8 Altered mental status and Coma Flashcards
5 general cause of delirium
- Primary intracranial disease
- Systemic diseases secondarily affecting the CNS
- Exogenous toxins (including prescribed pharmacotherapies
- Drug withdrawal and pain
- Major trauma or surgery
Features of delirium
Course over 24 h: Fluctuating
Attention: Disordered
Hallucination: visual and/or auditory
Delusions:Transient, poorly organized
Movements: asterixis, tremor may be present
Features of dementia
Course over 24 h: Stable
Attention: Normal
Hallucination: often absent
Delusions: usually absent
Movements: often absent
Impaired cognition and orientation
Features of psychiatric disorder
Course over 24 h: Stable
Attention: may be disordered
Hallucination: usually auditory
Delusions: sustained
Movements: absent (??)
Remarks on delirium
Compared to the patient’s baseline, the acute onset of attention deficits and cognitive abnormalities, fluctuating in course, is virtually diagnostic of delirium
Criteria for delirium triage screen
DTS - highly sensitive
altered level of consciousness (RASS)
inattention (spell backwards)
Features for brief Confusion Assessment Method (bCAM)
bCAM - highly specific
1 - altered mental status or fluctuating course
2 - inattention (backward months)
3 - aletred level of consciousness
4 - disorganized thinking
will a stone float on water?
are there fish in the sea?
hold up this many fingers (demonstrate) now do the same thing with the other hand (do not demonstrate)
Remarks on dementia evaluation
The possibility of a concurrent medical condition suddenly causing cognitive functioning to deteriorate should be strongly considered and often is the thrust of investigation in the ED.
e.g., UTI, CHF, hypothyroidism
Neuroimaging procedure of choice for coma
CT scan
“liberal use of CT scanning is encouraged because esceptions to the tentative clinical diagnosis are frequent”
Steroids in coma
In cases of of brain edema associated with tumor, dexamethasone 10 mg IV reduces edema for several hours
