Altered Mental Status Sean D. Foster, MD

Altered Mental Status Sean D. Foster, MD
Approach to the Patient with… Altered Mental Status Sean D. Foster, MD Department of Emergency Medicine University of Pennsylvania Perelman School of Medicine Department of Emergency Medicine University of Pennsylvania Health System

Questions/Comments/Suggestions
Department of Emergency Medicine University of Pennsylvania Health System

Outline Pathophysiology & Definitions (brief)
Approach to the “altered patient” Case examples Department of Emergency Medicine University of Pennsylvania Health System

Question for the audience:
What is “Altered Mental Status”? Symptom Change in Consciousness or diagnosis? The term “altered mental status” is common medical jargon, but is fairly nonspecific. Generally speaking, however, people are referring to some sort of perceived change in the patients consciousness. The first part of that, the change, is fairly straight forward from an emergency medicine standpoint. The vast majority of time we are going to be dealing with acute changes, occuring over seconds to days. Rarely will we be dealing with something subacute, and the differential for chronic changes is entirely different, and largely outside the scope of EM and this lecture The second element, though, the consciousness part, is a little more nebulous. Acute (rarely subacute) What about this? Department of Emergency Medicine University of Pennsylvania Health System

Consciousness Alertness or arousal Content of consciousness “Level”
“Confusion” Conceptually, consciousness may be divided into elements of alertness or arousal, and elements of content Department of Emergency Medicine University of Pennsylvania Health System

1. Level of Consciousness
Consciousness is an interaction between the reticular activating system and the cerebral cortex. Both must be intact for a patient to be fully conscious. RAS is located in the brainstem or the medulla. What sorts of things lead to disrupted consciousness: RAS: trauma (blow to chin), increased ICP, hypertensive hemorrhage CORTEX: trauma, drugs, alcohol, hypoxia, hypoglycemia, metabolic disarray. Rarely stroke or tumor.

Terms Minimally conscious state: Obtundation: Stupor:
Inconsistent but discernable evidence of consciousness. Able to follow commands. Obtundation: awake but not alert, with psychomotor retardation Stupor: awakens with stimuli but little motor or verbal activity when aroused Department of Emergency Medicine University of Pennsylvania Health System

Coma COMA: brainstem dysfunction and/or
Broadly defined as “a state of deep unconsciousness that lasts for a prolonged or indefinite period” More specifically: complete failure of the arousal system with no spontaneous eye opening Consciousness is an interaction between the reticular activating system and the cerebral cortex. Both must be intact for a patient to be fully conscious. RAS is located in the brainstem or the medulla. Cortex: trauma, CVA, tumor, surgeries, drugs, alcohol, hypoxia, hypoglycemia. RAF: trauma (blow to chin), increased ICP, hypertensive hemorrhage, *unilateral hemispheric dz should not result in coma*: brainstem or b/l cortical dz Disorders of consciousness grouped into: Dz that affect arousal functions Dz that affect content of consciousness functions Dz that affect both Locked-in syndrome (Count of Monte Cristo syndrome): patients appear motionless but their eyes are open. Lesion is destructino of the ventral pontine motor tracts. Only function retained is vertical eye movement. (Nortier de Villefort who is only able to communicate by blinking) Psychogenic unresponsiveness: patients can maintain normal motor and posturing, but for voluntary or involuntary reasons, they can’t communicate with the examiner. COMA: brainstem dysfunction and/or bilateral cortical disease Department of Emergency Medicine University of Pennsylvania Health System 9

2. Content of Consciousness
Alteration in higher cerebral functions Memory, awareness or attention Wide range of presentations: Mild confusion to delirium A state of disturbed consciousness with associated: Motor restlessness Transient hallucinations Disorientation Delusions Department of Emergency Medicine University of Pennsylvania Health System

2. Content of Consciousness
Cause: Widespread cortical dysfunction Substrate deficit Neurotransmitter dysfunction Circulatory dysfunction Reserve of CNS function varies by individual The pathophysiology of disrupted content of consciousness, or confusion, is not necessarily straightforward. Generally speaking it is caused by widespread cortical dysfunction, and this may be grouped into categories of substrate deficiency, neurotransmitter dysfunction (ie drug use or withdrawal), or circulatory dysfunction (hypotension, extreme hypertension, elevated ICP with decreased CPP) Department of Emergency Medicine University of Pennsylvania Health System

Common Classifications
DELIRIUM DEMENTIA PSYCHOSIS ONSET Rapid Slow Variable COURSE Fluctuating Progressive VITALS Often Abnormal Normal (Usually normal) PHYSICAL EXAM Normal (usually) HALLUCINATIONS Visual (External stimuli) Rare Auditory (Internal Stimuli) UNDERLYING CAUSE Organic (myriad) Organic (degenerative) Functional PROGNOSIS Poor (if cause not treated) Delirium Dementia Psychosis Typically, dementia is a slow progressively degenerative process that is managed by primary care physicians rather than in the ED. Sometimes families bring a dementia patient in to the ED and the true “emergency” is that they are no longer able to care for the patient at home. Admission may be necessary for safety, social assessment and placement. Psychosis is generally managed by psychiatry services rather than the ED. Decompensation of psychiatric illness, however, may lead to dangerous situations for the patient or others. Crisis intervention in these situations represents a true emergency. Management of these situations can be one of the most difficult challenges emergency physicians face. Delirium represents a true medical emergency. Normal consciousness requires both arousal and cognition. Arousal is mediated primarily by brainstem nuclei (reticular activating system) while cognition and organized thought is dependent on cortical functioning. Delirium is brain dysfunction resulting in alterations of both level of arousal and thought content. Isolated structural lesions are incredibly unlikely to involve brainstem and bilateral cortical structures and still leave the patient alive. Delirium is almost always caused by an underlying medical problem that has toxic or metabolic affects on the brain. Screening for delirium in all altered patients is critical because it may lead us down our diagnostic pathway. Recognizing delirium gives us a chance to avert disaster. Delirium has a very poor prognosis unless the underlying cause is recognized and remedied. Some focal neurological deficits can be mistaken for alterations in consciousness. Dysarthrias and aphasias (receptive, motor or mixed), spatial neglect syndromes, even hemianopsias and hemiparesis can be mistaken as confusion if not looked at closely. Functional (psychiatric) changes in behavior (like depression or fugue states) can be difficult to distinguish from organic causes of behavioral changes. Much of “medical clearance for psychiatry” deals with this conundrum. When in doubt, assume a medical (organic) etiology until it can be clearly ruled out. Adapted from: CDEM Curriculum “The Approach to Altered Mental Status”

Important points: Focal cortical dysfunction does not usually cause confusion Subcortical/brainstem dysfunction usually affects level of consciousness, rather than content Department of Emergency Medicine University of Pennsylvania Health System

Outline Pathophysiology (brief) Approach to the “altered patient”
Case examples Department of Emergency Medicine University of Pennsylvania Health System

A problem: Department of Emergency Medicine
University of Pennsylvania Health System

“Worst First” What are the immediately life threatening and/or reversible causes of altered mental status? Department of Emergency Medicine University of Pennsylvania Health System

Immediate and/or rapidly reversible life threats
Loss of airway Hypoxia Respiratory failure Narcotic overdose Hypotension/shock Dysrhythmia Intracranial catastrophe Major trauma Hypo/hyperthermia (Severe) Hypoglycemia A B C D E Vitals Glucose Department of Emergency Medicine University of Pennsylvania Health System

EM Approach Airway Breathing Circulation Disability (neurologic) Exposure Finger stick glucose **Should occur as patient is placed on monitor/vitals obtained/IV access established ***Deal with issues as they are identified Department of Emergency Medicine University of Pennsylvania Health System

Airway How do you assess? What do you look for?
What interventions can you make? A- Check to see that the airway is open and protected. Are there secretions or vomit that needs to be suctioned? Open the airway, check pulse-oxymetry and provide supplemental oxygen if needed. Hypoxia is a potentially reversible cause of AMS. - Intubate if GCS <8 comes mostly from trauma literature - Poisoned patients are unlikely to suffer from secondary brain injury, but decreased consciousness and loss of protective airway reflexes predispose to respiratory failure and aspiration injury. However, the risk of aspiration is not confined to patients with a GCS of 8 or less, and the loss of airway reflexes cannot be reliably predicted using the GCS alone - GCS is not a good predictor of pharyngeal control, however, risk of aspiration does increase as GCS decreases. Donald, C. et al. Predictors of the need for rapid sequence intubation in the poisoned patient with reduced Glasgow coma score. Emerg Med J Jul;26(7):510-2. - Single centre prospective observational study of all poisoned pts over one year (73 pts). None of the 12 pts with a GCS <8 had a poor outcome. However, all were in a monitored setting (ED) and some required OPA, NPAs. Department of Emergency Medicine University of Pennsylvania Health System

Airway: rapid differential
Loss of protective reflexes Many causes… Overdose Intracranial catastrophe Oropharyngeal swelling Anaphylaxis Angioedema Infections Ludwig’s angina, PTA Stridor Infection RPA, epiglottitis, tracheitis, croup Foreign body aspiration

Breathing How do you assess? What options are there for interventions?
Rate Depth Pattern Auscultation (bilateral and equal?) Pulse oximetry End Tidal CO2 What options are there for interventions? Supplemental O2 Positive pressure support (CPAP, BiPAP) BVM Consider narcan if AMS + hypoventilation Intubation Decompression B- Assess breathing. Inadequate ventilation will lead to elevated levels of CO2 (respiratory acidosis) and can cause AMS. Bag-valve-mask ventilation should be provided until adequate ventilation can be restored. In a patient with AMS and a depressed respiratory status, consider narcotic overdose as a possible cause. Hyperpnia: this is a great differential pretty short and all things that can kill you and with different management Department of Emergency Medicine University of Pennsylvania Health System

Breathing: rapid differential
Hypoxia pneumonia, CHF, PE, COPD Respiratory depression opioids, brainstem injury Hypercarbia = “CO2 narcosis” Tachypnea Profound Met Acidosis Methanol/EG DKA/AKA Sepsis Respiratory Stimulation Salicylates Asymmetric exam Pneumothorax, hemothorax Large effusion B- Assess breathing. Inadequate ventilation will lead to elevated levels of CO2 (respiratory acidosis) and can cause AMS. Bag-valve-mask ventilation should be provided until adequate ventilation can be restored. In a patient with AMS and a depressed respiratory status, consider narcotic overdose as a possible cause. Hyperpnia: this is a great differential pretty short and all things that can kill you and with different management Department of Emergency Medicine University of Pennsylvania Health System

Circulation How do you assess?
Distal pulses Blood Pressure Cardiac rhythm Distal perfusion What options are there for interventions? IV fluids Blood products Cardioversion Cardiac pacing Inotropes/chronotropes/vasopressors C- Assess circulatory status. Can you feel good distal pulses? Is the blood pressure very high or low? What is the cardiac rhythm? Hypoperfusion starves the brain of oxygen and glucose and leads to AMS. Nonperfusing rhythms require immediate CPR and ACLS. Hypotension should prompt IV fluid bolus and an immediate search for the cause. Department of Emergency Medicine University of Pennsylvania Health System

Circulation: rapid differential
Hypotension Shock differential (distributive, neurogenic, obstructive, hypovolemic, cardiogenic) Hypertension Hypertensive crisis Sympathomimetic abuse (cocaine, amphetamines, designer drugs) Elevated ICP (mass lesion, hemorrhage) Compensatory reflex (cushing’s, iscemic stroke) C- Assess circulatory status. good distal pulses? blood pressure very high or low? cardiac rhythm? Department of Emergency Medicine University of Pennsylvania Health System

Circulation (cont’d) Tachycardia Bradycardia Broad differential…
Drug overdose (BB, CCB, digoxin, lithium) Organophosphate exposure Uremic encephalopathy Hyperkalemia Myocardial ischemia (particularly in elderly) Neurogenic shock Department of Emergency Medicine University of Pennsylvania Health System

Disability (neurologic catastrophe)
How do you assess? GCS or AVPU Pupillary exam Look for seizure activity Evaluate extremity movement Signs of elevated ICP What interventions can you make? Anti-epileptics Consider c-spine immobilization Elevate head of bed Hypertonic agents D- Check for neurologic disability. Use Glasgow Coma Score (GCS) or Alert Verbal painful unresponsive (AVPU) scale (see below) for a quick assessment of level of consciousness. Look for seizure activity. Evaluate pupils. Observe spontaneous movements. Lack of movement on one side of the body night indicate stroke while lack of movement below a certain level of the body could indicate spinal cord injury. If there is any suspicion of trauma the cervical spine should be stabilized. Department of Emergency Medicine University of Pennsylvania Health System

Glascow Coma Score Department of Emergency Medicine
GCS First described in 1974 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81. Validated in Trauma, meningitis and SAH Good intra-observer reliability Easy to use Department of Emergency Medicine University of Pennsylvania Health System

AVPU Awake/Alert Voice Pain Unresponsive

Disability: rapid differential
Conjugate eye deviation Stroke (toward lesion) Seizure (away from lesion) Hemiparesis Stroke Post-ictal state ICH Signs of elevated ICP Mass lesions Stroke with swelling

Exposure What does this mean? What are you looking for?
Fully undress patient Head to toe rapid exam What are you looking for? Trauma Patches Lines, tubes, fistulas Rashes, wounds/decubitus ulcers E- Expose (fully undress) and perform a rapid head to toe look for signs of trauma, transdermal drug patches, dialysis access, infectious sources (such as catheters) or petechiae. Department of Emergency Medicine University of Pennsylvania Health System

Don’t forget the fingerstick!

Hypoglycemia Causes? Treatment? Insulin/hypoglycemic drug overdose
New renal dysfunction Accidental ingestion (Children) Dietary changes Sepsis (alcoholics, babies, elderly) Treatment? Childen (rule of 50) Adult (1-2 amps D50) All: Eat something! Department of Emergency Medicine University of Pennsylvania Health System

HYPERglycemia Can this cause AMS? DKA HHNK/HHS Sepsis
Medication effect (steroids, CCB overdose)

Now that you have treated life threatening emergencies and assessed for immediately reversible conditions….. Department of Emergency Medicine University of Pennsylvania Health System

Still a problem: Department of Emergency Medicine

E (endocrinopathy, encephalopathy, electrolytes)
A (alcohol) E (endocrinopathy, encephalopathy, electrolytes) I (insulin, infection, increased intracranial pressure) O (opiates, oxygen) U (uremia) T (trauma, toxicology, tumor, temperature) I (infection, inborn errors of metabolism) P (psychiatric, post-ictal state) S (seizure, stroke, shock, space-occupying lesions) The difficulty with the altered patient is the breadth of possible causes. So how do you approach these patients in the emergency department? Department of Emergency Medicine University of Pennsylvania Health System

History, History, History!
Diagnosis usually based on history! – Where can you get it? 37

Collateral EMS Family/friends Old charts Primary physician
Medic alert bracelet Department of Emergency Medicine University of Pennsylvania Health System

History Baseline – be specific How often do they see the patient?
What is the “change” they observed? Medical history Medications Social history ROS – any recent complaints? Department of Emergency Medicine University of Pennsylvania Health System

Physical Exam Complete physical exam always indicated
Look for stigmata of chronic disease Signs of trauma Evidence of toxidromes Undress your patients (always) Don’t forget the back exam Department of Emergency Medicine University of Pennsylvania Health System

Vital & Physical Any abnormality should increase your suspicious for delirium Department of Emergency Medicine University of Pennsylvania Health System

By the completion of the H&P, you should be able to:
Categorize as delirium, dementia, psychosis Initiate a diagnostic evaluation Department of Emergency Medicine University of Pennsylvania Health System

Differential diagnosis (treatable Causes)
A (alcohol) E (endocrinopathy, encephalopathy, electrolytes) I (insulin, infection, increased intracranial pressure) O (opiates, oxygen) U (uremia) T (trauma, toxicology, tumor, temperature) I (infection, inborn errors of metabolism) P (psychiatric, post-ictal state) S (seizure, stroke, shock, space-occupying lesions) **put this on the board** 2 categories: toxic/metabolic v structural dz, or medical v surgical A: respiratory depression, wernicke’s encephalopathy E: **most common cause of altered MS is hypoglycemia, extreme hypothyroidism, hyponatremia, adrenal insufficiency or adrenal crisis, severe thyroid storm, encephalopathy: hepatic, uremic, hypertensive I: diabetes, systemic infections: meningitis, sepsis, urosepsis in elderly, trauma: SAH, subdural, epidural hemorrhage, hydrocephalus, tumor O: heroin, anoxia: anemia, low cardiac output, pulmonary disease, cardiac disease U: uremia T: trauma, tox: alcohol, barbiturates, benzos, antidepressants, GHB, tumor, hypothermia/hyperthermia I: inborn errors, infection P: psychiatric, post-ictal: Todd’s paralysis S: Department of Emergency Medicine University of Pennsylvania Health System 43

Differential diagnosis
I: Infection - Sepsis, encephalitis, meningitis, syphilis, central nervous system (CNS) abscess, malaria W: Withdrawal - Alcohol, barbiturates, sedative-hypnotics A: Acute Metabolic and endocrine - Acidosis, electrolyte disturbance, hepatic or renal failure, magnesium, calcium, porphyria; endocrinopathies: diabetes, adrenal, thyroid T: Trauma – head trauma, burns, abuse C: CNS dz – Hemorrhage (EDH, SDH, SAH, intracerebral), stroke, vasculitis(TTP), seizures, tumor (benign, malignant primary vs metastatic) H: Hypoxia/Hypercarbia – chronic lung dz (ie COPD), acute (Pneumonia, CO, Methemoglobinemia), global hypoperfusion D: Deficiencies- Vitamin B12, hypovitaminosis, niacin, thiamine E: Environmental: Hypothermia, hyperthermia; A: Acute Vascular - Hypertensive emergency, subarachnoid hemorrhage, sagittal vein thrombosis T: Toxins/Drugs - Medications, street drugs, alcohol, pesticides, industrial poisons (e.g., carbon monoxide, cyanide, solvents), serotonin syndrome, NMS H: Heavy Metals - Lead, mercury, Iron Department of Emergency Medicine University of Pennsylvania Health System

Outline Pathophysiology & Definitions (brief)
Approach to the “altered patient” Case examples Department of Emergency Medicine University of Pennsylvania Health System

Case What is your next step?
22 yo M presenting with EMS after being found screaming at passersby in center city. He swung at a police officer and was tazed by police . He required restraints with EMS. He is thrashing violently and screaming “I am god”. He won’t answer your questions. What is your next step? Department of Emergency Medicine University of Pennsylvania Health System

Important point: You are responsible for the safety of yourself, your team and your patient At times this may require restraining and/or sedating your patient even before completing your physical exam Department of Emergency Medicine University of Pennsylvania Health System

Drug therapy for agitated patients
Benzodiazepines Antipsychotic Drug induced: Drug withdrawal: Psychiatric: Dementia: Unknown: Lorazepam 1-2 mg IV Midazolam mg IM haloperidol 2-5 mg IV => double the dose every minutes prn halperidol can be given IV and titrated to effect - initial dose of mg IV => double the dose every minutes prn (other suggest starting with 5mg IV) haloperidol should be used cautiously in patients with a prolonged QT interval, because there is some evidence that neuroleptic agents may cause torsade des pointes (some physicians would discontinue haloperidol if the QTc interval lengthens by > 25%) BZD: lorazepam good if IV access. Midaz 2.5-5mg IM if no IV access use escalating doses if not working Department of Emergency Medicine University of Pennsylvania Health System

Agitated delirium Association with illicit drug use Treat if:
not universal. Treat if: Presence of excited delirium Continued maximal struggle despite attempts at maximal restraint Department of Emergency Medicine University of Pennsylvania Health System

Sudden Cardiac Death Mechanism unknown
No definite etiology usually found at autopsy Catecholamine excess leading to stress cardiomyopathy vs profound metabolic acidosis likely leading to cardiac arrest? Hyperthermia, seizures, hyperkalemia often contributory Department of Emergency Medicine University of Pennsylvania Health System

Now he is calmer, what next?
BP 180/100 HR 137 SpO2 100% RA T 99.8 RR 16 FSBG 100 Airway: intact Breathing: lungs clear, good effort Circulation: normal pulses x 4, tachycardic & hypertensive Disability: PERRL (Dilated), MAE. GCS 14 (4-4-6) Exposure: no rashes. Skin flushed, sweaty. No patches or wounds. Department of Emergency Medicine University of Pennsylvania Health System

Detailed exam GEN: now drowsy but still awake
HEENT: pupils bilaterally dilated, trace reactive. Mucous membranes moist CV: tachycardic, regular PULM: clear bilaterally ABD: unremarkable EXT: no trauma or swelling SKIN: diaphoretic, otherwise normal NEURO: GCS 14. CN 2-12 intact. Moving all extremities equal. Department of Emergency Medicine University of Pennsylvania Health System

Differential Dx? Toxic ingestion Infection Psychiatric disease
Encephalitis Meningitis Psychiatric disease Neuroleptic malignant syndrome Serotonin syndrome Department of Emergency Medicine University of Pennsylvania Health System

What else can you try? Does that explain his symptoms?

Four Classic Toxidromes
Heart rate Oral Findings Blood pressure Mental status Eyes Skin Anticholinergic Tachy None Variable Delirium Mumbling Seizures Dilated Dry, flushed Warm-hot Sympathomimetic High Delusional Paranoia Agitation Diaphoretic Piloerection Sedative Brady Low lethargic Coma nonbreathing Constricted Or hypothermic Cholinergic salivation Confusion Seizure CNS depression

Workup EKG Basic Metabolic Panel Total CK UDS

Sympathomimetic Toxidrome: Treatment
Attempt to calm patient Maintain safety of team and patient Supportive Care Monitor airway IVF for insensible losses Benzodiazepines (IV or IM) for agitation or seizure EKG Avoid Beta blockers Department of Emergency Medicine University of Pennsylvania Health System

Questions? Department of Emergency Medicine

Case A 75 year old female is transferred to the emergency department from a skilled nursing facility. She arrived last night after discharge from the hospital for a hip fracture. Overnight she began screaming that someone was “trying to kill her”, and insisted that her husband was looking for her, though he is known to be deceased. The facility is stating that her dementia was not adequately described prior to transfer, and that they cannot meet her level of care needs. EMS found her to be awake, pleasant and cooperative. Department of Emergency Medicine University of Pennsylvania Health System

BP 146/82 HR 90 RR 16 SpO2 96%% T100.2 (O) FSBG: 132
Airway: intact. Phonates easily. Breathing: intact. Normal sats. Good bilateral air mvmt. Circulation: intact: normotensive. Equal pulses. Good distal perfusion. Disability: perrl, moves all extremities spontaneously. Alert. GCS 15 Exposure: no skin lesions, patches, rashes Department of Emergency Medicine University of Pennsylvania Health System

What else would you like to know?
GEN: thin elderly woman. Nontoxic. HEENT: atraumatic. PEERL. Sclera anicteric. NECK: supple, no jvd LUNGS: clear bilaterally CV: RRR ABD: soft, nontender EXT: no edema, deformity or tenderness SKIN: no rash NEURO: slightly drowsy but awake. Oriented to person and place but not time. CN 2-12 intact. Normal strength and sensation. What else would you like to know? Department of Emergency Medicine University of Pennsylvania Health System

Approximately 1 hour later, the nurse notifies you that the patient is becoming increasingly paranoid and is insisting that she is being held against her will. What is the diagnosis? Department of Emergency Medicine University of Pennsylvania Health System

Delirium Department of Emergency Medicine

Delirium vs Dementia Delirium always has an organic cause Delirium
Fluctuating course of confusion Acute onset Reversible cause Difficult to distinguish from acute psychosis Depressed level and content of consciousness Dementia Stable course of confusion Insidious onset Irreversible and slowly progressive No impairment of level of consciousness Clinical features of delirium: Activity level may increase with agitation Sleep-wake cycles are frequently reversed: “sundowning”: seen in elderly patients who are agitated at night 40% of patients: hallucinations, delusions (visual) Delirium always has an organic cause 65

Differential diagnosis?
Drug effect (most common overall) Infectious process UTI (!!!) Pneumonia Bacteremia Skin and soft tissue infection (bed sores?) CNS process ICH, Subdural Acute MI Department of Emergency Medicine University of Pennsylvania Health System

Meds to watch for Narcotics Benzodiazepines antibiotics
anticholinergic drugs antiepileptics anti-inflammatory agents (corticosteroids) cardiovascular medications (beta-blockers, antidysrhythmics, antihypertensives, cardiac glycosides) sympathomimetics Psychiatric medications (antidepressants, antipsychotics, mood stabilizers) medications are the most common cause of delirium, accounting for 22 to 39% of cases. Department of Emergency Medicine University of Pennsylvania Health System

Managing Delirium minimize sensory overload
limit the number of care-givers quiet environment Try to maintain day/night cycle if possible allow family members to remain in constant/frequent attendance do not leave patients unattended ensure that the bed side-rails are up Department of Emergency Medicine University of Pennsylvania Health System

Drug therapy for agitated patients
Benzodiazepines Antipsychotic benzodiazepines Drug induced: Drug withdrawal: Psychiatric: Dementia: Unknown: Lorazepam 1-2 mg IV Midazolam mg IM haloperidol 2-5 mg IV => double the dose every minutes prn halperidol can be given IV and titrated to effect - initial dose of mg IV => double the dose every minutes prn (other suggest starting with 5mg IV) haloperidol should be used cautiously in patients with a prolonged QT interval, because there is some evidence that neuroleptic agents may cause torsade des pointes (some physicians would discontinue haloperidol if the QTc interval lengthens by > 25%) BZD: lorazepam good if IV access. Midaz 2.5-5mg IM if no IV access use escalating doses if not working Department of Emergency Medicine University of Pennsylvania Health System

Case An 80 year old female is brought by EMS from the nursing home with concern for altered mental status. She was found “babbling nonsensically” in her room this morning. When you address her, she appears to regard you but doesn’t answer questions appropriately, instead making nonsensical strings of words. What is the next step of your evaluation? Department of Emergency Medicine University of Pennsylvania Health System

BP 175/100 HR 80 RR 14 SpO2 99% T FSBG 98 Airway: intact. Phonates. Handling secretions. Breathing: intact. Good sats, good bilateral air movement Circulation: intact. Hypertensive but equal pulses and good distal perfusion. Disability: GCS 13 (4-3-6). Gaze preference to the left. PERRL. Follows commands with R side. Exposure: no rashes, skin lesions, patches Department of Emergency Medicine University of Pennsylvania Health System

What else would you like to test?
GEN: awake, alert. HEENT: atraumatic. PERRL. Eyes deviated to the L side. PULM: clear bilaterally CV: regular rate and rhythm, no murmurs ABD: soft, nontender EXT: no swelling SKIN: no rash or lesions NEURO: awake, alert. CN exam reveals mild facial asymmetry with loss of nasal fold on R. gaze preference to the L. Strength decreased (3/5) on testing of RUE in all areas. Mildly decreased (4+/5) in RLE. What else would you like to test? Department of Emergency Medicine University of Pennsylvania Health System

Differential Diagnosis
Is this person experiencing “Altered Mental Status?” Ischemic Stroke Hemorrhagic stroke Complex partial seizure CNS mass lesion Department of Emergency Medicine University of Pennsylvania Health System

What workup would you initiate?
CT Head EKG Basic Metabolic Panel CBC Coags Chest XRAY Urinalysis Troponin (?) Department of Emergency Medicine University of Pennsylvania Health System

Take home points Generally speaking, stroke should not produce “altered mental status” Focal neurologic deficits may mimic altered mental status Aphasias, hemisensory neglect, cortical blindnes A detailed neurologic assessment is always indicated Department of Emergency Medicine University of Pennsylvania Health System

Case 19 yo F brought by friends from her dormitory stating that she isn’t “acting right”. They report that she was complaining of fatigue and malaise yesterday, and this morning of a headache. Nobody had seen her since breakfast and when they found her she was confused. What would you like to do next? Department of Emergency Medicine University of Pennsylvania Health System

BP 95/50 HR 120 RR 22 T 102.2 SpO2 99% RA Airway: intact
Breathing: mildy tachypneic, good sats, lungs clear Circulation: mildly hypotensive but bounding pulses x 4, well perfused digits. Disability: Opens eyes, moans and grabs your hand to painful stimulus (GCS?). PERRL CN intact, moves all extremities equally Exposure: scattered petechiae and purpura on extremities. Diaphoretic. Department of Emergency Medicine University of Pennsylvania Health System

Differential Dx: Sepsis Toxic ingestion Heat stroke NMS/SS
Meningitis Encephalitis Toxic ingestion Heat stroke NMS/SS What do you do next? Department of Emergency Medicine University of Pennsylvania Health System

What other exam information do you want?
GEN: lethargic, responds to painful stimuli by opening eyes,moaning and grabbing your hand HEENT: PERRL. Oropharnyx unremarkable aside from dry mucous membranes CV: tachycardic, regular PULM: clear bilaterally ABD: unremarkable EXT: no trauma or swelling SKIN: diaphoretic NEURO: CN 2-12 intact. Moving all extremities equal. What other exam information do you want?

Meningitis Treatment Various algorithms exist Options include:
Empiric BS Abx, followed by CT head/LP Immediate LP followed by empiric abx Largely depends upon degree of suspicion, risk factors for elevated ICP/mass lesions Department of Emergency Medicine University of Pennsylvania Health System

Meningitis Treatment **Role of steroids (Dexamethasone) unclear. If giving, give before or concurrently with abx

Case 35 yo F found by passersby unresponsive and apneic. Brought by EMS with active bagging en route. No ID or collateral information present. What do you do next? Department of Emergency Medicine University of Pennsylvania Health System

BP 118/72 HR 50 T 98.0 (R) RR 0 SpO2 95% BVM (100% O2) FSBG 110
Airway: no gag, sonorous with bagging Breathing: no spontaneous respirations Circulation: normotensive, mildly bradycardic. All extremities appear cyanotic. What next, doctor?

Show of hands: Intubate now
Finish rapid initial assessment, then decide how to proceed Administer antidote to her overdose Department of Emergency Medicine University of Pennsylvania Health System

Keeping going… Disability: pupils <1mm bilaterally. GCS 3.
Exposure: Now what? Department of Emergency Medicine University of Pennsylvania Health System

Naloxone Pure opioid antagonist Routes: IV, IM, IN, Subcutaneous
Dose: 0.4-2mg (generally) double q2-3 minutes until desired effect Onset: <1 minute (IV). 1-2 minutes (Other) Half life: ~30-60 min Department of Emergency Medicine University of Pennsylvania Health System

Naloxone What is the indication for administration?
Insufficient respiratory drive What is the target when administering? Sufficient respiratory drive NOT normalization of mental status Department of Emergency Medicine University of Pennsylvania Health System

Biggest problem: it wears off before the opiate agent does
Naloxone side effects Common: Dysphoria, nausea, pain (withdrawal symptoms) Uncommon (but real) Pulmonary edema Seizure Dysrhythmias Biggest problem: it wears off before the opiate agent does Department of Emergency Medicine University of Pennsylvania Health System

Coming soon to a heroin user near you!

Case 60 yo F brought by EMS after witnessed seizure activity in a restaurant. Per EMS, lasted 3-4 minutes and resolved spontaneously. There was reported tonic-clonic activity. Per family, she has a known seizure history. She has been unresponsive since the event, which was approximately 20 minutes ago. Department of Emergency Medicine University of Pennsylvania Health System

BP 142/72 HR 105T 99.1 (R) RR 18 SpO2 96% RA Airway: snoring respirations; handling secretions Breathing: adequate rate. Good air movement Circulation: normotensive, good pulses and distal perfusion Disability: eyes open but unresponsive to pain. Doesn’t follow commands. Nonspecifically withdraws L arm and leg to pain. GCS 9 (4-1-4) Exposure: no rashes, wounds, patches, lesions What next, doctor? Department of Emergency Medicine University of Pennsylvania Health System

FSBG: 110 Department of Emergency Medicine

GEN: eyes open but unresponsive to pain HEENT: Eyes deviated to L. PERRL. NECK: Ranges easily LUNGS: Clear CV: mildy tachy, regular, no murmers ABD: soft, nondistended EXT: no edema, no deformity SKIN: no rash NEURO: groans to pain. GCS is doesn’t participate in exam. What else would you like to know? Department of Emergency Medicine University of Pennsylvania Health System

Differential Dx Post-ictal state
Status epilepticus (complex partial status) Stroke Hemorrhagic Ischemic Encephalitis Department of Emergency Medicine University of Pennsylvania Health System

Workup Head CT Electrolytes Level her AEDs
Trial of treatment (first line?) Benzodiazepines Obtain stat EEG Department of Emergency Medicine University of Pennsylvania Health System

Seizures/Status Epilepticus
Post-ictal state common Should rarely last longer than minutes Should progressively improve Persistent neurologic deficits possible (todd’s paralysis), but should raise suspicion for alternative diagnosis or ongoing epileptic activity Complex partial status epilepticus (aka nonconvulsive status) is often missed Department of Emergency Medicine University of Pennsylvania Health System

Case Police bring a 30 year old male directly from the scene of a two car MVC. He was the unrestrained driver and hit a parked car at high speeds. They state that he smells of alcohol. He is actively being restrained and is thrashing violently. He is speaking incoherently and not following your commands. Department of Emergency Medicine University of Pennsylvania Health System

What do you do next? Department of Emergency Medicine

BP 75/40 HR 155 RR 24 SpO2 95% RA T96.0 (R) Airway: protecting (For now). Phonating. Breathing: equal bilateral. Circulation: weak distal pulses x 4. poor capillary refill. Disability: PERRL, GCS 12 (4-3-5), moves all extremities Exposure: bruising to scalp. Abrasions to abdomen and R chest wall. What next? Department of Emergency Medicine University of Pennsylvania Health System

Department of Emergency Medicine

BP 75/40 HR 155 RR 24 SpO2 95% RA T96.0 (R) Airway: protecting (For now). Phonating. Breathing: equal bilateral. Circulation: weak distal pulses x 4. poor capillary refill. Disability: PERRL, GCS 12 (4-3-5), moves all extremities Exposure: bruising to scalp. Abrasions to abdomen and R chest wall. Department of Emergency Medicine University of Pennsylvania Health System

Important Point Maintain a high index of suspicion for hypotension, hypoxia or intracranial abnormalities as cause of agitation in the trauma patient. Department of Emergency Medicine University of Pennsylvania Health System

Case A 20 year old male is brought by his concerned college roommates for altered mental status. They state that he is behaving erratically and seems delusional. They report 2 weeks of progressively increased agitation and for the last week he has been heard up all night in his room talking to himself. He hasn’t bathed himself either, stating “there’s no time”. Department of Emergency Medicine University of Pennsylvania Health System

BP 122/72 HR 92 RR 14 SpO2 100% T FSBG 101 Airway: intact. Phonating easily Breathing: good aeration bilaterally. Normal rate, normal sat Circulation: normotensive, good pulses and perfusion Disability: PERRL. GCS 15. Ambulates easily Exposure: No rashes, patches, wounds Department of Emergency Medicine University of Pennsylvania Health System

GEN: slightly disheveled, awake, alert. Talkative and pacing around the room. HEENT: atraumatic. Perrl. Oropharynx normal NECK: ranges easily, no tenderness LUNGS: clear bilaterally CV: regular rate and rhythm, no murmers ABD: soft, nontender EXT: no swelling SKIN: no rash NEURO: alert, oriented x 3. CN intact. Normal strength and sensation. What else would you like to know?

Psych: Poorly kempt. Clothes brightly colored, mismatched
slightly agitated with pressured speech. Thinking is disorganized and tangential. Demonstrates grandiosity (States “I’m going to call the president if you don’t release me!”). Appears to be responding to internal stimuli but doesn’t acknowledge hearing voices when asked. Denies suicidality (laughs, states he is too important for that) or homicidality. Department of Emergency Medicine University of Pennsylvania Health System

Differential Diagnosis?
Psychosis (acute psychotic break) Schizophrenia Bipolar disorder Drug induced psychosis Bath salts Stimulants Department of Emergency Medicine University of Pennsylvania Health System

Organic Vs Functional:
Functional (Psychiatric) History Acute onset Onset over weeks to months Any age Onset ages 12 to 40 years Mental status examination Fluctuating level of consciousness Alert Disoriented Oriented Attention disturbances Agitated, anxious Poor recent memory Poor immediate memory Hallucinations: visual, tactile, auditory Hallucinations: most commonly auditory Cognitive changes Delusions, illusions Physical examination Abnormal vital signs Normal vital signs Nystagmus No nystagmus Focal neurologic signs Purposeful movement Signs of trauma No signs of trauma 117

Management Assess willingness to obtain care
Assess need for involuntary hold (“302”) Trial anti-psychotic if needed No medical testing absolutely necessary Psychiatrists may request certain testing as “screen” UDS, CBC, BMP Department of Emergency Medicine University of Pennsylvania Health System

Confusion in the ED: Take Home Pearls
Delirium always has an organic etiology History from sources other than the patient may be critical and life saving Obtain a full set of vital signs and thorough exam on all patients (especially those with AMS) ED evaluation of AMS always follows the ABCDE approach Department of Emergency Medicine University of Pennsylvania Health System 120

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Altered Mental Status Sean D. Foster, MD

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