altered mental status and coma november 15, 2005 tintinalli chapter 229 dr. hadcock slides by scott...

Altered Mental Status Altered Mental Status and Comaand Coma

November 15, 2005November 15, 2005

Tintinalli Chapter 229Tintinalli Chapter 229

Dr. HadcockDr. Hadcock

Slides by Scott GundersonSlides by Scott Gunderson

Altered Mental StatusAltered Mental Status

Arousal FunctionArousal Function Content of ConsciousnessContent of Consciousness Or bothOr both

Arousal FunctionArousal Function

Reticular activating systemReticular activating system MidbrainMidbrain PonsPons MedullaMedulla

Content of ConsciousnessContent of Consciousness

Cerebral cortexCerebral cortex EmotionsEmotions ReasoningReasoning Self-awarenessSelf-awareness Spatial relationshipsSpatial relationships

DeliriumDelirium

DeliriumDelirium

Acute confusional state with impaired Acute confusional state with impaired alertnessalertness Alerting functionsAlerting functions

Overworking or underworkingOverworking or underworking Difficulty focusing, shifting or sustaining attentionDifficulty focusing, shifting or sustaining attention

Formal definition includes:Formal definition includes: Fluctuating confusionFluctuating confusion Disturbed sleep wake cycleDisturbed sleep wake cycle

PathophysiologyPathophysiology

4 general causes4 general causes

1.1. Primary intracranial diseasePrimary intracranial disease

2.2. Systemic disease affecting CNSSystemic disease affecting CNS

3.3. Exogenous toxinsExogenous toxins

4.4. Drug withdrawalDrug withdrawal

Clinical FeaturesClinical Features

Onset is within daysOnset is within days 3 general variants of activity and alertness3 general variants of activity and alertness

1.1. Hypoalert-hypoactiveHypoalert-hypoactive

2.2. Hyperalert-hyperactiveHyperalert-hyperactive

3.3. MixedMixed– May cycle rapidly between hyperactive and May cycle rapidly between hyperactive and

hypoactive.hypoactive.


Altered sleep wake cyclesAltered sleep wake cycles ““Sundowning”Sundowning” Tremor, tachycardia, diaphoresis, outbursts, Tremor, tachycardia, diaphoresis, outbursts,

delusions, hallucinations may occurdelusions, hallucinations may occur

DiagnosisDiagnosis

Diagnosis primarily by historyDiagnosis primarily by history Physical exam to look for causesPhysical exam to look for causes Additional testing to identify a causeAdditional testing to identify a cause

Labs: CMP, CBC, UALabs: CMP, CBC, UA +/- lumbar puncture+/- lumbar puncture

Radiology: CXR and head CTRadiology: CXR and head CT MMSEMMSE

TreatmentTreatment

Treat the underlying cause (Table 229-5)Treat the underlying cause (Table 229-5) Infections: pneumonia, UTI, meningitis, sepsisInfections: pneumonia, UTI, meningitis, sepsis Metabolic: hypoglycemia, electrolytes, hepatic, Metabolic: hypoglycemia, electrolytes, hepatic,

thyroid disorders, ETOH, or drugsthyroid disorders, ETOH, or drugs Neurologic: CVA, TIA, seizure, intracranial Neurologic: CVA, TIA, seizure, intracranial

hemorrhage or masshemorrhage or mass Cardiopulmonary: CHF, MI, PE, hypoxiaCardiopulmonary: CHF, MI, PE, hypoxia Drug related: Narcotics, sedatives, muscle Drug related: Narcotics, sedatives, muscle

relaxants, antiemetics, digoxinrelaxants, antiemetics, digoxin

TreatmentTreatment

SedationSedation HaloperidolHaloperidol LorazepamLorazepam

Confinement or restraints as appropriateConfinement or restraints as appropriate

Admit unless rapidly reversible cause is Admit unless rapidly reversible cause is identifiedidentified

DementiaDementia

DementiaDementia

2 main types2 main types Dementia of Alzheimer diseaseDementia of Alzheimer disease Vascular dementiasVascular dementias

Insidious loss of mental capacityInsidious loss of mental capacity Rapidly progressing or abrupt onset indicates Rapidly progressing or abrupt onset indicates

another organic causeanother organic cause Behavior problems are commonBehavior problems are common


Majority of causes are from Alzheimer’sMajority of causes are from Alzheimer’s Etiology is poorly understoodEtiology is poorly understood Reduced number of neurons in the cortexReduced number of neurons in the cortex Amyloid depositionAmyloid deposition Neurofibrillary tangles and plaquesNeurofibrillary tangles and plaques

Vascular DementiaVascular Dementia Multiple infarctionsMultiple infarctions

http://www-medlib.med.utah.edu/WebPath/CINJHTML/CINJ034.html

http://www-medlib.med.utah.edu/WebPath/CNSHTML/CNS178.html

http://www-medlib.med.utah.edu/WebPath/CNSHTML/CNS092.html


Memory impairment gradual & progressiveMemory impairment gradual & progressive Recent memory affected greatestRecent memory affected greatest Impairment of memory and orientation with Impairment of memory and orientation with

preserved motor and speech is characteristicpreserved motor and speech is characteristic 3 stages3 stages

Mild–minor memory lossMild–minor memory loss Moderate–memory now affecting social lifeModerate–memory now affecting social life Severe–affecting ADL’sSevere–affecting ADL’s


Vascular dementiaVascular dementia Similar insidious onsetSimilar insidious onset May also have exam findings of exaggerated May also have exam findings of exaggerated

DTR’s or weakness that AD will not have.DTR’s or weakness that AD will not have.

DiagnosisDiagnosis

Diagnosis primarily by historyDiagnosis primarily by history Usually no one specific eventUsually no one specific event If single or multiple distinct events more likely to If single or multiple distinct events more likely to

be vascular dementiabe vascular dementia Labs to rule out other causesLabs to rule out other causes

CBC, CMP, Thyroid, B12, RPR, +/- LPCBC, CMP, Thyroid, B12, RPR, +/- LP RadiologyRadiology

CT or MRICT or MRI

DiagnosisDiagnosis

Exacerbating factorsExacerbating factors UTIUTI CHFCHF HypothyroidismHypothyroidism Many othersMany others

TreatmentTreatment

Primarily environmental or psychosocialPrimarily environmental or psychosocial

PharmacologicPharmacologic AntiphychoticsAntiphychotics Mood stabilizersMood stabilizers Cholinesterase inhibitorsCholinesterase inhibitors All have little use in the ED except to manage an All have little use in the ED except to manage an

acute exacerbation acute exacerbation

DispositionDisposition

New diagnosis entertained in the ED but New diagnosis entertained in the ED but further testing is neededfurther testing is needed

Admit vs. outpatient follow up after treatable Admit vs. outpatient follow up after treatable causes ruled out or addressedcauses ruled out or addressed

Must consider safety of there environment Must consider safety of there environment when discharging.when discharging.

ComaComa

ComaComa

State of reduced alertness and responsiveness State of reduced alertness and responsiveness from which you cannot be arousedfrom which you cannot be aroused

Glasgow Coma ScaleGlasgow Coma Scale Motor, verbal, eye openingMotor, verbal, eye opening

Motor Motor ResponseResponse ExampleExample ScoreScore

CommandsCommands Follows simple commandsFollows simple commands 66

Localizes Localizes PainPain

Pulls examiner's hand away Pulls examiner's hand away when pinchedwhen pinched 55

Withdraws Withdraws from Painfrom Pain

Pulls a part of body away when Pulls a part of body away when pinchedpinched 44

Abnormal Abnormal FlexionFlexion

Flexes body inappropriately to Flexes body inappropriately to painpain 33

Abnormal Abnormal ExtensionExtension

Body becomes rigid in an Body becomes rigid in an extended position when extended position when examiner pinches himexaminer pinches him 22

No ResponseNo Response Has no motor response to pinchHas no motor response to pinch 11

Eye-OpeningEye-Opening ..

SpontaneousSpontaneous Opens eyes on ownOpens eyes on own 44

To VoiceTo VoiceOpens eyes when asked to Opens eyes when asked to in a loud voicein a loud voice 33

To PainTo Pain Opens eyes when pinchedOpens eyes when pinched 22

No ResponseNo Response Does not open eyesDoes not open eyes 11

Verbal Response Verbal Response (Talking)(Talking) ..

OrientatedOrientated

Carries on a conversation Carries on a conversation correctly and tells examiner correctly and tells examiner where he is, who he is, and where he is, who he is, and the month and yearthe month and year 55

Confused Confused ConversationConversation

Seems confused or Seems confused or disorienteddisoriented 44

Inappropriate WordsInappropriate Words

Talks so examiner can Talks so examiner can understand him but makes understand him but makes no senseno sense 33

SoundsSounds

Makes sounds that Makes sounds that examiner cannot examiner cannot understandunderstand 22

No ResponseNo Response Makes no noiseMakes no noise 11


GlobalGlobal Hypoglycemia, hypoxiaHypoglycemia, hypoxia

CNSCNS Brainstem diseaseBrainstem disease Bilateral cortical diseaseBilateral cortical disease

Unilateral should not present as comaUnilateral should not present as coma

Mass Lesions Causing ComaMass Lesions Causing Coma

Secondary to compression of the brainstemSecondary to compression of the brainstem

Primarily uncal vs. centralPrimarily uncal vs. central

Uncal herniationUncal herniation

Medial temporal lobe compresses brainstemMedial temporal lobe compresses brainstem

Decreased responsiveness going into a comaDecreased responsiveness going into a coma

Ipsilateral pupil dilated and nonreactiveIpsilateral pupil dilated and nonreactive

Central HerniationCentral Herniation

Progressive loss of consciousnessProgressive loss of consciousness

Decorticate posturingDecorticate posturing

Irregular respirationsIrregular respirations

Increased Intracranial PressureIncreased Intracranial Pressure

Localized vs. generalizedLocalized vs. generalized Cerebral blood flow constant with MAP of 50-Cerebral blood flow constant with MAP of 50-

100 mm of Hg100 mm of Hg CPP = MAP – ICPCPP = MAP – ICP Cushing reflex of hypertension and Cushing reflex of hypertension and

bradycardiabradycardia


Coma secondary to hemispheric hemorrhage Coma secondary to hemispheric hemorrhage may still have localizing featuresmay still have localizing features

Pupillary, muscle, and cranial nerve exam to Pupillary, muscle, and cranial nerve exam to determine central vs. focaldetermine central vs. focal

Pupillary response generally preserved in toxic Pupillary response generally preserved in toxic metabolic comametabolic coma

DiagnosisDiagnosis

Stabilization diagnosis and treatment overlapStabilization diagnosis and treatment overlap ABC’sABC’s Lab,+/- LPLab,+/- LP CT headCT head ExaminationExamination

Focal vs. diffuseFocal vs. diffuse

Specific IssuesSpecific Issues

C-spine immobilization if trauma suspectedC-spine immobilization if trauma suspected Pediatric coma commonly ingestion, infection, Pediatric coma commonly ingestion, infection,

or abuseor abuse SeizuresSeizures

Coma s/p seizure activityComa s/p seizure activity ““electromechanical dissociation of the brain and body”electromechanical dissociation of the brain and body”

TreatmentTreatment

Reverse identifiable causesReverse identifiable causes GlucoseGlucose

Thiamine prior if alcoholicThiamine prior if alcoholic NaloxoneNaloxone

If signs or history of opioid useIf signs or history of opioid use FlumazenilFlumazenil

Only recommended if history of benzo use not as Only recommended if history of benzo use not as routine.routine.

DispositionDisposition

Most cases will be admittedMost cases will be admitted Discharge rapidly reversible causes such as Discharge rapidly reversible causes such as

insulin induced hypoglycemiainsulin induced hypoglycemia Admit if unclear cause or poor follow-upAdmit if unclear cause or poor follow-up

ReferencesReferences Tintinalli, Judith E., Tintinalli, Judith E., Emergency Medicine a Comprehensive Study Guide.Emergency Medicine a Comprehensive Study Guide. Sixth edition. McGrw-Hill Sixth edition. McGrw-Hill

Companies, Inc. 2004. Chapter 229. Altered Mental status and Coma. Huff, J. Stephen. Pages 1390-1397.Companies, Inc. 2004. Chapter 229. Altered Mental status and Coma. Huff, J. Stephen. Pages 1390-1397.

Boon, Rosemary. “Sleeping Disorders.” http://home.iprimus.com.au/rboon/SleepingDisorders.htm. Boon, Rosemary. “Sleeping Disorders.” http://home.iprimus.com.au/rboon/SleepingDisorders.htm. Accessed 11/14/05.Accessed 11/14/05.

Klatt, Edward C. University of Utah Webpath. http://www.medlib.med.utah.edu/WebPath/ Accessed Klatt, Edward C. University of Utah Webpath. http://www.medlib.med.utah.edu/WebPath/ Accessed 11/14/05.11/14/05.

QuestionsQuestions

1.1. All of the following are features of delirium except:All of the following are features of delirium except:a.a. Fluctuating courseFluctuating courseb.b. Disordered attentionDisordered attentionc.c. Visual and/or auditory hallucinationsVisual and/or auditory hallucinationsd.d. Insidious onset over yearsInsidious onset over years

2.2. A fluctuating stepped course of mental impairment with A fluctuating stepped course of mental impairment with focal neurologic signs is suggestive of:focal neurologic signs is suggestive of:

a.a. Vascular dementiaVascular dementiab.b. Alzheimer’s dementiaAlzheimer’s dementiac.c. DeliriumDeliriumd.d. Parkinson’s diseaseParkinson’s disease

3.3. A patient arrives to the ED with an altered mental status. A patient arrives to the ED with an altered mental status. On examination he responds only to painful stimuli by On examination he responds only to painful stimuli by withdrawing, opens his eyes only with pain, and only withdrawing, opens his eyes only with pain, and only audible noises are moans. His GCS score is?audible noises are moans. His GCS score is?

a.a. 1212

b.b. 1010

c.c. 88

d.d. 44

4.4. (T/F) The reticular activating system responsible for arousal (T/F) The reticular activating system responsible for arousal functions is located in the midbrain, pons, and medulla.functions is located in the midbrain, pons, and medulla.

5.5. (T/F) Delirium always has an organic cause.(T/F) Delirium always has an organic cause.

Answers: 1-d, 2-a, 3-c, 4-T, 5-TAnswers: 1-d, 2-a, 3-c, 4-T, 5-T

altered mental status and coma november 15, 2005 tintinalli chapter 229 dr. hadcock slides by scott...

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