stokes: regularly increasing depth of breathing alternating with decreasing depth followed by a short period of apnea.
Diffuse cerebral injury
Absence of forebrain breathing control in metabolic disease
Hyperventilation: deep, rapid breathing
Midbrain lesion
Hypoxia, metabolic acidosis, pain, anxiety
Apneustic: prolonged pause at the end of inspiration
lesion proximal to CN V in the Pons
Cluster (Biot’s breathing): breathing in short bursts
Pontine lesion
Ataxic: irregular breathing
Leads to agonal respirations and death
Lesions of the medulla

17. Physical Exam Skin Color Temperature Moisture Needle tracks/scars
Ecchymosis
Pressure bullae
Signs of trauma

18. Physical Exam Eyes Pupil size and reactivity Ocular movements
Tectal: large & fixed
Midbrain: midpositioned, fixed
CN III: unilateral, dilated & fixed
Pons: pinpoint
Opiates, cholinergics, anti-adrenergics: pinpoint/small
Sympathomimetics, anti-cholinergics: dilated
Ocular movements
Roving movement confirm cortical control
Crossing of midline – intact brainstem
Deviation is away from inactive lesion, but towards seizure focus
Fundoscopic exam
If possible
Pappilledema

19. Physical Exam Neuro Exam-as able GCS CN Motor Sensory DTRs
Cerebellar Exam

20. Laboratory Data Fingerstick Glucose! Oxygen saturation Consider:
Electrolytes
ECG
Drug levels
Tox screens (need to know which drugs they are sensitive to)
TSH

21. Studies Dictated by physical findings/differential
Plain films (i.e. CXR)
CT scan (head CT)
MRI US

22. Management ABC’s Check Glucose Coma Cocktail: classic teaching/mantra
Naloxone: won’t hurt, may clear things up
Thiamine: debatable
Dextrose: if glucose low

23. Management Supportive Treat underlying cause Continue search
Question suicidality
Disposition

24. Case 1
Diagnosis?

26. Case 2 67 yo female CC: Altered mentation, frequent falls
HPI: Brought in by boyfriend due to changed behavior and frequent falls. Slurred speech, slow to respond. Usually “sharp as a tack”. C/o mild HA, multiple bruises from falls (head, legs, arms).
PMHx: hypertension

27. Case 2 All: NKDA Meds: HCTZ Surgical Hx: hysterectomy
Social Hx: lives alone. Boyfriend lives next door. 80 pk-yr tobacco, daily EtOH (last drink 2 days ago), no drugs.
FHx: not obtained

28. Case 2 Vitals: T 37 HR 70 RR 14 BP 120/60 SpO2 94% RA
HEENT: PERRL, EOMI, TMs clear. Bruising to L cheek. Mucous membranes dry.
Neck: supple
Lungs: diminished
Cor: S1S2 RRR without murmur
Abd: Soft NT/ND; no HSM
Ext: Large ecchymosis to L thigh; Full ROM x 4; 2+ pulses througout
Neuro: CN II-XII intact. 2+ DTRs; No focal motor or sensory deficit.

29. Case 2 What is your differential? AEIOU TIPS
A - Alcohol (drugs), Ammonia
E - Electrolytes, endocrine
I - Insulin (meaning glucose high-DKA, HHNK; low hypoglycemia)
O - Oxygen (hypoxia), Opiates
U - Uremia
T - Trauma, toxins
I - Infection (sepsis, meningitis)
P - Psychogenic, Porphyria
S - Stroke, SAH, Space occupying lesion, Shock

30. Case 2
What studies would you want?
Labs
Imaging

31. Case 2
Tox
EtOH negative
Imaging
Head CT negative
CXR unremarkable

32. Case 2 CBC CMP WBC 10K Hb 10 Hct 30.2 Plts 168 Na 120 K 3.2 CO2 18
Gluc 125
BUN 30
Cr 1.8
Ca 7.4
LFTs nml

33. Brief H&P You come up with most likely Dx
Rapid Cases
Brief H&P
You come up with most likely Dx

34. Rapid Case 1 88 yo female with confusion Lives at assisted living
Confusion, urinary incontinence
h/o CAD, HTN
Vitals: T 38.9 HR 100 RR 18 BP 104/54 Sat 96% RA
Exam: non focal
Glucose 140
Lytes nml, WBC 10K UA++++
UTI/Urosepsis

35. Rapid Case 2 21 yo female Found by friends unresponsive at a party
PMHx: none
Vitals: T 36 HR 98 RR 8 BP 90/60 Sat 90% RA
Physical: Pinpoint pupils, bilateral rales, unresponsive.
Glucose 90
Dx: Opiate overdose (with non-cardiogenic pulmonary edema)

36. Rapid Case 3 5 yo male Presents with lethargy Recent URI
Low grade temp, decreased appetite, increased thirst, frequent urination.
Vitals: T 38 HR 130 RR 28 BP 90/50 Sat 98% RA
Dehydrated, lethargic, tachypneic, non-focal neuro exam
Glucose 405
Dx: DKA

37. Rapid Case 4 36 yo male Presents with wife with AMS
More confused, forgetful, waxing and waning.
PMHx: Hep C s/p blood transfusion
Vitals: T 37 HR 80 RR 18 BP 110/60 Sat 98% RA
Physical Exam: Scleral icterus, multiple contusions, hepatomegally, non-focal neuro exam
Glucose: 105
Ammonia level: 90
Dx: Hepatic encephalopathy

38. Rapid Case 5 90 yo female Lethargy Lives alone
Found unresponsive at home
Winter – using kerosene heater
Vitals T 34 HR 50 RR 10 BP 85/40 Sat 84% RA
Glucose 90
DDx:
Hypothermia
CO poisoning
Hypothermia: rectal temp and thermometer that reads low temps
Cold hands = falsely low O2 Sat

39. Rapid Case 6
40 yo female
MVA, low speed, confusion without signs of trauma
PE: VSS; non-focal neuro exam, confused and mildly combative. Multiple small ecchymoses on abdomen (non-tender)
Glucose 30
Dx: hypoglycemia

40. Rapid Case 7
57 yo male
MVA into a tree, no seat belt, no skid marks, significant damage
Vitals: T 37 HR 120 RR 18 BP 90/50 SpO2 90% RA
Exam: Odor resembling EtOH, laceration to forehead, L chest crepitation, +abdominal pain, multiple abrasions; neuro – intoxicated, combative, non-focal
Glucose 90
Differential Dx:
Head injury
Hypoxemia
Shock
EtOH intoxication
Other toxin
Suicide attempt?

41. Summary AMS = Broad differential Difficult historians Be a detective
When the history is suspect you must rely on objective data i.e. physical exam, labs, imaging
Be a detective
Don’t forget GLUCOSE!