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Altered Mental Status (AMS)

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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!

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