David T. Matero, M.D.Assistant Professor

Emergency MedicineUniversity of Colorado Denver

Altered Mental Status

OverviewAltered mental status: It Could Be

[almost] Anything! requires a thorough work-up

What is the differential for altered mental status?

What is the type of problem that could cause it?

What is the organ system(s) that could be involved?

Example63 yo female found down next to park

bench. Bystander called EMS who are now moving patient from gurney onto bed.

You ask for history: There is noneYou ask for ROS: There is noneYou ask for PMH, Meds, Anything!: There is

none

WELCOME TO EMERGENCY MEDICINE

What Could Be Wrong With Her?

Tramua: Brain laceration/injuryConcussionDepressed skull fractureHead traumaBrain, contusionBrain injury, massiveDiffuse axonal injury/Acute brain traumaShaken Baby SyndromeElectromagnetic, Physics, trauma, Radiation CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea waterDrowning/Near- drowningHeat exhaustion/prostrationHeat strokeEncephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposureElectrocution/lightning strikeHigh altitude cerebral edemaDecompression sicknessHigh altitude pulmonary edemaIatrogenic, Self Induced DisordersWater intoxicationHypothermic anesthesiaHyponatremia correction, rapidSurgical, Procedure ComplicationAnesthesia, generalBrain surgeryInfectious Disorders (Specific Agent)Pneumonia, bacterialAIDS MeningoencephalitisEncephalitis, herpes simplexEncephalitis, secondary viralEncephalitis, viralMeningitis BacterialMeningitis, aseptic/viralMeningitis, HemophilusMeningitis, pneumococcalMeningococcal meningitisPneumonia/BronchopneumoniaPneumonia, acute lobarPneumonia, pneumococcalTyphoid feverMeningitis, tuberculosisAmebic (Naegleria) meningoencephalitisBacterial overwhelming sepsisCandidiasis systemicChickenpox encephalitisEncephalitis, bacterial/cerebritisEncephalitis, Dawsons/inclusion bodyEncephalitis, Eastern equineEncephalitis, mumpsEncephalitis, Murray valleyEncephalitis, non-viralEncephalitis, St Louis BEncephalitis, Western equineGram negative (e coli) meningitisHistoplasmosis meningitisKunjin viral encephalitisLa Crosse viral encephalitisLegionella meningoencephalitisLeptospiral meningitisLeptospirosis/severe (Weils) typeListeria meningitisLyme meningoencephalitisMalaria, cerebralMeningitis, candidaMeningitis, Coxacki viralMeningitis, echo viralMeningitis, staphylococcus aureusMononucleosis encephalitisPlague meningitisPost-viral/infectious encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes syndromeRussian tick-bourne encephalitisToxic shock syndromeTrichinella meningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisLegionaires diseaseListeria monocytogenes/listeriosisMeningitis, fungalRocky mountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleeping sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, CaliforniaEncephalitis, equine, VenezuelanEncephalitis, Japanese BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acuteFungus brain abscessLeptospirosis IctohemorrhagicaInfected organ, AbscessesInfectionsAbscess, intracranialBacteremia/SepticemiaBrain abscessEmbolism, septic, cerebralEndocarditis, infectiveMeningoencephalitisPneumonia, aspirationSepsisSepsis, overwhelmingSeptic shockUrosepsis/septicemiaEncephalomyelitis, acuteEncephalopathy/secondary/toxic/sepsisNecrotizing fasciitis/mixedBrain stem encephalitisEncephalitisMeningitisPneumoniaGranulomatous, Inflammatory DisordersHemorrhagic pancreatitis, necrotizingPancreatitis/resp distress syndromeNeoplastic DisordersHypercalcemia of malignancyMetastatic brain diseaseBrain stem tumorBrain tumorFrontal lobe tumorMedulloblastomaMeningeal carcinomatosisParietal lobe tumorPrimary CNS lymphomaTemporal lobe tumorBrain tumor , malignant (astrocytoma)CraniopharyngiomaGlioblastoma multiformeInsulinoma/Islet cell tumorMeningiomaPontine gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune DisordersEncephalitis, hemorrhagic, acuteEncephalitis, post viralEncephalomyelitis, necrotizing hem. ac.Encephalomyelitis, post-infectiousStevens-Johnson syndromeTransfusion reaction, hemolyticLupus cerebritisPolyarteritis nodosaBehcet's syndromeHashimotos EncephalitisMetabolic, Storage DisordersHypoglycemia, reactive diabeticDiabetic ketoacidosis/comaHyperosmolar hyperglycemic coma, nonketNeonatal hyperbilirubinemiaMetabolic disordersMethemoglobinemia, HereditaryPorphyria, acute intermittentGlutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical DisordersEncephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHypercalcemiaHypercapnea HypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontine myelinolysis, centralDeficiency DisordersDehydration and feverDehydrationWernicke's encephalopathyMalnutrition/StarvationPellagra/niacin deficiencyMarchiafava-Bignami syndromeCongenital, Developmental DisordersNephrogenic diabetes insipidusHereditary, Familial, Genetic DisordersMELAS EncephalopathyVan Bogaert encephalitisUsage, Degenerative, Necrosis, Age Related DisordersAlzheimer's syndromeDementia, Lewy-body typeMultiple sclerosisRelational, Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia, factitiousCatatoniaManic deleriumAnatomic, Foreign Body, Structural DisordersAcute subdural hematoma/hemorrhageBrain compressionEpidural hematomaIntracerebral hematomaIntraventricular brain hemorrhageSubdural hematomaTamponade, cardiacBrain stem herniation/peduncle/tonsilsFat embolismSuperior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolismCerebral hemorrhageCerebral vein thrombosis/phlebitisIntracerebral hemorrhageMyocardial infarction, acuteSubarachnoid hemorrhageTransient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosisCerebral/Venous sinus thrombophlebitisSuperior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexiaSleep deprivationVegetative, Autonomic, Endocrine DisordersCardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shockConvulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotensionOrthostatic hypotensionPost-ictal statusThyrotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignantMalignant hyperthermiaMyxedema comaMyxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart blockInappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, juvenileNarcolepsyPickwick's syndromeReference to Organ SystemShockCerebral edemaDisseminated intravascular coagulopathyHepatic encephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndromeBrain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremic encephalopathyEncephalopathyHyperviscosity syndromePernicious anemiaPontine lesion/disorderThrombotic thrombocytopenic purpuraCombined system disease/pernicious an.Fever Unknown OriginReversable Posterior Encephalopathy SyndromePathophysiologicSepsis encephalopathy/elderlyCardiac output reductionCerebral depressed functionsDrugsMedication/drugsBenzodiazepines Administration/ToxicitySedative drugs Administration/ToxicityDigitalis toxicity/poisoningHypoglycemia, diabetic/treatmentInsulin overdose/exogenousIntoxication/overdose syndromeSalicylate intoxication/overdoseTricyclic overdoseBarbiturate/sedative abuse/dependentDrug induced Hypoglycemia.Oral hypoglycemic Administration/Toxicity/effectInsulin (Humulin/Novulin) Administration/ToxicityIsoniazid (INH/Nydrazid) Administration/ToxicityErgot toxicityIsoniazid hepatitisMilk-alkali syndromePoisoning (Specific Agent)Opiate overdose toxidromeKitchen gas/propane exposureAlcohol/Ethanol ingestion/intakeAlcohol amnestic disorderAlcohol induced hypoglycemiaAlcohol intoxication, acuteAlcohol seizure (rum fits)Cholinergic crisis toxidromeDelirium tremensInsecticide/organophosphate typeOverdose, drug/alcoholPoisoningSnakebite (neurotoxic/coral/cobra type)Snakebite (rattlesnake/pit viper type)Alcohol withdrawalHallucinogen abuseLead poisoning in childrenSmoke inhalationHeroin/morphine usage/addictionCyanide/Hydrogen cyanide exposure/poisoningVomiting CBW agent (Dm/Da/Dc) Weapon exposureArsine gas (Hydrogen arsenide) poisoningCarbon monoxide poisoning/exposureDiethylene Glycol poisoningEthylene glycol [Antifreeze] ingestionInsecticide/pesticide poisoningIntentional poisoningIsopropyl alcohol ingestion/poisoningMustard gas exposure/poisoningNerve gas exposureAluminum toxicity/syndromeAmmonia exposure/inhalationHydrogen sulfide poisoning/inhalationInsecticide/chlorinated/non-ester's inhLead poisoningLead encephalopathyNitrogen narcotic actionCarbon disulfide inhalant/poisoningChlorine gas poisoningMethane gas poisoning/asphyxiaCarbon dioxide gas inhalation/asphyxiaOrgan Poisoning (Intoxication)Neuroleptic malignant syndrome

From Vertebrobasilar migraine syndrome to Hyponatremia It’s TOO MUCH

You need a clue:-EMS report-Cell phone (call family members)-Bystander account-PMH from meds, alert bracelet, wallet, PhysEx (e.g fistula)-Phys Exam for current physiological state of patient-Labs-Imaging

Physiologic Reserve Determines How Readily the Patient Will Have AMS!

Frail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.

Young Healthy Patient: Likely to be something significant that has gone wrong

Patient With Obvious Comorbidities: Other causes (than primary medical problem) will more readily alter this patient (less reserve!)

You May Get Frustrated at this Patient and Say (ddx):

M: Metabolic—B12 or thiamine deficiency, serotonin syndrome

O: Hypoxemia (pulmonary, cardiac, anemia); high CO2

V: Vascular causes—hypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MI

E: Electrolytes and endocrine

S: Seizures / status epilepticus, post-ictal

T: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes )

U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy

P: Psychiatric, porphyria

I: Infection (inflammatory-see vasculitis above)

D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRI’s, BZD’s, barbiturates, alcohol)

M: Metabolic—B12 or thiamine deficiency, serotonin syndrome

Glucose metabolism uses up even more thiamine

Serotonin syndrome=serotonin toxicity and caused by various drugs, medicines and combinations thereof

-increased heart rate, shivering, sweating, dilated pupils, myoclonus, as well as overresponsive reflexes

O: Hypoxemia (pulmonary, cardiac, anemia); high CO2

Purely Hypoxic patient is anxious/agitated-PE

Purely Hypercarbic patient is sleepy -Jet Insufflation in kids or bad COPDer

V: Vascular causes—hypertensive emergency, ischemic/hemorrhagic

CVA, vasculitis, MI

All of these cause poor perfusion of the brain either focally or globally through local effects (CVA) or through loss of forward flow to brain (MI)

E: Electrolytes and endocrine

Electrolyte shifts can cause swelling in the brain

High Na or Ca global depression (any electrolyte involved in ion-channel transmission in the brain can cause a problem)

Hypoglycemia most common cause of endocrine-related MS depression

S: Seizures / status epilepticus, post-ictal

Post-ictal state typically resolves in 20-40minutes

Non-epileptiform seizures can be cause of depressed mental status-No tonic-clonic activity-Ultimately diagnosed with EEG-Eye movement, hx, ’trial of Ativan’ may give clue

T: Tumor, trauma, temperature, toxins (lead, mercury, CO, toxidromes )

Tumor causes compression or diffuse edema

Hypothermia: Global depression of ion-channels

Toxins: Wide range of responses depending on individual and their reserve

Look for Toxidromes- A symptom constellation specific to a given toxin (e.g. Slurred speech, B lateral-gaze nystagmus, cerebellar deficits, altered mood is the toxidrome for Ethanol)

U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy

Electrolyte AbnormalitiesUremia-Urea build-up AND electrolyte

abnormalitiesHepatic Encephalopathy- elevated

Ammonia (level should be high but poorly correlated with actual degree of AMS)

P: Psychiatric, porphyriaCatatonia: no focal neurological deficits but

unresponsive (responds to Ativan!)Porphyria: A group of enzyme deficiencies

in hematologic biosynthesis pathway that results in accumulation of Porphyrins (or precursors): Multiple s/sx including various MS effects

I: Infection (inflammatory-see vasculitis above)

Meningitis (A constant concern in all patient, esp at extremes of age)

Cerebritis

D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRI’s,

BZD’s, barbiturates, alcohol)

Learn and look for Toxidromes (withdrawal states are usually essentially opposite in symptoms)

In Summary: It ALL Boils Down to One of Two Things

Both cerebral hemispheres are depressed

The Reticular Activating System is not functioning.

In Summary: It ALL Boils Down to One of Two Things

Both cerebral hemispheres are depressed

The Reticular Activating System is not functioning.

Diffuse Process– most ofthe cases arise from this

In Summary: It ALL Boils Down to One of Two Things

Both cerebral hemispheres are depressed

The Reticular Activating System is not functioning.

Diffuse Process– most ofthe cases arise from this

?

In Summary: It ALL Boils Down to One of Two Things

Both cerebral hemispheres are depressed

The Reticular Activating System is not functioning.

Diffuse Process– most of

the cases arise from this

Stroke, Seizure or Trauma to this region

Approach the Patient Covering Most Urgent Bases First

ABCsIntravenous access, oxygen

therapy, cardiac monitoring with pulse oximetry

Accu-check / glucose / thiamineCervical spine precautionsNaloxone

Approach the Patient Covering Most Urgent Bases First

EKG / cardiac monitoringABG with carboxyhemoglobinCBC, electrolytes, Ca, MgDrug screen, EtOH, serum osmolarityUrinalysis Imaginglumbar punctureliver, thyroid

Approach the Patient Covering Most Urgent Bases First

EKG / cardiac monitoringABG with carboxyhemoglobinCBC, electrolytes, Ca, MgDrug screen, EtOH, serum osmolarityUrinalysis Imaginglumbar punctureliver, thyroid

Frail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.

63 yo female found down next to park bench

You have no information: You do a physical exam-A: Breath sounds CTAB, +gag, trachea midline, no pooling of secretions, -B: Spontaneous respirations-C: Regular rhythm , tachycardia, B femoral pulses, diminished DP pulses (but present)-VS:101, 88/45, T- 35.6, 92% RA

63 yo female found down next to park bench

-HEENT: PERRL, TMs clear, MM slightly dry-Neck: Supple, no JVD-Chest: no crepitus, atraumatic-GI: soft, BS present/normal; rectal no gross blood, NL tone-Extrem: UE and LE with no clubbing, cyanosis, edema pulses present except as noted in ABCs-Back: Atraumatic, no step-offs-Neuro: CN grossly intact, MAE, withdraws to pain, no gross focal neurol deficits, reflexes symmetrical, does not answer Qs or follow commands, moaning -Skin: well perfused-GU: Perineum atraumatic, no discharge or lesions

What Was Abnormal?What Could It Mean?

What Was Abnormal?What Could It Mean?

You have no information: You do a Physical Exam-A: Breath sounds CTAB, +gag, trachea midline, no pooling of secretions, -B: Spontaneous Respirations-C: Regular rhythm , tachycardia, B Femoral pulses, diminished DP pulses (but present)-VS:101, 88/45, T- 35.6, 92% RA

63 yo female found down next to park bench

-HEENT: PERRL, TMs clear, MM slightly dry-Neck: Supple, no JVD-Chest: no crepitus, atraumatic-GI: soft, BS present/normal; rectal no gross blood, NL tone-Extrem: UE and LE with no clubbing, cyanosis, edema, pulses present except as noted in ABCs-Back: Atraumatic, no step-offs-Neuro: CN grossly intact, MAE, withdraws extrem to pain,no gross focal neurol def, reflexes symmetrical, does not answer Qs or follow commands, moaning -Skin: well perfused-GU: Perineum atraumatic, no discharge or lesions

Putting the Physical Exam Findings Together:

Do you think this is a Global or a Focal Process?

How would you summarize the state of the patient based on PEX?

What could cause this state?

What is more likely now?M: Metabolic—B12 or thiamine deficiency, serotonin

syndromeO: Hypoxemia (pulmonary, cardiac, anemia); high

CO2V: Vascular causes—hypertensive emergency,

ischemic/hemorrhagic CVA, vasculitis, MIE: Electrolytes and endocrine

S: Seizures / status epilepticus, post-ictal

T: Tumor, trauma, temperature, toxins (lead, mercury, CO, toxidromes)

U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy

P: Psychiatric, porphyria

I: Infection (inflammatory-see vasculitis above)

D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRI’s, BZD’s, barbiturates, alcohol)

What is more likely now?M: Metabolic—B12 or thiamine deficiency, serotonin

syndromeO: Hypoxemia (pulmonary, cardiac, anemia); high

CO2V: Vascular causes—hypertensive emergency,

ischemic/hemorrhagic CVA, vasculitis, MIE: Electrolytes and endocrine

S: Seizures / status epilepticus, post-ictal

T: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes )

U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy

P: Psychiatric, porphyria

I: Infection (inflammatory-see vasculitis above)

D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRI’s, BZD’s, barbiturates, alcohol)

Next Step: Diagnostic StudiesPrioritize acute life threats firstGet high-yield, easy items first: Glc, EKGKeep modifying testing as DDX changes

with results’Shotgun Approach’ (parallel processing)Is patient stable to go to imaging or to

wait for lab result before making treatment decision?

How Do I Know What to Order?Balance these two things to

determine what tests/priority:-Shotgun approach (intended to move things along quickly and cast wide net)-What you’ve learned from your H&P

LABS

141

4.1

101 2617 1.1

101

14.5 380

14.4

41.9

UA:Spec grav 1.026pH 6.0Ketones +Glucose –Bile –Blood +Bacteria ++WBC ++Nitrite +Leuk. Est +

LFTs- NormalASA, APAP, Coags Normal

LABS

141

4.1

101 2617 1.1

101

14.5 380

14.4

41.9

UA:Spec grav 1.026pH 6.0Ketones +Glucose –Bile –Blood +Bacteria ++WBC ++Nitrite +Leuk. Est +

LFTs- NormalASA, APAP, Coags Normal

Do We Know What’s Going On?

We know the patient has a UTIIs this enough to explain the patient’s

sepsis?Can we stop our work-up?Could the UTI be a red herring?

Do We Know What’s Going On?

We know the patient has a UTIIs this enough to explain the patient’s

sepsis? YESCan we stop our work-up?Could the UTI be a red herring?

Do We Know What’s Going On?

We know the patient has a UTIIs this enough to explain the patient’s

sepsis? YES Can we stop our work-up? NOCould the UTI be a red herring?

Do We Know What’s Going On?

We know the patient has a UTIIs this enough to explain the patient’s

sepsis? YES Can we stop our work-up? NOCould the UTI be a red herring? YES

What Else Should We Do?Pt does have Sepsis and a UTI, this could

be Urosepsis. HOWEVER, it could also be something else (and there just happens to be a UTI)

What Else Should We Do?EKG MI, Intervals (Toxins), Other-CXR PNA (Sepsis), Edema, Trauma-Head CT Bleed, Swelling, Mass -Lumbar Puncture Bleed, Infection -Urine Drug Screen Drugs of Abuse

-

What Else Should We Do?EKG MI, Intervals (Toxins), Other-

NORMALCXR PNA (Sepsis), Edema, Trauma-

NORMALHead CT Bleed, Swelling, Mass -

NORMALLumbar Puncture Bleed, Infection -

NORMALUrine Drug Screen Drugs of Abuse

- NORMAL

We THINK We Know the Cause

Urosepsis

We THINK We Know the Cause

UrosepsisRe-Examine the patient and make

sure nothing has changed and that the exam is consistent w Dx

Don’t become ”emotionally attached” to a Dx, as the clinical picture can change and start looking like something else “The only atypical presentation is

a typical presentation”

CONCLUSIONMaintain a wide differentialGet a Grip on the Diagnosis through

systematic ”clue finding”Remember: It’s focal in the RAS, or diffuse

in the Bilateral HemispheresRe-evaluate patient frequently and do

frequent ”hypothesis-testing” in your mind