altered mental status

1. Altered Mental Status
David T. Matero, M.D.
AssistantProfessor
EmergencyMedicine
University of Colorado Denver

2. Overview
Altered mental status: It Could Be [almost] Anything! requires a thorough work-up
What is the differential for altered mental status?
What is the type of problem that could cause it?
What is the organ system(s) that could be involved?
3. Example
63 yo female found down next to park bench.Bystander called EMS who are now moving patient from gurney onto bed.
You ask for history: There is none
You ask for ROS: There is none
You ask for PMH, Meds, Anything!: There is none
WELCOMETO EMERGENCY MEDICINE
4. What Could Be Wrong With Her?
Tramua: Brain laceration/injuryConcussionDepressed skull fractureHead traumaBrain, contusionBrain injury, massiveDiffuse axonal injury/Acute brain traumaShaken Baby SyndromeElectromagnetic, Physics, trauma, Radiation CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea waterDrowning/Near- drowningHeat exhaustion/prostrationHeat strokeEncephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposureElectrocution/lightning strikeHigh altitude cerebral edemaDecompression sicknessHigh altitude pulmonary edemaIatrogenic, Self Induced DisordersWater intoxicationHypothermic anesthesiaHyponatremia correction, rapidSurgical, Procedure ComplicationAnesthesia, generalBrain surgeryInfectious Disorders (Specific Agent)Pneumonia, bacterialAIDS MeningoencephalitisEncephalitis, herpes simplexEncephalitis, secondary viralEncephalitis, viralMeningitis BacterialMeningitis, aseptic/viralMeningitis, HemophilusMeningitis, pneumococcalMeningococcal meningitisPneumonia/BronchopneumoniaPneumonia, acute lobarPneumonia, pneumococcalTyphoid feverMeningitis, tuberculosisAmebic (Naegleria) meningoencephalitisBacterial overwhelming sepsisCandidiasis systemicChickenpox encephalitisEncephalitis, bacterial/cerebritisEncephalitis, Dawsons/inclusion bodyEncephalitis, Eastern equineEncephalitis, mumpsEncephalitis, Murray valleyEncephalitis, non-viralEncephalitis, St Louis BEncephalitis, Western equineGram negative (e coli) meningitisHistoplasmosis meningitisKunjin viral encephalitisLa Crosse viral encephalitisLegionella meningoencephalitisLeptospiral meningitisLeptospirosis/severe (Weils) typeListeria meningitisLyme meningoencephalitisMalaria, cerebralMeningitis, candidaMeningitis, Coxacki viralMeningitis, echo viralMeningitis, staphylococcus aureusMononucleosis encephalitisPlague meningitisPost-viral/infectious encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes syndromeRussian tick-bourne encephalitisToxic shock syndromeTrichinella meningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisLegionaires diseaseListeria monocytogenes/listeriosisMeningitis, fungalRocky mountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleeping sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, CaliforniaEncephalitis, equine, VenezuelanEncephalitis, Japanese BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acuteFungus brain abscessLeptospirosis IctohemorrhagicaInfected organ, AbscessesInfectionsAbscess, intracranialBacteremia/SepticemiaBrain abscessEmbolism, septic, cerebralEndocarditis, infectiveMeningoencephalitisPneumonia, aspirationSepsisSepsis, overwhelmingSeptic shockUrosepsis/septicemiaEncephalomyelitis, acuteEncephalopathy/secondary/toxic/sepsisNecrotizing fasciitis/mixedBrain stem encephalitisEncephalitisMeningitisPneumoniaGranulomatous, Inflammatory DisordersHemorrhagic pancreatitis, necrotizingPancreatitis/resp distress syndromeNeoplastic DisordersHypercalcemia of malignancyMetastatic brain diseaseBrain stem tumorBrain tumorFrontal lobe tumorMedulloblastomaMeningeal carcinomatosisParietal lobe tumorPrimary CNS lymphomaTemporal lobe tumorBrain tumor , malignant (astrocytoma)CraniopharyngiomaGlioblastoma multiformeInsulinoma/Islet cell tumorMeningiomaPontine gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune DisordersEncephalitis, hemorrhagic, acuteEncephalitis, post viralEncephalomyelitis, necrotizing hem. ac.Encephalomyelitis, post-infectiousStevens-Johnson syndromeTransfusion reaction, hemolyticLupus cerebritisPolyarteritis nodosaBehcet's syndromeHashimotos EncephalitisMetabolic, Storage DisordersHypoglycemia, reactive diabeticDiabetic ketoacidosis/comaHyperosmolar hyperglycemic coma, nonketNeonatal hyperbilirubinemiaMetabolic disordersMethemoglobinemia, HereditaryPorphyria, acute intermittentGlutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical DisordersEncephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHypercalcemiaHypercapnea HypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontine myelinolysis, centralDeficiency DisordersDehydration and feverDehydrationWernicke's encephalopathyMalnutrition/StarvationPellagra/niacin deficiencyMarchiafava-Bignami syndromeCongenital, Developmental DisordersNephrogenic diabetes insipidusHereditary, Familial, Genetic DisordersMELAS EncephalopathyVan Bogaert encephalitisUsage, Degenerative, Necrosis, Age Related DisordersAlzheimer's syndromeDementia, Lewy-body typeMultiple sclerosisRelational, Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia, factitiousCatatoniaManic deleriumAnatomic, Foreign Body, Structural DisordersAcute subdural hematoma/hemorrhageBrain compressionEpidural hematomaIntracerebral hematomaIntraventricular brain hemorrhageSubdural hematomaTamponade, cardiacBrain stem herniation/peduncle/tonsilsFat embolismSuperior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolismCerebral hemorrhageCerebral vein thrombosis/phlebitisIntracerebral hemorrhageMyocardial infarction, acuteSubarachnoid hemorrhageTransient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosisCerebral/Venous sinus thrombophlebitisSuperior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexiaSleep deprivationVegetative, Autonomic, Endocrine DisordersCardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shockConvulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotensionOrthostatic hypotensionPost-ictal statusThyrotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignantMalignant hyperthermiaMyxedema comaMyxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart blockInappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, juvenileNarcolepsyPickwick's syndromeReference to Organ SystemShockCerebral edemaDisseminated intravascular coagulopathyHepatic encephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndromeBrain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremic encephalopathyEncephalopathyHyperviscosity syndromePernicious anemiaPontine lesion/disorderThrombotic thrombocytopenic purpuraCombined system disease/pernicious an.Fever Unknown OriginReversable Posterior Encephalopathy SyndromePathophysiologicSepsis encephalopathy/elderlyCardiac output reductionCerebral depressed functionsDrugsMedication/drugsBenzodiazepines Administration/ToxicitySedative drugs Administration/ToxicityDigitalis toxicity/poisoningHypoglycemia, diabetic/treatmentInsulin overdose/exogenousIntoxication/overdose syndromeSalicylate intoxication/overdoseTricyclic overdoseBarbiturate/sedative abuse/dependentDrug induced Hypoglycemia.Oral hypoglycemic Administration/Toxicity/effectInsulin (Humulin/Novulin) Administration/ToxicityIsoniazid (INH/Nydrazid) Administration/ToxicityErgot toxicityIsoniazid hepatitisMilk-alkali syndromePoisoning (Specific Agent)Opiate overdose toxidromeKitchen gas/propane exposureAlcohol/Ethanol ingestion/intakeAlcohol amnestic disorderAlcohol induced hypoglycemiaAlcohol intoxication, acuteAlcohol seizure (rum fits)Cholinergic crisis toxidromeDelirium tremensInsecticide/organophosphate typeOverdose, drug/alcoholPoisoningSnakebite (neurotoxic/coral/cobra type)Snakebite (rattlesnake/pit viper type)Alcohol withdrawalHallucinogen abuseLead poisoning in childrenSmoke inhalationHeroin/morphine usage/addictionCyanide/Hydrogen cyanide exposure/poisoningVomiting CBW agent (Dm/Da/Dc) Weapon exposureArsine gas (Hydrogen arsenide) poisoningCarbon monoxide poisoning/exposureDiethylene Glycol poisoningEthylene glycol [Antifreeze] ingestionInsecticide/pesticide poisoningIntentional poisoningIsopropyl alcohol ingestion/poisoningMustard gas exposure/poisoningNerve gas exposureAluminum toxicity/syndromeAmmonia exposure/inhalationHydrogen sulfide poisoning/inhalationInsecticide/chlorinated/non-ester's inhLead poisoningLead encephalopathyNitrogen narcotic actionCarbon disulfide inhalant/poisoningChlorine gas poisoningMethane gas poisoning/asphyxiaCarbon dioxide gas inhalation/asphyxiaOrgan Poisoning (Intoxication)Neuroleptic malignant syndrome
5. From Vertebrobasilar migraine syndrome to HyponatremiaIts TOO MUCH
You need a clue:
-EMS report
-Cell phone (call family members)
-Bystander account
-PMH from meds, alert bracelet, wallet, PhysEx (e.g fistula)
-Phys Examfor current physiological state of patient
-Labs
-Imaging
6. PhysiologicReserveDeterminesHowReadily the PatientWillHave AMS!
Frail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.
Young Healthy Patient: Likely to be something significant that has gone wrong
Patient With Obvious Comorbidities:Other causes (than primary medical problem) will more readily alter this patient (less reserve!)
7. YouMayGetFrustrated at thisPatient and Say (ddx):
M: MetabolicB12 or thiamine deficiency, serotonin syndrome
O: Hypoxemia (pulmonary, cardiac, anemia);high CO2
V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MI
E: Electrolytes and endocrine
S: Seizures / status epilepticus, post-ictal
T: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes )
U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy
P: Psychiatric, porphyria
I: Infection (inflammatory-see vasculitis above)
D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol)
8. M: MetabolicB12 or thiamine deficiency, serotonin syndrome
Glucose metabolism uses up even more thiamine
Serotonin syndrome=serotonin toxicity and caused by various drugs, medicines and combinations thereof
-increased heart rate, shivering, sweating, dilated pupils,myoclonus, as well as overresponsive reflexes
9. O: Hypoxemia (pulmonary, cardiac, anemia);high CO2
Purely Hypoxic patient is anxious/agitated
-PE
Purely Hypercarbic patient is sleepy
-Jet Insufflation in kids or bad COPDer
10. V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MI
All of these cause poor perfusion of the brain either focally or globally through local effects (CVA) or through loss of forward flow to brain (MI)
11. E: Electrolytes and endocrine
Electrolyte shifts can cause swelling in the brain
High Na or Ca global depression (any electrolyte involved in ion-channel transmission in the brain can cause a problem)
Hypoglycemia most common cause of endocrine-related MS depression
12. S: Seizures / status epilepticus, post-ictal
Post-ictal state typically resolves in 20-40minutes
Non-epileptiform seizures can be cause of depressed mental status
-No tonic-clonic activity
-Ultimately diagnosed with EEG
-Eye movement, hx, trial of Ativan may give clue
13. T: Tumor, trauma, temperature, toxins (lead, mercury, CO, toxidromes )
Tumor causes compression or diffuse edema
Hypothermia: Global depression of ion-channels
Toxins: Wide range of responses depending on individual and their reserve
Look for Toxidromes- A symptom constellation specific to a given toxin (e.g. Slurred speech, B lateral-gaze nystagmus, cerebellar deficits, altered mood is the toxidrome for Ethanol)
14. U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy
Electrolyte Abnormalities
Uremia-Urea build-up AND electrolyte abnormalities
Hepatic Encephalopathy- elevated Ammonia (level should be high but poorly correlated with actual degree of AMS)
15. P: Psychiatric, porphyria
Catatonia: no focal neurological deficits but unresponsive (responds to Ativan!)
Porphyria: A group of enzyme deficiencies in hematologic biosynthesis pathway that results in accumulation of Porphyrins (or precursors): Multiple s/sx including various MS effects
16. I: Infection (inflammatory-see vasculitis above)
Meningitis (A constant concern in all patient, esp at extremes of age)
Cerebritis
17. D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol)
Learn and look for Toxidromes (withdrawal states are usually essentially opposite in symptoms)
18. In Summary:It ALL Boils Down to One of TwoThings
Both cerebral hemispheres are depressed
The Reticular Activating System is not functioning.
Diffuse Process most of
the cases arise from this
?
Stroke, Seizure or Trauma to this region
22. Approach the PatientCoveringMostUrgentBasesFirst
ABCs
Intravenous access, oxygen therapy, cardiac monitoring with pulse oximetry
Accu-check / glucose / thiamine
Cervical spine precautions
Naloxone
EKG / cardiac monitoring
ABG with carboxyhemoglobin
CBC, electrolytes, Ca, Mg
Drug screen, EtOH, serum osmolarity
Urinalysis
Imaging
lumbar puncture
liver, thyroid
EKG / cardiac monitoring
ABG with carboxyhemoglobin
CBC, electrolytes, Ca, Mg
Drug screen, EtOH, serum osmolarity
Urinalysis
Imaging
lumbar puncture
liver, thyroid
Frail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.
25. 63 yo female found down next to park bench
You have no information: You do a physical exam
-A: Breath sounds CTAB,+gag, trachea midline, no pooling of secretions,
-B: Spontaneous respirations
-C: Regular rhythm , tachycardia, B femoral pulses, diminished DP pulses (but present)
-VS:101,88/45, T- 35.6, 92% RA
-HEENT: PERRL, TMs clear, MM slightly dry
-Neck: Supple, no JVD
-Chest: no crepitus, atraumatic
-GI: soft, BS present/normal; rectal no gross blood, NL tone
-Extrem: UE and LE with no clubbing, cyanosis, edema pulses present except as noted in ABCs
-Back: Atraumatic, no step-offs
-Neuro: CN grossly intact, MAE, withdraws to pain, no gross focal neurol deficits, reflexes symmetrical, does not answer Qs or follow commands, moaning
-Skin: well perfused
-GU: Perineum atraumatic, no discharge or lesions
27. What Was Abnormal?What Could It Mean?
28. What Was Abnormal?What Could It Mean?
You have no information: You do a Physical Exam
-A: Breath sounds CTAB,+gag, trachea midline, no pooling of secretions,
-B: Spontaneous Respirations
-C: Regular rhythm , tachycardia, B Femoral pulses, diminished DP pulses (but present)
-VS:101,88/45, T- 35.6, 92% RA
-HEENT: PERRL, TMs clear, MM slightly dry
-Neck: Supple, no JVD
-Chest: no crepitus, atraumatic
-GI: soft, BS present/normal; rectal no gross blood, NL tone
-Extrem: UE and LE with no clubbing, cyanosis, edema, pulses present except as noted in ABCs
-Back: Atraumatic, no step-offs
-Neuro: CN grossly intact, MAE, withdraws extrem to pain,no gross focal neurol def, reflexes symmetrical, does not answer Qs or follow commands, moaning
-Skin: well perfused
-GU: Perineum atraumatic, no discharge or lesions
30. Putting the PhysicalExamFindingsTogether:
Do you think this is a Global or a Focal Process?
How would you summarize the state of the patient based on PEX?
What could cause this state?
31. What is more likely now?
T: Tumor, trauma, temperature, toxins (lead, mercury, CO, toxidromes)
32. What is more likely now?
T: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes )
33. Next Step: Diagnostic Studies
Prioritize acute life threats first
Get high-yield, easy items first: Glc, EKG
Keep modifying testing as DDX changes with results
Shotgun Approach (parallel processing)
Is patient stable to go to imaging or to wait for lab result before making treatment decision?
34. How Do I Know What to Order?
Balance these two things to determine what tests/priority:
-Shotgun approach (intended to move things along quickly and cast wide net)
-What youve learned from your H&P
35. LABS
141
101 26
101
4.1
17 1.1
UA:
Spec grav 1.026
pH 6.0
Ketones +
Glucose
Bile
Blood +
Bacteria ++
WBC ++
Nitrite +
Leuk. Est +
14.4
41.9
14.5380
LFTs- Normal
ASA, APAP, Coags Normal
36. LABS
141
101 26
101
4.1
17 1.1
UA:
Spec grav 1.026
pH 6.0
Ketones +
Glucose
Bile
Blood +
Bacteria ++
WBC ++
Nitrite +
Leuk. Est +
14.4
41.9
14.5380
LFTs- Normal
ASA, APAP, Coags Normal
37. Do We Know Whats Going On?
We know the patient has a UTI
Is this enough to explain the patients sepsis?
Can we stop our work-up?
Could the UTI be a red herring?
Is this enough to explain the patients sepsis? YES
Can we stop our work-up?
Can we stop our work-up? NO
Can we stop our work-up? NO
Could the UTI be a red herring?YES
41. What Else Should We Do?
Pt does have Sepsis and a UTI, this could be Urosepsis.HOWEVER, it could also be something else (and there just happens to be a UTI)
EKG MI, Intervals (Toxins), Other-
CXR PNA (Sepsis), Edema, Trauma-
Head CT Bleed, Swelling, Mass -
Lumbar Puncture Bleed, Infection -
Urine Drug Screen Drugs of Abuse -
EKG MI, Intervals (Toxins), Other- NORMAL
CXR PNA (Sepsis), Edema, Trauma- NORMAL
Head CT Bleed, Swelling, Mass - NORMAL
Lumbar Puncture Bleed, Infection - NORMAL
Urine Drug Screen Drugs of Abuse - NORMAL
44. We THINK We Know the Cause
Urosepsis
45. We THINK We Know the Cause
Urosepsis
Re-Examine the patient and make sure nothing has changed and that the exam is consistent w Dx
Dont become emotionally attached to a Dx,as the clinical picture can change and start looking like something else
The only atypical presentation is a typical presentation
46. CONCLUSION
Maintain a wide differential
Get a Grip on the Diagnosis through systematic clue finding
Remember: Its focal in the RAS, or diffuse in the Bilateral Hemispheres
Re-evaluate patient frequently and do frequent hypothesis-testing in your mind

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