Emergency Department Evaluation of the Altered Mental Status Patient by pyw18970

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									Dr. Docherty                      Altered Mental Status                           Page 1 of 7


               Emergency Department Evaluation of the Altered Mental Status Patient

   I.     Introduction
          a. The spectrum of the behavioral/mental status changes can range all the way from being very
              minimal to the patient who is completely comatose.
          b. In many cases these patients may be extremely agitated and violent making their evaluation
              more difficult and a hazard to the ER staff
          c. Some ppl don’t even know that their mental status is altered
   II.    The Question To Be Answered
          a. Ask yourself – What’s causing this?
          b. Is the patient’s altered mental status secondary to:
                    i. Toxic/metabolic disorder: alcohol, recreational pharm, prescription medication,
                       cocaine, heroine, hypoglycemia
                   ii. Structural central nervous system disease
                           1. Alzheimer
                           2. Brain tumor
                           3. Hemorrhage
                  iii. Functional disease (psychiatric)
                           1. if no history of mental illness - need to get laboratory work up to rule out
                               physical disease
                           2. if have history – need to make sure it’s not something else
                           3. don’t bias yourself
   III.   Definitions
          a. Coma – unresponsive and can’t arouse
                    i. GCS - <8 score is considered comatose
          b. Stupor – unresponsive but can be arouse with vigorous stimuli but will not rtn to normal
              awareness
                    i. Talk to you but not coherent
          c. Sleep – nonpathological decreased mental status and can be easily aroused to full
              consciousness
          d. Altered Mental Status – spectrum of disability ranging from mild confusion  deep coma
   IV.    Initial Evaluation
          a. 1st priority – ABC
                    i. Airway
                   ii. Breathing
                  iii. Circulation
          b. Protect cervical spine if there’s suspicion of trauma
          c. Restraints
                    i. Indicated for patient and/or staff protection when evaluating the agitated/combative
                       patient
                   ii. Two general types of restraints
                           1. Physical restraints: soft and Harvey (leather)
                           2. Pharmacological restraints - medication
                  iii. When restrain, you are taking away for freedom, so it’s Important to document
                       indications for restraint use, the type of restraints to be used , the duration of use, and
                       should include frequent reassessments
          d. Pharmacological Restraints
                    i. Examples of drugs
                           1. Haloperidol – (they call it vit H deficiency) ;
Dr. Docherty                      Altered Mental Status                        Page 2 of 7


                                    a. It takes some time to work;
                                    b. might need several doses to work;
                                    c. v. unlikely to cause respiratory depression;
                                    d. might get mm spasm
                           2. Droperidol – might cause cardiac arrythmia
                           3. Lorazepam - cause respiratory depression
                   ii. Use lower doses in elderly
                  iii. For Halo and Drop use with cogentin or bendryl to minimize extrapyramidal effects
                           1. bendryl – makes you feel drowsy
          e.   Evaluation
                    i. Brief history/physical to include brief neurological examination using Glasgow Coma
                       Scale/AVPU
                           1. focused history
                   ii. Cardiac Monitor
                  iii. Pulse Oximeter –
                           1. tells oxygen saturation – how well pt is oxygenated;
                           2. can be used as a diagnostic feature
                  iv. Oxygen Supplementation
                   v. Establish Intravenous Access/Draw initial blood samples also allow to give
          f.    Accucheck – rapid bedside glucose determination
                    i. 1 test everybody get if confused
                   ii. Take drop of blood and put in machine to get blood sugar level
                  iii. If Patient Is Hypoglycemic, then Treat With
                           1. 50cc of 50% dextrose IV in adults
                           2. 4ml/kg 25% dextrose IV in children
                           3. 5ml/kg 10% dextrose IV in neonate
                           4. Give kids lower concentration of glucose bc high concentration will sclerosis
                               their veins bc their veins are much smaller and sensitive that’s why we give
                               them a dilute soln
                  iv. If Patient Is Hyperglycemic Consider DKA or HyperosmolarNonketotic
                       Syndrome(HHNK) which causes confusion because of exceedingly high blood
                       glucose…he had a patient with blood sugar level of 2400
                   v. If blood sugar level is too high (more than 400) the machine will say – too high to
                       read
                  vi. Mental status can be cause by both too low of a blood glucose and too high due to
                       osmotic shift, fluid across the brain and electrolyte imbalance (said he’s not going to
                       dive into that at this point)
                 vii. Normal blood sugar ~ 110; Diabetic pt ~ 400- 800;
          g.   Overdose on Narcotic
                    i. If you suspect someone OD on narcotics, check their arms…you can treat them with
                       the following drugs
                   ii. Narcan (Naloxone)
                           1. Narcotic Antagonist – reverses the effect of narcotics  patients wake up in a
                               couple of minutes
                           2. Adults – 2mg IV
                           3. Children- 0.1mg IV
          h.   Vital Signs (don’t know why this is here, he never talked about it in this regards)
          i.   Flumazanil –
                    i. Drug that reverses the effects of benzodiazepines: valium, lorazepines
Dr. Docherty                     Altered Mental Status                        Page 3 of 7


                  ii. But don’t use that often because if take benzo all the time and if you give them
                      flumazanil which will lead to seizures because benzo is to control acute seizures so if
                      you block benzo  then get seizures
                iii. Not considered part of the routine coma cocktail. Precautions in tricyclic ingestions
                      and patients with dependence on benzodiazepines
          j. Thiamine 100mg IV
                   i. If people have history of substance abuse, especially alcohol, they usually have
                      deficiency in thiamine
                  ii. Deficiency can cause werinke? encephalopathy, korscof’s? psychosis
                          1. Put 100mg in IV bag
                          2. Yellow bag in ER = multivitamins (K, Mg,) and 100 mg thiamine
                          3. alcoholics usually need this because deficient in those vitamins
   V.     History
          a. Use any available resources to obtain historical information about patients
                   i. Friends
                  ii. Family
                iii. Private physicians
                 iv. Police/Paramedics – where and how did you find the patient
                  v. Old Hospital records/medic alert tags
          b. Ask about
                   i. Onset of Symptoms (including rate of onset)
                          1. acute vs. chronic
                  ii. Recent complaints/symptoms
                iii. Past/Present Medical Illness
                 iv. Recent Trauma. Eg. Head trauma
                  v. Social History (including substance abuse)
                 vi. Psychiatric History(including prior suicidal ideation or attempts)
                          1. don’t put on the blinder, be open minded because pple who have psychiatric
                              history can have other problems, too
                vii. Medications/Allergies
   VI.    Physical Examination
          a. Vital Signs
                   i. Often can be helpful in trying to identify the underlying etiology of AMS/Coma
                          1. like high bp  stroke?
                  ii. Repeat vitals frequently
                iii. Pulse Oximetry should be considered a vital sign
                 iv. Examples
                          1. Tachypnea- consider hypoxemia/acidosis
                          2. Fever(rectal temp)- sepsis, meningitis, encephalitis
                          3. Hypertension- Consider hypertensive encephalopathy
          b. General - Evidence of trauma
                   i. Head- Battles sign (bruise or echocomosis), Raccoon eyes (echomosis around the
                      orbital area)  could be indicative of head trauma
                          1. Cephalohematoma, CSF leak,
                          2. VP-Shunt, Hemotympanum (blood behind ear drums)
                  ii. Neck- Immobilize if any suspicion of trauma
                iii. Look for any signs of external trauma to the patient: abdominal, back, pelvic, etc
                          1. Sometimes pt who are confused get a P***? Scanned (head, back, everything)
                              to make sure there aren’t any fractures
Dr. Docherty                      Altered Mental Status                         Page 4 of 7


          c. Skin
                  i.   Needle tracks – suggesting IV drug abuse (scarring of the veins)
                 ii.   Cyanosis – suggesting hypoxemia
               iii.    Jaundice – suggesting possible liver disease (yellowing of their sclera)
                iv.    Rashes
                 v.    Temperature
          d. Breath
                  i. Alcohol – possible etoh intoxication
                         1. don’t assume that if their breath smells like alcohol that that is the cause of
                             their altered mental status
                 ii. Fruity – ketones/acetone in DKA (he said, “we are not going to worry about it here”)
                iii. Almonds – cyanide poisoning
                         1. sometimes when you smell it …its too late
          e. Neck
                  i. Meningismus = stiffening of their neck could be sign of meningitis/encephalitis
                 ii. Thyroid – thyromegaly, old surgical scar
                         1. hyperthyroidism can cause altered mental status
                         2. hypothyroidism can cause it too (common in elderly people)
          f. Cardiac
                  i. Need to get an electric cardiogram
                 ii. Certain types of cardiac dysrhythmias can lead to hypoperfusion and/or cerebral
                     emboli
                iii. Patients can get cardiac rhythms (atrial fibulation, which he doesn’t expect us to
                     know) that form clots in the atria of their heart  get embolized out  clot in brain
                      stroke  cause behavior problem
          g. Abdomen
                  i. Ascites – possible hepatic encephalopathy
                 ii. Bowel sounds – hyperactive/hypoactive/absent
                iii. Hepatomegally- possible hepatic encephalopathy
          h. Neruologic
                  i. Detailed neurological examination
                 ii. Serial examinations essential
          i. Need to assess patients before and after to determine if it’s getting better or worse
                  i. For example, blood alcohol level to be arrested is 80mg/dL…and body metabolize
                     25mg/L so after some times, people become more coherent
   VII.   Glasgow Coma Score (GCS)
          a. Lowest score is 3 and highest is 15
Dr. Docherty                      Altered Mental Status                         Page 5 of 7



                 Glasgow Coma Score

                 Eye Opening (E)            Verbal Response (V)                    Motor Response (M)

                 4=Spontaneous              5=Normal conversation                  6=Normal
                 3=To voice                 4=Disoriented conversation             5=Localizes to pain
                 2=To pain                  3=Words, but not coherent              4=Withdraws to pain
                 1=None                     2=No words......only sounds            3=Decorticate posture
                                            1=None                                 2=Decerebrate
                                                                                   1=None



                                                                                   Total = E+V+M

           b.

   VIII.   Diagnostic Studies
           a. Glucose
           b. Pulse Oximetry
           c. CBC – which white count and Hb
           d. Electrolytes, BUN,Cr, Calcium, Mg,Phosphorus
           e. UA
           f. Serum and urine tox screen, Etoh level
           g. ABG, serum osmolality
           h. Serum therapeutic drug levels as indicated
           i. Liver function tests/Serum ammonia
           j. Serum osmolality
           k. Thyroid function tests (check TSH level)
           l. EKG
           m. Carboxyhemoglobin level – if suspect inhalation problems, check CO
           n. Order tests that are clinically indicated based on the patient’s history and physical findings
           o. CT Scan of head – check structural issues that can alter mental status
                   i. Acute hemorrhage – Subdural hematoma
                          1. Epidural Hematoma
                          2. Intracerebral Hemorrhage
                          3. Subarachnoid Hemorrhage
                  ii. Mass lesions- Tumors
                 iii. Hydrocephalus
                 iv. Brain Abscess
           p. Lumbar Puncture
                   i. Done if suspect CNS infection after CT comes back negative
                  ii. CNS Infections – Meningitis, Encephalitis
                 iii. Take CSF fluid, test to see if there’s white blood cells, bacteria
                 iv. If a patient comes into ER with fever and altered mental state we give them
                      antibiotics like ceftriaxone
Dr. Docherty                    Altered Mental Status                        Page 6 of 7


          q. Subarachnoid Hemorrhage –
                   i. 10% of SAH can NOT be visualized on CT Scan but can be identified on LP
                  ii. Look for xanthochromia/rbc – yellowish coloration of the spinal fluid which is an
                      indication of rbc breakdown
   IX.    Differential Diagnosis for Altered Mental Status
   X.     AEIOU-TIPS
          a. A-Alcohol,drugs,toxins
          b. E-Endocrine,Electrolytes
          c. I-Insulin(DM)
          d. O-Oxygen,Opiates
          e. U-Uremia,Renal causes
          f. T-Trauma,Temperature
          g. I-Infection
          h. P-Psychiatric,Porphyria
          i. S-Space occupying lesions: Stroke,Shock Subarchnoid hemorrhage
   XI.    Case Study
          a. A 50yo male was found unconscious in a downtown park. He appears disheveled and smells
              of alcohol. The paramedics are called to seen by bystanders. The paramedics arrive and
              find the patient comatose. His Glasgow Coma Score was 7 (no eye opening=1; unintelligible
              sounds=2; flexion withdrawal=4)
                   i. Remember that 8 or less is comatose
                  ii. When writing SOAP notes, not what GCS components are like eye opening etc
          b. The patient’s breathing was noisy but improved with a jaw thrust maneuver. His gag reflex
              was intact but weak. He was placed on a backboard with spinal precautions. Vital signs were
              BP140/90, pulse 90, respirations 24/min. Naloxone (narcotic antagonist) was given without
              response and his accucheck was 85.
                   i. Why do a jaw thrust maneuver? To open airway, because you have to protect
                      spine…can’t do usually way of CPR (lift chin, etc)
                  ii. Use backboard and cervical collar when think patient injured back
                 iii. What’s up with vital sign?
                          1. BP is high but not high enough to do anything
                          2. Respiration is high (normal – 16)
                          3. Blood sugar is normal
          c. An empty bottle of wine was found in his jacket, along with a nearly full bottle of dilantin
              capsules (one of the most common seizure medication) dated 2 weeks earlier. A companion
              stated that his friend had complained of headaches for about 2 weeks. The patients pants
              were urine stained.
                   i. People who have seizures can have a period of postepiletic?…where they have
                      transients periods of 30 minutes or longer where they can have altered mental state
                  ii. Urine stain? Patients that have seizures can be incontinence – lose their bladder and
                      bowel
          d. The right pupil was 6mm and nonreactive and left pupil was 3mm and reactive. The patient
              was orotracheally intubated. Upon arrival in the Emergency Department the patient remained
              comatose with a GCS=7 and an unreactive left pupil. Old scars were noted on his forehead
              and a more recent wound with sutures
                   i. Orotracheal incubation – give them drug and put a tube in the tracheal and put them
                      on the ventilator briefly to protect airway. Because patients who have GCS of 8 or
                      less have risk of aspirating – if vomit an go into lungs they can get aspiration
                      pneumonia
Dr. Docherty                    Altered Mental Status                        Page 7 of 7


                 ii. Unequal lesion  mass lesion?? Or herniated brainstem
                iii. The old scar and suture tells us that patient have history of head trauma
          e. In response to noxious stimuli, his left side moved less than his right. Laboratory tests were
             drawn CXR,C-Spine and EKG were obtained, thiamine was given, a CT scan of the head was
             obtained and a neurosurgeon consulted. The patient received mannitol 50 grams IV.
                  i. Mannitol is osmotic diuretic, which lowers the intracranial pressure and if have mass
                     lesion it will prevent the brain from herniating
          f. The CT scan shows a large, right parietofrontal chronic subdural hematoma. Fresh blood
             within the hematoma probably explained the deterioration. The blood alcohol level was
             35mg%. Tox screen was negative.
                  i. This patient has some alcohol but not enough to alter behavior

								
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