Acute AMS Approach Flashcards
Altered Mental Status: History taking
- Onset- trauma, illness, gradual or sudden
- Progression of symptoms,
- Source- Bystander, EMS, Family, Caregivers
- Last seen “at baseline”
- Medical history, substance abuse history
- Clues found at the scene- pill bottles, containers
- Prior episodes
Rapidly Reversible Causes of AMS
- Hypoglycemia
- Hypothermia/ Hyperthermia
- Opioid overdose
- Shock
- Hypoxemia
- Hypertensive Encephalopathy
Life Threatening Causes of AMS
- Meningitis
- Intracranial Lesions
- Increased ICP
→ Decreased cerebral perfusion→ Altered mental status - Renal/Hepatic failure
- Sepsis
- Toxins
- Acid/Base Disorders
AEIOU-TIPS
Alcohol, Acid Base
Encephalopathy, Electrolytes
Endocrinopathy, Eclampsia
Insulin (hypoglycemia, hyperglycemia)
Intussusception
Opiates (drugs and toxins), Oxygen
Uremia (and other metabolic Dx)
Trauma, Temperature
Infection (Sepsis)
Intracerebral (Hemorrhage)
Psychiatric
Syncope, Shock, Seizures
Delirium
● Acute state
● Altered attention or cognition
● Days
● Fluctuating
● Hallucinations
Dementia
● Chronic state of deteriorating
cognition
● Insidious
● Stable course
● Maybe alert with intact attention
● Hallucinations often absent
Delirium Causes
– Intracranial disease
– Systemic disease with CNS affect
– Toxins or pharmacologics
– Withdrawl or pain
– Major trauma or surgery
Delirium course
- Develops over days
- Symptoms may fluctuate
- Different behaviors may be witnessed
- Agitation
- Altered sleep patterns
- Hallucinations
Delirium evaluation
- What is their baseline?
– Family, caregivers - Are they altered? This could mean several things
- Medication assessment
– OTC and prescribed, drug interactions, toxins - Infection, Sepsis, Metabolic, Trauma, Neurologic, Cardio
- Seizure activity
- Admit if further Dx and Tx required? Patient safety?
What other Findings might go along with delirium?
- Tremors
- Tachycardia
- Asterixis
- Sweating
- Fever
- Hypertension
- Emotional outbursts
- Hallucinations
Delirium labs
– CBC
– CMP
– Urinalysis
– Toxicology screening (urine, serum)
– Chest X-ray
– Head CT for possible intracranial etiology
– Lumbar puncture if indicated
Delirium treatment
- Directed at underlying cause
- Address lighting, support, orientation to time of day
- Activities, meal times, mobilization
Mental Status Exam
Mini Mental Status Exam
* Detecting delirium
– Rapid changes in MMSE
* Given high numbers of delirium in older hospitalized
patients, some propose it as an admission screening tool
If dementia is gradually progressive, then why would a patient go to the ER?
- Illness (eg. UTI) with worsened condition or cognition
– “Acute on Chronic” ie. Acute delirium on chronic dementia - Symptoms have become noticeable
– Recalling if rapid onset or altered from baseline evaluate for
delirium and/or underlying illness. - Injuries or trauma, patient getting lost
- Behavioral or psychiatric symptoms Eg. agitation
Treatment in the ED for dementia
- Focused on investigating underlying conditions
- Evaluate patients welfare, home situation
- Treating the symptoms of dementia (ie psychiatric)
– Antipsychotic could be considered, if potential for harm to self
and others. Otherwise strong reservations exist - In the ED, a dementia diagnosis could be entertained, but
is usually an exhaustive outpatient work-up
