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

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As life happens

• Youre an Emory Family Medicine Resident at
  EUHMat 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.

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• you arrive to find a 63 year old male ESRD pt
  on HD who is not quite conscious.
• You attempt to get a history hes not
  responsive enough. No one came with him by
  ambulance.
• You do a cursory examhumABCs okay,
  lungsheartabdokay, legs and arms attached and
  moving ?

4

• Your nurse is drawing your usual rainbow tubes
  while putting in an IV
• Thats when you notice the vital signs
• Pulse 68
• RR 14
• BP 110/58
• Temp 100.5

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Todays 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

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Define AMS
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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

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Diagnosis and Treatment

• What exam features and tests are routinely
  performed for AMS?
• ABCs, etc
• Finger stick blood sugar
• Finger stick hemoglobin
• ABG, pulse ox
• Routine labs like
• CMP, CBC, UA
• Drug levels acetaminophen, ASA, etc
• UDS

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Diagnosis and Treatment

• Other labs
• Anion gap
• Osmolality
• Procedures/tests
• Head CT
• Lumbar puncture
• CXR/radiology as indicated

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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

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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

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Clinical tests that are helpful to evaluate AMS

• Glascow Coma Scale (GCS)
• Mini-Mental State Exam (MMSE)
• MOCA

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Common causes of AMS on FMS

• Hypoglycemia
• Infection
• Head injury
• Stroke
• Tumor/mets in brain
• Undiagnosed dementia
• Electrolyte imbalance
• Overdose
• Psychiatric causes

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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

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Case 1 continued

• After the second round, he then stands in the
  swimming pool at his sports complex at Lake
  Lanier to cool off

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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.

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Divide into teams and formulate a differential
diagnosis
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DDx?

• Group 1 first

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Case 1 contd

• In the ER, he has already recd 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)

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Case 1 contd

• Hg/Hct 12.5/39
• Plt Ct and WBC normal
• Na 117
• K 3.8
• Cl 89
• HCO3 25
• BUN 10
• Creatinine 1.0
• Glucose 200

• AST 100
• ALT 87
• Albumin 4.2
• T Bili 1.3
• Ammonia 37
• UA normal with spec. grav. 1.005, no blood

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Refine your DDx and initial treatment plans as a
group
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Case 1 contd

• Hg/Hct 12.5/39
• Plt Ct and WBC normal
• Na 117
• K 3.8
• Cl 89
• HCO3 25
• BUN 10
• Creatinine 1.0
• Glucose 200

• AST 100
• ALT 87
• Albumin 4.2
• T Bili 1.3
• Ammonia 37
• UA normal with spec. grav. 1.005, no blood

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DDx and Rx?

• Group 2

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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 812 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?

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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 ? rate 60cc/hr and
  check the sodium on the hour.

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Take a breather
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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.

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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.

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Case 2 labs

• Hg 13
• Hct 40
• Plt Ct 117
• WBC 3.2
• MCV 102
• Na 137
• K 3.8
• HCO3 15
• Cl 100
• BUN/Cr 28/1.5

• Glucose 180
• AST 52
• ALT 48
• T. Bili 1.7
• Albumin 3.9

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Formulate a DDx and Rx plan
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Case 2 labs

• Hg 13
• Hct 40
• Plt Ct 117
• WBC 3.2
• MCV 102
• Na 137
• K 3.8
• HCO3 15
• Cl 100

• Glucose 180
• AST 52
• ALT 48
• T. Bili 1.7
• Albumin 3.9

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DDx? Any other info requested?

• Group 3

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More info

• ABG pH 7.32/pO2 88/pCO2 36/HCO3 16, on room air
• Anion Gap Na (Cl HCO3) ?
• 137 (10015) 22, high.
• DDx from the PGY 1 class?

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MUDPILESMemorize 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

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DDx in this patient?

• Methanol or ethylene glycol?
• How can you tell in the ER?
• Urine calcium oxalate crystals with?
• Ethylene Glycol
• Its the middle of the night and the lab wont
  look at the urine until the morning
• What now?

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Can you prevent this?
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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 lt10)

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Danger, Will Robinson, Danger
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Treatment?

• Fomepizole (expensive- 1000 a vial)
• Alcohol drip
• Get nephrology on board ASAP
• Emergency dialysis
• Critical care medicine/ICU
• Poison control/toxicology consult

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Relax with the mist and the critters
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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.

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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

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DDx and Rx?
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Ddx and Rx?

• Group ?

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Case 3 DDx

• Meningitis bacterial and others
• Malaria, especially falciparum - deadly
• HIV CNS infections Toxoplasmosis, cryptococcus,
  HSV, others

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Another classic case of AMS

• Middle-aged male alcoholic is found down and
  brought to the ER.
• Head CT shows

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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

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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, EgtI, no rales

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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

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Helpful things not usually done

• Peak Flow
• Pulsus paradoxus
• Exercise challenge assess ADLs

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Summary

• List ten causes of AMS
• Stabilize the patient
• ABCs
• Labs the usual rainbow
• X-rays strongly consider a head CT
• Dont miss the uncommon things
• Put the MMSE/GCS on your blackberry
• Put the AEIOUTIPS on your blackberry