Presentation on theme: "Altered Mental Status (AMS)"— Presentation transcript:
1Altered Mental Status (AMS) University of Utah Medical CenterDivision of Emergency MedicineStudent Orientation
2Case 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 traumaPMHx: CAD, PAF, HTN, cholesterol
4Case 1 Vitals: T 38 HR 56 RR 10 BP 210/100 SpO2 94% RA HEENT: pupils sluggish, equalChest: CTA, heart RRRAbd: soft NT/NDExt: scattered healing ecchymoses, 2+ pulsesNeuro: unresponsive, decerebrate posturing to painful stimulus
5What’s going on? Diagnosis? Hint: that’s your job
6Altered Mental Status Up to 40% of geriatric population Metabolic vs. structural80% metabolicMultifactorialMay have more than one etiology at a timeYou need to be a (medical) detective40% 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):
7Altered Mental Status Inattention Confusion Lethargy Stupor Coma Intact mental status with misinterpretation of external stimuliLethargyWakefulness with depressed awareness of self and environmentStuporUnresponsiveness from which the pt. may be aroused with vigorous noxious stimuli w/o achieving the normal baselineComaUnresponsiveness from which the patient cannot be aroused by verbal or physical stimuliBe careful re: how you describe a patients mentation.
8Mechanism Cerebral cortex disruption must be BIHEMISPHERIC Diffuse axonal injuryToxins (drugs, EtOH)Metabolic toxins (ammonia, urea)Deficiency of substrates (glucose, oxygen)InfectionsFocal lesions typically do not cause AMS
9Mechanism Disruption of the Reticular Formation A grouping of fibers that traverses the brainstem to the thalamusMediates state of wakefulness through continuous stimulation of the cerebral cortexInterruption usually from structural lesionsSupratentorial 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.
12History Many patients with AMS are poor historians – where to look? Wallet / belongingsFriends / familyWitnessesEMSPolice (can go to scene)Medical recordNeed to know how quickly this came on, antecedent symptoms etc.
13History PMHx Medicines Allergies Social History Psychiatric Hx recent changesaccount for pillsinteractionsAllergiesSocial HistoryEtoHDrug use
14Physical Exam Vitals Temp Heart rate Respiratory rate Blood pressure SpO2GlucoseNot really a vital sign but so important it should be
15Physical Exam ABC’s Head to toe, detailed exam Undress patient completelyLook everywhereSigns of traumaSources of infection
16Respiratory PatternsCheyne-Stokes: regularly increasing depth of breathing alternating with decreasing depth followed by a short period of apnea.Diffuse cerebral injuryAbsence of forebrain breathing control in metabolic diseaseHyperventilation: deep, rapid breathingMidbrain lesionHypoxia, metabolic acidosis, pain, anxietyApneustic: prolonged pause at the end of inspirationlesion proximal to CN V in the PonsCluster (Biot’s breathing): breathing in short burstsPontine lesionAtaxic: irregular breathingLeads to agonal respirations and deathLesions of the medulla
17Physical Exam Skin Color Temperature Moisture Needle tracks/scars EcchymosisPressure bullaeSigns of trauma
18Physical Exam Eyes Pupil size and reactivity Ocular movements Tectal: large & fixedMidbrain: midpositioned, fixedCN III: unilateral, dilated & fixedPons: pinpointOpiates, cholinergics, anti-adrenergics: pinpoint/smallSympathomimetics, anti-cholinergics: dilatedOcular movementsRoving movement confirm cortical controlCrossing of midline – intact brainstemDeviation is away from inactive lesion, but towards seizure focusFundoscopic examIf possiblePappilledema
19Physical Exam Neuro Exam-as able GCS CN Motor Sensory DTRs Cerebellar Exam
20Laboratory Data Fingerstick Glucose! Oxygen saturation Consider: ElectrolytesECGDrug levelsTox screens (need to know which drugs they are sensitive to)TSH
21Studies Dictated by physical findings/differential Plain films (i.e. CXR)CT scan (head CT)MRIUS
22Management ABC’s Check Glucose Coma Cocktail: classic teaching/mantra Naloxone: won’t hurt, may clear things upThiamine: debatableDextrose: if glucose low
23Management Supportive Treat underlying cause Continue search Question suicidalityDisposition
26Case 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
27Case 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
28Case 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: suppleLungs: diminishedCor: S1S2 RRR without murmurAbd: Soft NT/ND; no HSMExt: Large ecchymosis to L thigh; Full ROM x 4; 2+ pulses througoutNeuro: CN II-XII intact. 2+ DTRs; No focal motor or sensory deficit.
29Case 2 What is your differential? AEIOU TIPS A - Alcohol (drugs), AmmoniaE - Electrolytes, endocrineI - Insulin (meaning glucose high-DKA, HHNK; low hypoglycemia)O - Oxygen (hypoxia), OpiatesU - UremiaT - Trauma, toxinsI - Infection (sepsis, meningitis)P - Psychogenic, PorphyriaS - Stroke, SAH, Space occupying lesion, Shock
32Case 2 CBC CMP WBC 10K Hb 10 Hct 30.2 Plts 168 Na 120 K 3.2 CO2 18 Gluc 125BUN 30Cr 1.8Ca 7.4LFTs nml
33Brief H&P You come up with most likely Dx Rapid CasesBrief H&PYou come up with most likely Dx
34Rapid Case 1 88 yo female with confusion Lives at assisted living Confusion, urinary incontinenceh/o CAD, HTNVitals: T 38.9 HR 100 RR 18 BP 104/54 Sat 96% RAExam: non focalGlucose 140Lytes nml, WBC 10K UA++++UTI/Urosepsis
35Rapid Case 2 21 yo female Found by friends unresponsive at a party PMHx: noneVitals: T 36 HR 98 RR 8 BP 90/60 Sat 90% RAPhysical: Pinpoint pupils, bilateral rales, unresponsive.Glucose 90Dx: Opiate overdose (with non-cardiogenic pulmonary edema)
36Rapid 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% RADehydrated, lethargic, tachypneic, non-focal neuro examGlucose 405Dx: DKA
37Rapid Case 4 36 yo male Presents with wife with AMS More confused, forgetful, waxing and waning.PMHx: Hep C s/p blood transfusionVitals: T 37 HR 80 RR 18 BP 110/60 Sat 98% RAPhysical Exam: Scleral icterus, multiple contusions, hepatomegally, non-focal neuro examGlucose: 105Ammonia level: 90Dx: Hepatic encephalopathy
38Rapid Case 5 90 yo female Lethargy Lives alone Found unresponsive at homeWinter – using kerosene heaterVitals T 34 HR 50 RR 10 BP 85/40 Sat 84% RAGlucose 90DDx:HypothermiaCO poisoningHypothermia: rectal temp and thermometer that reads low tempsCold hands = falsely low O2 Sat
39Rapid Case 640 yo femaleMVA, low speed, confusion without signs of traumaPE: VSS; non-focal neuro exam, confused and mildly combative. Multiple small ecchymoses on abdomen (non-tender)Glucose 30Dx: hypoglycemia
40Rapid Case 757 yo maleMVA into a tree, no seat belt, no skid marks, significant damageVitals: T 37 HR 120 RR 18 BP 90/50 SpO2 90% RAExam: Odor resembling EtOH, laceration to forehead, L chest crepitation, +abdominal pain, multiple abrasions; neuro – intoxicated, combative, non-focalGlucose 90Differential Dx:Head injuryHypoxemiaShockEtOH intoxicationOther toxinSuicide attempt?
41Summary AMS = Broad differential Difficult historians Be a detective When the history is suspect you must rely on objective data i.e. physical exam, labs, imagingBe a detectiveDon’t forget GLUCOSE!