Definitions zOrganic brain syndrome=delirium=acute confusional state=metabolic encephalopathy=reversible cerebral dysfunction zreduced ability to focus, maintain or shift attention zcognitive dysfunction -- memory, language orientation -- not due to pre-existing dementia zdevelops over hours to days and tends to fluctuate throughout day
Making the Diagnosis zConfusional Assessment Method (CAM) yacute onset and fluctuating course yinattention ydisorganised thinking yaltered LOC xneed to have first 2 and 1 of last 2 xsens 90% and spec 95% (?Gold standard)
Cell zGeneralised alteration in cerebral metabolic activity zcerebral cortex and subcortical structures affected ycauses changes in altertness, arousal,attention and ability to process information zAch transmission implicated zelderly more susceptible ymedication MC cause (upto 40%) Rosen 2002.
Case 1 z36 yo woman with a history of anxiety attacks yc/o difficulty breathing and chest pain. Can’t catch her breath. ySudden onset approx 45 minutes ago while on the phone with her boyfriend who she is having relationship problems with. ySaid she almost fainted, then called 911.
Case 1 zPMH: ypost-partum 3weeks uncomplicated vaginal delivery of FT male yanxiety without agorophobia ydepression yprevious suicide attempts yunder the care of a psychiatrist
Case 1 zO/E y110, 25, 90% on RA 110/80, 37.9, c/s 4.2. xpale, moderate respiratory distress, anxious. xWon’t answer questions; thinks its 1999. xmaybe JVP up xresp exam normal xCVS exam tachycardic, no murmurs, no edema or signs of increased right heart pressure. Peripheral pulses present xremainder of exam WNL
Case 1 zWhat’s your top 3? yI WATCH DEATH zInvestigations? zNurse wants her out of the monitored area and into a psych room zCXR normal zECG sinus tach z7.47/90/30/20/-4(nrb) zCBC normal zlytes normal, no gap zd-dimer >1.00 zTnT 0.04 z??
Case 2 z82 yo woman sent from Crossbow yhas become drowsy but also intermittently belligerent to staff and family over last 2 days ynausea and vomiting yrefusing to eat yusually she is up and around by herself but recently has not been. yIncontinent of urine
Case 2 zNo current complaints except that you let her go back to work zO/E y70, 100/60, 96% r/a, 18, 38.2, c/s 6.0. xalert, disoriented to year and place xthin and pale, in NAD xno meningismus/lymphadenopathy, JVP 3 cm ASA xResp/CVS normal xAbd -- generalised tenderness lower quadrants xGU -- ?suprapubic tenderness. No CVA. xExt -- no rashes
Case 2 zDifferential? yI WATCH DEATH zInvestigations? zWBC 3.1 all neuts zHb/PLT normal zlytes normal, AG 14 zCr 100 BUN 6.0 zU/A +nitrites/leuks/blood/ ketones
Case 3 z33 yo woman brought in by husband yc/o incoordination and severe restlessness in her legs over last few days. yHusband states she has recently become confused and today asked him how many years they’d been married.
Case 3 zPMH: hypertension, bipolar. zMeds: lithium, prozac, clomipramine (recently started by psychiatrist) zO/E y110, 130/90, 25, 99% r/a, 39.2. yDiaphoretic, in NAD, restless ypupils 6mm, reactive, no memingismus yresp/cvs/abd normal yfine tremor yincreased tone symmetrically y?hyperreflexic
Case 3 zInvestigations ycbc, lytes, AG, cr, lfts, d-dimer, tnt all normal ytox screen neg yecg normal ycxr normal zTop 3 yserotonin syndrome yNMS ysympathomimetic yanticholinergic
Syndromes with altered mentation and hypertonia EMR March 1999 zSerotonin syndrome zmalignant hyperthermia zneuroleptic malignant syndrome zthyrotoxicosis zheatstroke zCNS hemorrhage ztetanus
Case 5 z23 yo girl brought by EMS from drop-in yshe’s yelling and is uncooperative yEMS say they think she may be diabetic zVS 130, 100/60, 30, 97%r/a, 36.5 yc/s 23.4 zTop 3?
Case 5 zABG 6.9/130/26/10/-12 zCBC normal zlytes 140/5.3/95/10 AG 35 Cr 110 Bun 9 zu/a ketones zDiagnosis? yDKA
Case 6 z45 yo male brought in by partner for acute change in mentation ypartner states patient has HIV/AIDS and over last 12 hours has become drowsy, disoriented and is ‘unlike himself’. yPMH:recent admission for PCP, last serology and titres unknown. yMeds: 3TC, AZT, nelfinavir yc/o headache
Case 6 zo/e y96,110/80,20,90%r/a, 38.0, c/s 6.8 yGCS 13 (E3,V4,M6) disoriented to place and year ydry and cachectic y?meningismus ?fundoscopy, no lymphadenopathy yno focal neurologic signs yresp/cvs/abd wnl yno rashes
Case 6 zAnything else? zTop 3 zInvestigations yCT yLP yCBC zantibiotics? SOC? zSteroids? When? zMeningitis yHIV/AIDS xbacterial (strep or neisseria) xtoxoplasmosis xcryptococcus xCMV xHSV xlymphoma Consent for LP in delirium
Case 7 z50 yo male brought from cells for uncontrollable behavior. Maybe a seizure. yknown alcoholic ypicked-up yesterday night (approx 18hrs ago) on an outstanding charge. Last EtOH unknown. yPMH -- unknown yMed -- unknown yAllergies -- unknown
Case 7 zo/e y130, 160/90, 30, SaO2?, T 39.5, c/s 2.1 yrestless and very agitated, sweating. yPupils 5mm, reactive yVisual hallucinations ycoarse tremor yurinary incontinence
Case 7 zTop 3? yEtOH withdrawal ymeningitis ysympathomimetic OD zInvestigations yCT head normal yLP normal ycbc, lytes, AG, Cr, BUN, LFTs, INR normal ytox screen neg. zWhat is this? zAlcohol Withdrawal Syndromes yminor x6-36hrs xmild autonomic dysfunction, nausea, anorexia, coarse tremor, tachycardia, hypertension, hyperreflexia, and anxiety ymajor x24hrs to 5d xabove plus hypertonia, hyperthermia, hallucinations ydelirium tremens x...
Delirium Tremens zMedical emergency zextreme end of withdrawal spectrum zgross tremor, profound confusion, fever, incontinence, frightening visual hallucinations, and mydriasis zOnly 5% of patients hospitalized for alcohol withdrawal develop delirium tremens zuntreated -- mortality 10%
Case 8 z27 yo male ypicked-up by CPS for yelling and shouting at people at LRT station ymany previous visits for psychotic symptoms yunsure about compliance with meds yhe states that he’ll talk to you if you can establish your level of clearance
Case 8 zo/e y90, 120/80, 20, 99% r/a, 37.1, c/s 6.8 ydishevelled, oriented, distracted, irritable yflat affect, disorganized thought yadmits to auditory hallucinations yspeech is clear yphysical exam in psych room xare you going to do one?
Case 8 zP/E ypoor hygiene and dentition yrest wnl zAny investigations? zKorn et al Journal of Emergency Medicine 2000 18(2)173- yretrospective review yin pts with prior psych history and who present with an isolated psych complaint ywith normal vitals and normal exam y‘little benefit from lab tests or imaging.
Case 4 z16 yo male you intubated on his birthday for a GCS of 5 following a night of celebration. yHis friends who dropped him off denied use of drugs or toxic alcohols ystate he’s an otherwise healthy guy on the hockey team y30 minutes after the tube...
Case 4 z40.3, 130, 160/80 zrespirator alarming d/t high insp pressures zmasseter muscle spasm and generalised hypertonia symmetric throughout zMalignant Hyperthermia yd/s precipitating agent ydantrolene boluses of 2mg/kg to max 10mg/kg over 24hrs ycooling measures prn ysupportive measures
Case 9 z25 yo male with diarrhea x3/52 brought in by sister for acute onset confusion ymultiple ?bloody episodes/day, none formed ymild abdominal pain and emesis as well yno recent travel, well water, uncooked meat yPMH: Crohn’s for 3yrs; 2 exacerbations requiring hospitalisation. Not taking steroids
Case 9 zo/e 100, 110/70, 16, 99% r/a, T 36.5, c/s 3.9. yc/o intermittent blurred vision, no H/A yHe was oriented to person only and was able to follow one-step commands. yMarked confusion and agitation. Recent memory was impaired, but long-term memory was intact yAbdominal examination unremarkable. The patient complained of double vision on lateral gaze, and there was limitation of lateral eye movements bilaterally. Motor power was normal, and deep tendon reflexes were diminished in the legs. There was mild dysmetria on finger-to-nose testing and marked heel-to-shin ataxia. Gait was wide-based. y???
Case 9 zTop 4? zInvestigations? zEmpiric treatment? zWernicke’s Encephalopathy yOpthalmoplegia, ataxia and confusion xopthalmoplegia usually bilateral horizontal nystagmus or bilat CN VI palsy ydue to thiamine deficiency ypathology confined to mammiliary bodies, cerebellum and hypothalamus
Wernicke’s Encephalopathy zAcute Treatment yiv thiamine xopthalmoplegia usually resolves within 30mins xataxia and confusion slower to resolve
Case 10 z39 yo woman, previously healthy. ybrought in by husband for 3-4 days of intermittent disorientation and yellow eyes. yCan’t remember what she was doing or where she was this am ynot complaining of new pains but says has felt warm over last 3-4 days. yPMH/Meds/Allergies: none stated
Case 10 zO/E y90,20,120/80,96% R/A,39.0, c/s 4.2. yPale mucous membranes yScleral icterus yResp/CVS/GI exam normal yalert and oriented to year and month, thinks she is in McDonalds
Case 10 zHb 80, Plts 80, smear pending zbili 40 zLFTs normal zCr 120 (? prev) zTop 2?
Thrombotic Thrombocytopenic Purpura zPentad of altered mentation, thrombocytopenia, hemolytic anemia, ARF, proteinuria and fever zassoc with toxigenic bacteria, post-partum state, BMT, auto-immune diseases, certain medications (quinine, plavix) zphysical exam usu. normal (rarely petichial rash)
Case 11 z73 yo woman brought in by EMS yson called her as per usual at 12pm and she said she wasn’t feeling well yasked where her husband was yhe called EMS zPMH: HT, T2DM, OA zMeds: norvasc, metformin, glucosamine
Case 11 zo/e y50, 100/60, 90% 5L, 18, 36.5, c/s 5.0 yunable to co-operate with exam yconfused, diaphoretic, restless ybibasilar crackes yCVS exam ?S4 no signs inc Rt heart pressures, no murmurs. yRadial pulses equal bilaterally yabd exam normal
Case 11 zCXR redistribution, mediastinum normal zblood work normal zu/a normal zd-dimer, TnT pending zAnything else you want doctor?
Silent AMI zAtypical presentations of AMI more common in elderly
Case 12 z87 yo woman sent from nursing home by GP. ynoted today to be more disoriented, irritable and refusing to eat or drink. yNo volunteered complaints zPMH; Alzheimer’s, glaucoma, restless legs, bipolar disease. zMeds: list pending
Case 12 zo/e y80, 120/80, 16, 97% on 2l NP, 37.2, c/s 5.1 yvery confused, agitated. yin NAD yJVP not visible yno meningismus or lymphadenopathy yresp/cvs exam wnl yabd distended, soft, very uncomfortable with percussion/light palpation throughout.
Case 12 zWhat’s going on? zTop 3 zInvestigations zDementia -- Diagnostic Criteria zMemory impairment yinability to learn new information or recall recently learned information yusually long term memory intact yCognitive disturbances xaphasia xapraxia xagnosia xdisturbance in executive functioning Apraxia -- failure to carry out motor activities agnosia -- failure to recognise objects Apraxia -- failure to carry out motor activities agnosia -- failure to recognise objects