Altered Mental Status

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					Altered Mental Status




       Susan Schayes, MD, M.P.H
            Program Director
Emory Family Medicine Residency Program
          Adapted from Dr. Eddie Needham
         As life happens
You’re an Emory Family Medicine
Resident at EUHM…at 4pm.
You get the call from the ER that you
Have a patient with altered mental status
in the ER for admission. He was “not right
at home”, and brought by ambulance to
the ER.
… you arrive to find a 63 year old male
ESRD pt on HD who is not quite conscious.
You attempt to get a history – he’s not
responsive enough. No one came with him
by ambulance.
You do a cursory exam…hum…ABCs
okay, lungs…heart…abd…okay, legs and
arms attached and moving J
Your nurse is drawing your usual rainbow
tubes while putting in an IV…
That’s when you notice the vital signs…
Pulse 68
RR 14
BP 110/58
Temp 100.5
         Today’s Goals
Define “Altered Mental Status” (AMS)
Create an algorithm for the work up of
AMS
List ten causes of AMS using the
A-E-I-O-U-T-I-P-S mnemonic
Use the MMSE, and the above mnemonic
to evaluate patient cases
Define AMS
                           AMS
No clear definition
Delirium
–   Acute vs chronic
–   Fluctuating level of consciousness
–   Impaired attention/concentration
–   Disorientation, hallucinations
–   Incoherent speech
–   Agitation
Coma
– Complete behavioral unresponsiveness to external stimulus
– Patient lies still with the eyes closed
  Diagnosis and Treatment
What exam features and tests are
routinely performed for AMS?
– ABC’s, etc…
– Finger stick blood sugar
– Finger stick hemoglobin
– ABG, pulse ox
– Routine labs … like …
    CMP, CBC, UA
    Drug levels – acetaminophen, ASA, etc…
    UDS
   Diagnosis and Treatment
Other labs:
– Anion gap
– Osmolality
Procedures/tests
– Head CT
– Lumbar puncture
– CXR/radiology as indicated
            Mnemonic
A Alcohol,        T Tumor,
  Alzheimer's       Trauma
E Endocrine,      I Insulin
  Environmental   P Poisonings,
I Infection         Psychosis
O Opiates,        S Stroke
  Overdose          Seizures
U Uremia            Syncope
            Mnemonic
A Alcohol,        T Tumor,
  Alzheimer's       Trauma
E Endocrine,      I Insulin
  Environmental   P Poisonings,
I Infection         Psychosis
O Opiates,        S Stroke
  Overdose          Seizures
U Uremia            Syncope
 Clinical tests that are helpful to
           evaluate AMS
Glascow Coma Scale (GCS)

Mini-Mental State Exam (MMSE)
MOCA
 Common causes of AMS on
          FMS
Hypoglycemia
Infection
Head injury
Stroke
Tumor/mets in brain
Undiagnosed dementia
Electrolyte imbalance
Overdose
Psychiatric causes
                Case 1
29 year old male training outside for the
Peachtree Road race :
– 100 push ups
– 100 sit ups
– Runs for one hour at 6 minutes/mile
– Repeats above
Is drinking water as he is training
        Case 1 continued
After the second round, he then stands in
the swimming pool at his sports complex
at Lake Lanier to cool off
        Case 1 continued
After 10 minutes, he goes down.
He is rescued by his neighbors.
At this point, he is combative and
unresponsive.
He is being brought to your ER.
Divide into teams and formulate
     a differential diagnosis
  DDx?

Group 1 first
            Case 1 cont’d
In the ER, he has already rec’d 3 mg Ativan to
sedate him.
VS: Temp 100.5 RR 16 P 84 BP 100/60 Wt 90 Kg
Lungs/CV/Abd normal
Neck – moving without apparent discomfort
Neuro – no focal deficits, PERRL
GCS – Opens eyes to pain, nonspecific cuss
words, tries to knock your hand away on sternal rub
GCS = 10 (E2, V3, M5)
             Case 1 cont’d
Hg/Hct     12.5/39      AST        100
Plt Ct and WBC normal   ALT        87
Na         117          Albumin 4.2
K          3.8          T Bili     1.3
Cl         89           Ammonia 37
HCO3       25           UA – normal with spec.
BUN        10           grav. 1.005, no blood
Creatinine 1.0
Glucose 200
Refine your DDx and initial
treatment plans as a group
             Case 1 cont’d
Hg/Hct     12.5/39      AST        100
Plt Ct and WBC normal   ALT        87
Na         117          Albumin 4.2
K          3.8          T Bili     1.3
Cl         89           Ammonia 37
HCO3       25           UA – normal with spec.
BUN        10           grav. 1.005, no blood
Creatinine 1.0
Glucose 200
DDx and Rx?

  Group 2
        Case 1 teaching point
Acute exertional hyponatremia
–   Consider treating with 3% NaCl
–   Imperative to calculate sodium deficit
–   (Desired sodium – measured sodium) x 0.6 x weight
    in Kg = (140-117)x0.6x90 = 1242 mEq
–   3% NaCl has 513 mEq/L of Na+
–   Correct half the deficit over 8–12 hours, and the
    remainder over 16-24 hours.
–   Goal is to raise the plasma sodium 1-2 mEq/L/hr, no
    more than 8 mEq/L in the first 24 hours (Wash.
    Manual)
–   Your drip rate will be?
              3% Saline
Your drip rate will be?
– 1242/2 = 620mEq. Over 8-12 hours (say 10)
  = 62 mEq per hour
– This is 62/513 = 120cc/hour.
– I always take this corrected number and
  divide in 2 to make sure I go slow à rate =
  60cc/hr and check the sodium on the hour.
Take a breather
               Case 2
35 yo AAM male is found semi-conscious
in the street after he has been at a party
with some friends.
He has the smell of alcohol on his breath.
Because he is not easily arousable, he is
brought to the ER.
                Case 2
Hx – are you kidding? Difficult to ascertain.
Exam – VSS
Gen – not tremulous, GCS 13
Neuro – nonfocal
Lungs/CV/Abd/Extremities – normal, no
trauma.
              Case 2 labs
Hg       13          Glucose   180
Hct      40          AST       52
Plt Ct   117         ALT       48
WBC      3.2         T. Bili   1.7
MCV      102         Albumin   3.9
Na       137
K        3.8
HCO3     15
Cl       100
BUN/Cr   28/1.5
Formulate a DDx and Rx plan
Hg        13           Glucose   180
Hct       40           AST       52
Plt Ct
WBC
         Case 2 labs
          117
          3.2
                       ALT       48




MCV       102
Na        137
K         3.8
HCO3      15           T. Bili   1.7
Cl        100
BUN/Cr    28/1.5       Albumin   3.9
DDx? Any other info
   requested?

      Group 3
           More info
ABG: pH 7.32/pO2 88/pCO2 36/HCO3 16,
on room air
Anion Gap = Na – (Cl + HCO3) = ?
137 – (100+15) = 22, high.
DDx from the PGY 1 class?
            MUDPILES
           Memorize this!
M - Methanol
U - Uremia
D - DKA
P – Paraldehyde (more of historical note)
I – (Ischemia - lactic acidosis, not INH)
L – lactic acidosis
E – Ethylene glycol
S - Salicylates
       DDx in this patient?
Methanol or ethylene glycol?
How can you tell in the ER?
Urine – calcium oxalate crystals with?
– Ethylene Glycol
It’s the middle of the night and the lab
won’t look at the urine until the morning
What now?
Can you prevent this?
          Osmolar Gap
Measured - Calculated osmoles
Calculated osmoles – does that hurt to
do?
2(Na) + BUN/2.8 + Glucose/18
2(137) + 28/2.8 + 180/18 = 294
Measured osmoles = 328
Osmolar gap = 328-294 = 34 (normal <10)
Danger, Will Robinson, Danger
           Treatment?
Fomepizole (expensive- $1000 a vial)
Alcohol drip
Get nephrology on board ASAP
Emergency dialysis
Critical care medicine/ICU
Poison control/toxicology consult
Relax with the mist …
   and the critters
               Case 3
43 yo African female is brought to the ER
because she her speak is incoherent and
she is hot, per her family.
She recently immigrated from Kenya.
         Case 3 - Exam
Pt is gently rolling around in the bed,
mumbling.
Hx is as above
VSS – Temp 104.5, RR 24, Pulse 110, BP
108/54, pulse ox on RA 99%
Skin quite warm
Otherwise unremarkable exam
DDx and Rx?
Ddx and Rx?

  Group ?
            Case 3 DDx
Meningitis – bacterial and others
Malaria, especially falciparum - deadly
HIV CNS infections – Toxoplasmosis,
cryptococcus, HSV, others
Another classic case of AMS
Middle-aged male alcoholic is found down
and brought to the ER.
Head CT shows …
              Case #5
57 yo male presents to clinic with
progressive dyspnea and mental
sluggishness x 1 week.
PMHx – HTN – stable, no HF/CAD/CRF
Meds – occasional albuterol
ROS – no fevers, no chest pain, no cough,
no recent falls
              Case #5
VS: Pulse 80 sitting, BP 120/75, T 98.9,
RR 22
Pulse Ox on RA = 93-94%
Gen – speaking in 3-5 word sentences
with lips pursed
Exam normal except for:
Lungs – decreased breath sounds bilateral
but moving air, E>I, no rales
              Case #5
Pt walked 30 feet
Repeat VS: P 120, BP stable, RR 26,
Pulse Ox 93%
Repeat after 3 minutes: P 90, RR 26,
Pulse Ox 84%

Home O2 ordered urgently for patient
Helpful things not usually done
Peak Flow
Pulsus paradoxus
Exercise challenge – assess ADLs
                  Summary
List ten causes of AMS
…
Stabilize the patient
–   ABCs
–   Labs – the usual rainbow
–   X-rays – strongly consider a head CT
–   Don’t miss the uncommon things
Put the MMSE/GCS on your blackberry
Put the AEIOUTIPS on your blackberry

				
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posted:7/23/2013
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