Altered Mental States

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Altered Mental States

• by
• Paul Rega, M.D., FACEP
• OMNI Health Services

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First Things First

• Is the patient a threat to you?
• Airway intact?
• What are the vital signs?
• Includes oxygen saturation
• Blood sugar?

3
Organic Brain Syndrome

• Alterations in cortical brain function
• Affects alertness, orientation, emotion,
  behavior, memory, perception, language skills,
  problem solving, judgment, psychomotor activity
• Acute Delirium
• Chronic Dementia

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Features Delirium
Dementia Psych
Sudden Insidious Sudden
Onset
Course
Fluctuating Stable
Stable
Reduced Alert
Alert
Consciousness
Disordered /-
/-
Attention
Disordered Impaired /-
Impaired
Cognition
Impaired Often
Possibly
Orientation
Hallucinations
Visual/auditory Absent
Auditory
Delusions
Transient Absent
Sustained
Votes Hillary
McCain Nader
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Differential Diagnosis

• Trauma
• Neurovascular
• Cardiovascular
• Neurologic
• Infection

• Major Organ Dysfunction
• Toxic
• Other
• Psychiatric

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Head Trauma

• Subarachnoid hemorrhage
• Epidural hematoma
• Subdural hematoma

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Neurovascular

• Ischemic stroke
• Hemorrhagic stroke
• Hypertensive encephalopathy
• CNS vasculitis

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Cardiovascular

• Acute MI
• Dysrhythmia
• Bradycardia
• Tachycardia
• Hypotension
• Hemorrhagic
• Hypovolemic

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Neurologic

• Seizure
• Postictal state

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Infection

• CNS
• Meningitis
• Encephalitis
• Pneumonia
• UTI
• Sepsis

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Major Organ Dysfunction

• Lung
• Hypoxia
• PE
• Hypercarbia
• COPD
• Liver
• Hepatic encephalopathy
• Kidney

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Metabolic

• Hyper/hyponatremia
• Dehydration
• Hyper/hypoglycemia
• Hyper/hypothroid
• Hyper/hypothermia

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Toxic

• Street drugs
• ETOH intoxication/withdrawal
• CO Poisoning
• Anticholinergic poisoning
• Serotonin syndrome

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Other

• Tumor
• Abscess
• Neuroleptic malignant syndrome

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Psychiatric

• Depression
• Psychogenic coma
• Schizophrenia
• Sundowning

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Dont use

• Stuporous
• Lethargic
• Funny

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Neurologic Scales

• Glasgow Coma Scale
• AVPU
• ACDU
• Swedish Reaction Level Scale

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GCS

• Eye Opening
• Spontaneous
• Speech
• Pain
• Zip
• Verbals
• Oriented
• Confused
• Inappropriate
• Incomprehensible
• Zip

• Motor
• Obeys
• Localizes pain
• Withdraws from pain
• Decorticate
• Decerebrate
• Zip

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AVPU

• Alert
• Responds to verbal stimuli
• Responds to painful stimuli
• Unresponsive (Al-Gore-like)

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ACDU

• Alert
• Confused
• Drowsy
• Unresponsive

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Simplified Motor Scale

• Obeys commands (2)
• Localizes pain (1)
• Withdrawal to pain or less (0)
• Note Best interrator reliability for assessment
  of altered levels of consciousness among scales
  tested.
• Gill, 2007.

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Swedish Reaction Level Scale

• I Ducks when salmon thrown
• II Does not avoid getting hit with salmon
• III Who got hit with what?
• IV No reaction to getting hit with school of
  salmon

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Mini Mental Status Exam (MMSE)

• Orientation Year, season, date, day, month (5)
• Orientation State, county, town, hospital, floor
  (5)
• Registration 3 objects and have repeated (3)
• Attention, calculation Serial 7s or spell
  world backwards (5)
• Recall Repeat back 3 objects (3)
• Language Name an object (watch, pencil) (2)
• Repetition No ifs and or buts (1)
• Complex command 3 stages (3)
• Read/perform Close your eyes (1)
• Write a sentence with subject verb (1)
• Copy 2 pentagon design (1)
• Best score 30
• Score lt 24 delirium

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MMSE alternative

• Draw face of clock with arms at 820.

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Quick Confusion Scale

• Year 0-1 x2
  
• Month 0-1 x2
  
• Memory Phrase
• Time now 0-1 x2
• 20 to 1 0,1,2 x1
  
• Reverse months 0,1,2 x1
• Repeat phrase 0-5 x1
• Top score 15
• Score lt 11 No good (like lt24 on MMSE)

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The Hunt for Clues
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Start with Vital Signs

• A,B,Cs first
• You got a pulse, a blood pressure, a reasonable
  pulse ox, youve got time
• But check vital signs often
• Pulse oximetry CO2 retention

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Occult Trauma?

• Raccoons eyes
• Hemotympanum
• Battles sign
• Oto-rhinorrhea
• Drop of blood on filter paper looking for clear
  ring.

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Skin

• Pallor
• Cyanosis
• Diaphoresis
• Track marks
• Dried blood
• Lacerated tongue

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Odor

• ETOH
• Acetone
• Fetor hepaticus

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Eyes

• Icterus
• Movements
• Size symmetry
• Pinpoint Narcotics, pontine hemorrhage
• Dilated Hallucinogens, amphetamines, cocaine,
  anticholinergics

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Body Temperature

• Infection
• Exogenous hyperthermia
• Thyroid storm
• Withdrawal syndromes
• Fever Pinpoint Pupils Pontine hemorrhage

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Respiratory Rate

• Fast
• DKA
• Sepsis
• Drugs
• Salicylate OD
• Metabolic acidosis
• PE
• CHF

• Slow
• Narcotic OD
• CNS insult
• Over-sedation

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Pulse

• Fast
• Fever
• Sepsis
• Withdrawal syndromes
• Anticholinergics
• PE
• CHF
• Dehydration
• Thyroid storm
• Overdose
• TCA
• Theophylline
• Salicylates
• Anticholinergics

• Slow
• Increased intracranial pressure
• Hypothyroidism
• Cholinergic poisoning
• Stokes-Adams

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Blood Pressure

• Elevated
• Malignant hypertension
• Note Elevated B/P bradycardia Increased ICP
• Stimulant abuse

• Low
• Dehydration
• Traumatic hemorrhage
• GI bleed
• Hemorrhage anywhere
• Addisonian crisis
• Hypothyroidism

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Breathing patterns

• Cheyne-Stokes
• Hyperventilation
• Apneustic
• Long pauses at end of inspiration
• Cluster
• Short bursts of breathing
• Ataxic
• Chaotic, irregular

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Body movements

• Symmetry
• Nuchal rigidity
• Only if no suspicion of trauma
• Decorticate
• Decerebrate

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What to do, what to do? Oh, my God, what to
do?????

• Check own pulse
• ABCs
• Protect that airway
• VS
• Monitor
• IV (2?)

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Labs

• BS, CBC, CMP
• Ca, MG
• Serum Ammonia
• PT,PTT
• RPR/VDRL
• U/A
• B12/folate
• Tox screen
• Thyroid screen
• LP

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Imaging

• CXR
• Head CT

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EKG

• Low voltage Hypothyroidism, pericardial effusion
• Wide QRS, Long QT intervals TCA

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Treatment Options

• Narcan 4mg
• Thiamine 100 mg IV
• Ativan 1-2 mg IM/IV
• Haldol 2.5-5 mg IM
• Keep Romazicon handy
• 0.2 mg IV q 60 sec. up to 1 mg

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References

• Bently B. Behavioral Disorders Emergency
  Assessment Stabilization in Emergency Medicine,
  4th edition ed Clive DH, Me O, et al. 1996.
• Gough JE. Coma Altered States of Consciousness
  in Emergency Medicine, 4th edition ed Clive DH,
  Me O, et al. 1996.
• Anonymous. Altered Mental Status in Emergency
  Medicine On Call. Ed. Keim SM. Lange Medical
  Books, McGraw-Hill Companies, NY, NY. 2004

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References

• Gersteen PS. Delirium, Dementia, Amnesia.
  www.emedicine.com/emerg/topic345.html. Accessed
  4/1/08
• Gill M, Martens K, et al. Interrater Reliability
  of 3 Simplified Neurologic Scales Applied to
  Adults Presenting to the Emergency Department
  With Altered Levels of Consciousness. Ann Emerg
  Med 2007 49403-407