altered mental status (ams) university of utah medical center division of emergency medicine student...

Altered Mental Status (AMS)University of Utah Medical Center

Division of Emergency Medicine

Student Orientation

Case 1

• 78 yo male

• CC: Unresponsive

• HPI: Arrives by EMS who state he was found in bed this morning by his wife, unresponsive. Usual state of health last night. No complaints. No recent illnesses. No signs of trauma

• PMHx: CAD, PAF, HTN, cholesterol

Case 1

• All: PCN

• Meds: metoprolol, Lipitor, coumadin, nitro

• Surg Hx: appendectomy, L inguinal hernia repair

• Soc Hx: remote tobacco use, 2 drinks per evening, married, 3 children, retired police officer.

• FHx: CAD, HTN

Case 1• Vitals: T 38 HR 56 RR 10 BP 210/100

SpO2 94% RA• HEENT: pupils sluggish, equal• Chest: CTA, heart RRR• Abd: soft NT/ND• Ext: scattered healing ecchymoses, 2+

pulses• Neuro: unresponsive, decerebrate

posturing to painful stimulus

What’s going on? Diagnosis?

Hint: that’s your job

Altered Mental Status

• Up to 40% of geriatric population

• Metabolic vs. structural– 80% metabolic

• Multifactorial

• May have more than one etiology at a time

• You need to be a (medical) detective

Naughton, Bruce et al. “Delerium and Other Cognitive Impairment in Older Adults in an Emergency Department: Ann of EM 1995(25): 751-5.

Altered Mental Status

• Inattention• Confusion

– Intact mental status with misinterpretation of external stimuli

• Lethargy– Wakefulness with depressed awareness of self and environment

• Stupor– Unresponsiveness from which the pt. may be aroused with

vigorous noxious stimuli w/o achieving the normal baseline

• Coma– Unresponsiveness from which the patient cannot be aroused by

verbal or physical stimuli

Mechanism• Cerebral cortex disruption

– must be BIHEMISPHERIC• Diffuse axonal injury• Toxins (drugs, EtOH)• Metabolic toxins (ammonia, urea)• Deficiency of substrates (glucose, oxygen)• Infections

– Focal lesions typically do not cause AMS

Mechanism• Disruption of the Reticular Formation

– A grouping of fibers that traverses the brainstem to the thalamus

• Mediates state of wakefulness through continuous stimulation of the cerebral cortex

• Interruption usually from structural lesions– Supratentorial pressure (mass effect)– Infratentorial pressure (compression of brainstem)– Intrinsic brainstem lesions (pontine hemorrhage)

Midline Shift which leads to herniation

Differential Diagnosis

• AEIOU TIPS• A - Alcohol (drugs), Ammonia• E - Electrolytes, endocrine, environment (too hot/too cold)• I - Insulin (meaning glucose. High-DKA, HHNK; low

hypoglycemia)• O - Oxygen (hypoxia), Opiates• U - Uremia• T - Trauma, toxins• I - Infection (sepsis, meningitis)• P - Psychogenic, Porphyria• S - Stroke, SAH, Space occupying lesion, Shock

History

• Many patients with AMS are poor historians – where to look?– Wallet / belongings– Friends / family– Witnesses– EMS– Police (can go to scene)– Medical record

History

• PMHx– Psychiatric Hx

• Medicines – recent changes– account for pills– interactions

• Allergies• Social History

– EtoH– Drug use

Physical Exam

• Vitals– Temp– Heart rate– Respiratory rate– Blood pressure– SpO2– Glucose

• Not really a vital sign but so important it should be

Physical Exam

• ABC’s

• Head to toe, detailed exam– Undress patient completely– Look everywhere

• Signs of trauma• Sources of infection

Respiratory Patterns• Cheyne-Stokes: regularly increasing depth of breathing

alternating with decreasing depth followed by a short period of apnea. – Diffuse cerebral injury– Absence of forebrain breathing control in metabolic disease

• Hyperventilation: deep, rapid breathing – Midbrain lesion – Hypoxia, metabolic acidosis, pain, anxiety

• Apneustic: prolonged pause at the end of inspiration– lesion proximal to CN V in the Pons

• Cluster (Biot’s breathing): breathing in short bursts – Pontine lesion

• Ataxic: irregular breathing– Leads to agonal respirations and death– Lesions of the medulla

Physical Exam

• Skin – Color– Temperature– Moisture– Needle tracks/scars– Ecchymosis– Pressure bullae – Signs of trauma

Physical Exam • Eyes

– Pupil size and reactivity• Tectal: large & fixed• Midbrain: midpositioned, fixed• CN III: unilateral, dilated & fixed• Pons: pinpoint• Opiates, cholinergics, anti-adrenergics: pinpoint/small• Sympathomimetics, anti-cholinergics: dilated

– Ocular movements• Roving movement confirm cortical control• Crossing of midline – intact brainstem• Deviation is away from inactive lesion, but towards seizure focus

– Fundoscopic exam• If possible• Pappilledema

Physical Exam

• Neuro Exam-as able– GCS– CN– Motor– Sensory– DTRs– Cerebellar Exam

Laboratory Data

• Fingerstick Glucose!• Oxygen saturation• Consider:

– Electrolytes– ECG– Drug levels– Tox screens (need to know which drugs they

are sensitive to)– TSH

Studies

• Dictated by physical findings/differential

• Plain films (i.e. CXR)

• CT scan (head CT)

• MRI

• US

Management

• ABC’s

• Check Glucose

• Coma Cocktail: classic teaching/mantra– Naloxone: won’t hurt, may clear things up– Thiamine: debatable– Dextrose: if glucose low

Management

• Supportive

• Treat underlying cause

• Continue search

• Question suicidality

• Disposition

Case 1

Diagnosis?

Case 2

• 67 yo female

• CC: Altered mentation, frequent falls

• HPI: Brought in by boyfriend due to changed behavior and frequent falls. Slurred speech, slow to respond. Usually “sharp as a tack”. C/o mild HA, multiple bruises from falls (head, legs, arms).

• PMHx: hypertension

Case 2

• All: NKDA

• Meds: HCTZ

• Surgical Hx: hysterectomy

• Social Hx: lives alone. Boyfriend lives next door. 80 pk-yr tobacco, daily EtOH (last drink 2 days ago), no drugs.

• FHx: not obtained

Case 2

• Vitals: T 37 HR 70 RR 14 BP 120/60 SpO2 94% RA• HEENT: PERRL, EOMI, TMs clear. Bruising to L cheek.

Mucous membranes dry.• Neck: supple• Lungs: diminished• Cor: S1S2 RRR without murmur• Abd: Soft NT/ND; no HSM• Ext: Large ecchymosis to L thigh; Full ROM x 4; 2+

pulses througout• Neuro: CN II-XII intact. 2+ DTRs; No focal motor or

sensory deficit.

Case 2

• What is your differential?• AEIOU TIPS• A - Alcohol (drugs), Ammonia• E - Electrolytes, endocrine• I - Insulin (meaning glucose high-DKA, HHNK; low

hypoglycemia)• O - Oxygen (hypoxia), Opiates• U - Uremia• T - Trauma, toxins• I - Infection (sepsis, meningitis)• P - Psychogenic, Porphyria• S - Stroke, SAH, Space occupying lesion, Shock

Case 2

• What studies would you want?– Labs– Imaging

Case 2

• Tox– EtOH negative

• Imaging– Head CT negative– CXR unremarkable

Case 2

• CBC– WBC 10K– Hb 10– Hct 30.2– Plts 168

• CMP– Na 120– K 3.2– CO2 18– Gluc 125– BUN 30– Cr 1.8– Ca 7.4– LFTs nml

Rapid Cases

•Brief H&P

•You come up with most likely Dx

Rapid Case 1

• 88 yo female with confusion• Lives at assisted living• Confusion, urinary incontinence• h/o CAD, HTN• Vitals: T 38.9 HR 100 RR 18 BP 104/54 Sat

96% RA• Exam: non focal• Glucose 140• Lytes nml, WBC 10K UA++++• UTI/Urosepsis

Rapid Case 2

• 21 yo female• Found by friends unresponsive at a party• PMHx: none• Vitals: T 36 HR 98 RR 8 BP 90/60 Sat 90% RA• Physical: Pinpoint pupils, bilateral rales,

unresponsive.• Glucose 90• Dx: Opiate overdose (with non-cardiogenic

pulmonary edema)

Rapid Case 3

• 5 yo male• Presents with lethargy• Recent URI• Low grade temp, decreased appetite, increased

thirst, frequent urination.• Vitals: T 38 HR 130 RR 28 BP 90/50 Sat 98%

RA• Dehydrated, lethargic, tachypneic, non-focal

neuro exam• Glucose 405• Dx: DKA

Rapid Case 4

• 36 yo male• Presents with wife with AMS• More confused, forgetful, waxing and waning.• PMHx: Hep C s/p blood transfusion• Vitals: T 37 HR 80 RR 18 BP 110/60 Sat 98% RA• Physical Exam: Scleral icterus, multiple contusions,

hepatomegally, non-focal neuro exam• Glucose: 105• Ammonia level: 90• Dx: Hepatic encephalopathy

Rapid Case 5

• 90 yo female• Lethargy• Lives alone• Found unresponsive at home• Winter – using kerosene heater• Vitals T 34 HR 50 RR 10 BP 85/40 Sat 84%

RA• Glucose 90• DDx:

– Hypothermia– CO poisoning

Rapid Case 6• 40 yo female

• MVA, low speed, confusion without signs of trauma

• PE: VSS; non-focal neuro exam, confused and mildly combative. Multiple small ecchymoses on abdomen (non-tender)

• Glucose 30

• Dx: hypoglycemia

Rapid Case 7• 57 yo male• MVA into a tree, no seat belt, no skid marks, significant damage• Vitals: T 37 HR 120 RR 18 BP 90/50 SpO2 90% RA• Exam: Odor resembling EtOH, laceration to forehead, L chest

crepitation, +abdominal pain, multiple abrasions; neuro – intoxicated, combative, non-focal

• Glucose 90• Differential Dx:

– Head injury– Hypoxemia– Shock– EtOH intoxication– Other toxin– Suicide attempt?

Summary

• AMS = Broad differential

• Difficult historians– When the history is suspect you must rely on

objective data i.e. physical exam, labs, imaging

• Be a detective

• Don’t forget GLUCOSE!