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Altered Mental Status Intern Survival Series July 2011 JeanPierre ELKHOURY, MD AKA JP !!

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Presentation on theme: "Altered Mental Status Intern Survival Series July 2011 JeanPierre ELKHOURY, MD AKA JP !!"— Presentation transcript:

1 Altered Mental Status Intern Survival Series July 2011 JeanPierre ELKHOURY, MD AKA JP !!

2 DEFINITION Consciousness is a condition in which an individual is fully responsive to stimuli and demonstrates awareness of the environment An alteration in mental status is the hallmark sign of central nervous system (CNS) injury or illness

3 What is Consciousness? Arousal function Alerting and wakefulness Anatomically-reticular activating system Content functions Language, reasoning Anatomically-cerebral cortex DEFINITION


5 Content of Consciousness Cerebral cortex Emotions Reasoning Self-awareness Spatial relationships DEFINITION

6 Disorder of Arousal functions Content functions disrupted Altered Mental Status ? DEFINITION

7 7 The nurse will page for Any or all of the following… Seems drowsy or sleepy; not alert Awake and cooperative, but seems confused Awake, but used inappropriate words reported unconscious, but is now awake, with or without impaired memory Awake, but not oriented to self, time, place, or events Unconscious, but responds to verbal or painful stimuli Unresponsive DEFINITION

8 Pathophysiology 4 general causes 1.Primary intracranial disease 2.Systemic disease affecting CNS 3.Exogenous toxins 4.Drug withdrawal CAUSES














22 Causes of Altered Mental Status

23 Mnemonic AAlcohol, Alzheimer's EEndocrine, Environmental I Infection OOpiates, Overdose U Uremia T Tumor, Trauma IInsulin P Poisonings, Psychosis SStroke Seizures Syncope

24 Interns Role Primary survey Establish unresponsiveness A,B,Cs Resuscitation glucose, thiamine Secondary assessment Definitive care ASSESSMENT & MANAGEMENT

25 Gather History… Signs and symptoms Gradual or sudden onset? Associated symptoms? Did they get progressively worse? Medications Inpatient Medications and rule out drugs abuse last doses Last oral intake Alcohol Intoxication in ER Events leading up to Any seizure activity? Any trauma in last two weeks? Any complaints of headache? Was patient acting normal prior to events? Has patient been ill? Any witnesses ? ASSESSMENT & MANAGEMENT

26 Physical Examination Head- any evidence of trauma Pupils Unequal or fixed- increased intracranial pressure (head injury or stroke) Pinpoint- narcotics Sluggish- hypoxia Mouth and oral mucosa- check for cyanosis Chest- trauma, equal rise and fall of chest, lung sounds Abdomen- trauma, check for tenderness with palpation Extremities- pulse, movement, and sensation; edema in lower extremities ASSESSMENT & MANAGEMENT

27 Neurological Examination Observation, Cranial nerves, Sensory, Motor, Reflexes If assessment findings indicate potential stroke, do a FAST Assessment: Face: Smile, is one side drooping? Arm: Raise arms, does one side drift down? Speech: Repeat a phrase, are your words slurred? Time: Quick treatment if CVA suspected ASSESSMENT & MANAGEMENT

28 How to do A Mental Status Exam? Appearance, behavior, attitude Thought disorders Perception disorders Mood and affect Insight and judgment Sensorium and intelligence ASSESSMENT & MANAGEMENT

29 Six Elements of Mental Status Evaluation Appearance, behavior, and attitude Disorders of thought Are the thoughts logical and realistic? Are false beliefs or delusions present? Are suicidal or homicidal thoughts present? Disorders of perception Are hallucinations present? Mood and affect ASSESSMENT & MANAGEMENT

30 Six Elements of Mental Status Evaluation Insight and judgment Does the patient understand the circumstances surrounding the visit? Sensorium and intelligence Is the level of consciousness normal? Is cognition or intellectual functioning impaired? ASSESSMENT & MANAGEMENT

31 How to do A Mental Status Exam? Informal testing used most often BUT, informal testing insensitive If a formal screening examination performed, assessments, workup, and dispositions change Formal mental status Mini-mental status exam Brief mental status exam Others ASSESSMENT & MANAGEMENT

32 The Brief Mental Status Examination ITEM(number of errors)X (weight) = (Total) What year is it now?0 or 1x 4 =____ What month is it?0 or 1x 3 =____ Present memory phrase: Repeat this phrase after me and remember it: John Brown, 42 Market Street, New York. About what time is it?0 or 1x 3 =____ (Answer correct if within one hour) Count backwards from 20 to 1.0, 1, or 2x 2 =____ Say the months in reverse0, 1, or 2x 2 =____ Repeat memory phrase0,1,2,3,4,or 5x 2 =____ (each underlined portion is worth 1 point) ASSESSMENT & MANAGEMENT

33 The Brief Mental Status Examination Final Score is the sum of the totals For each response, circle the number of errors and multiply the circled number by the weight to determine the score. ______________________________________ Possible score range from 0 to 28. ASSESSMENT & MANAGEMENT

34 The Brief Mental Status Examination The lowest possible score (indicating the least impairment) is 0. The highest possible score is 28. Categories of scores: 0-8 normal 9-19mildly impaired severely impaired ASSESSMENT & MANAGEMENT

35 Work Up Check Vital Signs (BP, Pulse Ox, RR…) Finger stick blood sugar CBC, CMP, UA, ABG Drug levels – acetaminophen, ASA, etc… UDS Apply monitor and make sure patient has IV Access Be prepared to initiate CPR Head CT without contrast before LP if possible CXR LP ASSESSMENT & MANAGEMENT

36 When Is a Spinal Tap Indicated in Delirium? The primary indication for an emergent spinal tap is the possibility of CNS infection. CSF should be examined in patients with a fever of unknown origin, especially if an alteration in consciousness is present… ASSESSMENT & MANAGEMENT

37 Treatment of underlying cause Sedation Restraints if needed TREATEMENT

38 Treat the underlying cause Infections: pneumonia, UTI, meningitis, sepsis Metabolic: hypoglycemia, electrolytes, hepatic, thyroid disorders, ETOH, or drugs Neurologic: CVA, TIA, seizure, intracranial hemorrhage or mass Cardiopulmonary: CHF, MI, PE, hypoxia Drug related: Narcotics, sedatives, muscle relaxants, antiemetics, digoxin TREATEMENT

39 If low blood sugar is present: Administer oral glucose if patient is alert and able to swallow (Basic providers) Dextrose 50% IVP or Glucagon IM If narcotic overdose is suspected and airway compromise and/or inadequate respiratory effort is present: Narcan IV or IM Ventilation Support TREATEMENT Treat the underlying cause

40 Sedation Haloperidol IV/IM Lorazepam IV Confinement or restraints if patient is at risk of harming himself or others (Hospital staff…) TREATEMENT Sedation and Restraints


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