Altered Mental Status

Intern Survival SeriesJuly 2011

JeanPierre ELKHOURY, MDAKA JP !!

DEFINITION

Consciousness is a condition in which an individual is fully responsive to stimuli and demonstrates awareness of the environment

An alteration in mental status is the hallmark sign of central nervous system (CNS) injury or illness

What is Consciousness?

Arousal function Alerting and wakefulness Anatomically-reticular activating

system Content functions

Language, reasoning Anatomically-cerebral cortex

DEFINITION

Content of Consciousness

Cerebral cortex Emotions Reasoning Self-awareness Spatial relationships

DEFINITION

Disorder of Arousal functions

Content functions disrupted

Altered Mental Status ?

DEFINITION

7

The nurse will page for Any or all of the following…

Seems drowsy or sleepy; not alert

Awake and cooperative, but seems confused

Awake, but used inappropriate words

reported unconscious, but is now awake, with or without

impaired memory

Awake, but not oriented to self, time, place, or events

Unconscious, but responds to verbal or painful stimuli

Unresponsive

DEFINITION

Pathophysiology

4 general causes

1. Primary intracranial disease

2. Systemic disease affecting CNS

3. Exogenous toxins

4. Drug withdrawal

CAUSES

http://www.mribhatia.com/braintf14/braintf14-large1.html

Causes of Altered Mental Status

Mnemonic

• A Alcohol, Alzheimer's

• E Endocrine, Environmental

• I Infection• O Opiates,

Overdose• U Uremia

• T Tumor, Trauma

• I Insulin• P Poisonings,

Psychosis• S Stroke

Seizures Syncope

Intern’s Role

Primary survey Establish unresponsiveness A,B,C’s

Resuscitation glucose, thiamine

Secondary assessment Definitive care

ASSESSMENT & MANAGEMENT

Gather History… Signs and symptoms

Gradual or sudden onset? Associated symptoms? Did they get progressively worse?

Medications Inpatient Medications and rule out drugs abuse last doses

Last oral intake Alcohol Intoxication in ER

Events leading up to Any seizure activity? Any trauma in last two weeks? Any complaints of headache? Was patient acting normal prior to events? Has patient been ill? Any witnesses ?

ASSESSMENT & MANAGEMENT

Physical Examination

Head- any evidence of trauma Pupils

Unequal or fixed- increased intracranial pressure (head injury or stroke)

Pinpoint- narcotics Sluggish- hypoxia

Mouth and oral mucosa- check for cyanosis Chest- trauma, equal rise and fall of chest, lung sounds Abdomen- trauma, check for tenderness with palpation Extremities- pulse, movement, and sensation; edema in lower extremities

ASSESSMENT & MANAGEMENT

Neurological Examination

Observation, Cranial nerves, Sensory, Motor, Reflexes

If assessment findings indicate potential stroke, do a FAST Assessment: Face: Smile, is one side drooping? Arm: Raise arms, does one side drift

down? Speech: Repeat a phrase, are your words

slurred? Time: Quick treatment if CVA suspected

ASSESSMENT & MANAGEMENT

How to do A Mental Status Exam?

Appearance, behavior, attitude Thought disorders Perception disorders Mood and affect Insight and judgment Sensorium and intelligence

ASSESSMENT & MANAGEMENT

Six Elements of Mental Status Evaluation Appearance, behavior, and attitude Disorders of thought

Are the thoughts logical and realistic? Are false beliefs or delusions present? Are suicidal or homicidal thoughts present?

Disorders of perception Are hallucinations present?

Mood and affect

ASSESSMENT & MANAGEMENT

Six Elements of Mental Status Evaluation Insight and judgment

Does the patient understand the circumstances surrounding the visit?

Sensorium and intelligence

Is the level of consciousness normal?

Is cognition or intellectual functioning impaired?

ASSESSMENT & MANAGEMENT

How to do A Mental Status Exam?

Informal testing used most often BUT, informal testing insensitive

If a formal screening examination performed, assessments, workup, and dispositions change

Formal mental status Mini-mental status exam Brief mental status exam Others

ASSESSMENT & MANAGEMENT

The Brief Mental Status ExaminationITEM (number of errors) X (weight) = (Total)

What year is it now?What year is it now? 0 or 10 or 1 x 4 =x 4 =________

What month is it?What month is it? 0 or 10 or 1 x 3 =x 3 =________

Present memory phrase: “Repeat this phrase after Present memory phrase: “Repeat this phrase after me and remember it: me and remember it: John Brown, 42 Market John Brown, 42 Market Street, New York.Street, New York.””

About what time is it?About what time is it? 0 or 10 or 1 x 3 =x 3 =________

(Answer correct if within one hour)(Answer correct if within one hour)

Count backwards from 20 to 1.Count backwards from 20 to 1. 0, 1, or 20, 1, or 2x 2 =x 2 = ________

Say the months in reverseSay the months in reverse0, 1, or 20, 1, or 2 x 2 =x 2 =________

Repeat memory phraseRepeat memory phrase 0,1,2,3,4,or 50,1,2,3,4,or 5 x 2 =x 2 =________

(each underlined portion is worth 1 point)(each underlined portion is worth 1 point)

ASSESSMENT & MANAGEMENT

The Brief Mental Status Examination Final Score is the sum of the totals

For each response, circle the number of errors and

multiply the circled number by the weight to determine the score.

______________________________________

Possible score range from 0 to 28.

ASSESSMENT & MANAGEMENT

The Brief Mental Status Examination The lowest possible score (indicating

the least impairment) is 0. The highest possible score is 28. Categories of scores:

0-8 normal 9-19 mildly impaired 20-28 severely impaired

ASSESSMENT & MANAGEMENT

Work Up

Check Vital Signs (BP, Pulse Ox, RR…) Finger stick blood sugar CBC, CMP, UA, ABG Drug levels – acetaminophen, ASA, etc… UDS Apply monitor and make sure patient has IV Access Be prepared to initiate CPR Head CT without contrast before LP if possible CXR LP

ASSESSMENT & MANAGEMENT

When Is a Spinal Tap Indicated in Delirium?The primary indication for an emergent spinal tap is the possibility of CNS infection.

CSF should be examined in patients with a fever of unknown origin, especially if an alteration in consciousness is present…

ASSESSMENT & MANAGEMENT

Treatment of underlying cause

Sedation

Restraints if needed

TREATEMENT

Treat the underlying cause

Infections: pneumonia, UTI, meningitis, sepsis

Metabolic: hypoglycemia, electrolytes, hepatic, thyroid disorders, ETOH, or drugs

Neurologic: CVA, TIA, seizure, intracranial hemorrhage or mass

Cardiopulmonary: CHF, MI, PE, hypoxia Drug related: Narcotics, sedatives, muscle relaxants, antiemetics, digoxin

TREATEMENT

If low blood sugar is present: Administer oral glucose if patient is alert and

able to swallow (Basic providers) Dextrose 50% IVP or Glucagon IM

If narcotic overdose is suspected and airway compromise and/or inadequate respiratory effort is present:

Narcan IV or IM Ventilation Support

TREATEMENT

Treat the underlying cause

Sedation Haloperidol IV/IM Lorazepam IV

Confinement or restraints if patient is at risk of harming himself or others (Hospital staff…)

TREATEMENT

Sedation and Restraints