Altered Mental Status

Question 1

Altered Mental Status:

A

Answer 1

• Alcohol: methanol, ethylene glycol, isopropyl, EtOH (AKA, Wernicke’s, DTs) Ammonia: liver failure, Reye’s Arterial Gas Embolism,
  acidosis

Question 2

Altered Mental Status:

E

Answer 2

Encephalopathy: HTN, hepatic
Electrolyte: K, Na, Ca, Mg
Endocrine: Thyroid, Adrenal
Exposure: Hyper / hypothermia

Question 3

Altered Mental Status:

I

Answer 3

Insulin: Hypoglycemia, DKA, Hyperosmolar non-ketotic state

Question 4

Altered Mental Status:

O

Answer 4

Oxygen: MI, PE, CVA, COPD, hypoxia, O2 toxicity, hypercarbia

Question 5

Altered Mental Status:

U

Answer 5

Uremia: ARF, CRF

Question 6

Altered Mental Status:

T

Answer 6

• Trauma: epidural, subdural, SAH, DAI, concussion, NAT
  Toxins: CO, CN, organophosphates, sympathomimetics, opiates, THC, NMS, benzos, ecstasy, GHB, LSD, PCP, serotonin syndrome,
  Tumor
  Thiamine deficiency
  Thyroid (storm or myxedema)

Question 7

Altered Mental Status:

I

Answer 7

Infection: meningitis, encephalitis, sepsis, UTI, CJD, endocarditis, toxoplasmosis, crypto, TB

Question 8

Altered Mental Status:

P

Answer 8

Psych: Delirium, dementia, psychosis, Paraldehyde, Porphyria

Question 9

Altered Mental Status:

S

Answer 9

Seizure, Syncope, Shock (many kinds)

Question 10

Altered Mental Status:

ASAP:

Answer 10

ABCs, IV, O2, monitor/EKG, accu✓, VS w rectal temp, C-collar if ?,   RSI/ETT, full primary survey.
If accu✓ < 80… give 1 amp D50 IV
If malnourished… Thiamine 100mg IV
If drugs… Narcan 0.4-2mg IV/IM
If ↓BP… IV fluid bolus x 2

Question 11

Altered Mental Status:

If meningitis…

Answer 11

dexamethasone (10mg IV)
ceftriaxone 2 mg
+/- vancomycin 1 g
ampicillin (listeria)
acyclovir (10 mg/kg)

Question 12

Altered Mental Status:

If meningitis..Neonates

Answer 12

• GBS, listeria, gram neg bacilli
  – ampicillin 50 mg/kg
  + cefotaxime 50 mg/kg or gentamicin 2.5 mg/kg

Question 13

Altered Mental Status:

If meningitis…Infants

Answer 13

• GBS, listeria, H flu, S. pneumo, N. men- Cefotaxime 50mg/kg or ceftriaxone 100 mg/kg +vancomycin and ampicillin for
  resistance

Question 14

Altered Mental Status:

If meningitis…3mo-18 yrs

Answer 14

• H flu, s. Pneumonia, N men- Ceftriaxone (max 2 g) + vancomycin 15-20 mg/kg for resistance

Question 15

Altered Mental Status:

If meningitis…18-50

Answer 15

• s. Pneumonia, n.men- Ceftriaxone (max 2 g) + vancomycin 15-20 mg/kg for resistance

Question 16

Altered Mental Status:

If meningitis…>50, immunosuppressed, alcoholic

Answer 16

S. Pneumonia, n. Men, listeria, aerobic gram neg- Ceftriaxone 2 g, ampicillin 2 g, +
vancomycin for resistance

Question 17

Altered Mental Status:

If myxedema coma…hypothyroid state signs and symptoms

Answer 17

Decrease T4 and T3- stressor ignites- hypothermia, hypotension, bradycardia, hypoxia,
non-pitting edema- low voltage, diffuse T wave inversions- hyponatremia, increased CPK and LDH, hypocalcemia (if s/p thyroidectomylong
QT), elevated WBC, elevated TSH

Question 18

Altered Mental Status:

If myxedema coma…hypothyroid treatment

Answer 18

Supportive (IVF, glucose, antibiotics if infection), treat hyponatremia, hydrocortisone 100 mg q8, Thyroxine 400-500 mcg

Question 19

Altered Mental Status:

Thyroid storm presentation

Answer 19

Hyperthyroidism plus stressful event- fever, AMS, tachycardia, widened pulse pressure, diaphoresis, goiter,
exophthalmos, a fib, CHF- TSH decreased, elevated free T4

Question 20

Altered Mental Status:

Thyroid storm treatment

Answer 20

Propranolol- decrease stim of adrenergic receptors, blocks peripheral conversion of T4→ T3- 1 mg q 10-15min
methimazole (PTU in pregnancy)- block synthesis of new thyroid hormone (PTU blocks conversion)
PTU- 600-1000 mg → 100-300 mg q4-6 hrs
Methimazole- 90-120 mg
Steroids- prevent adrenal hyperfunction, decrease conversions
Hydrocortisone 100 mg q8 or Dexamethasone 2 mg q 6h
Iodide- inhibits release of hormone- give 1 hour after antithyroid medications

Question 21

Altered Mental Status:

Hx:

Answer 21

Pt, family bystanders, EMS, medical records, meds, SAMPLE hx

Question 22

Altered Mental Status:

Exam:

Answer 22

Review VS, reassess life threats, evidence of trauma or toxidromes, GCS, pupils/papilledema

Question 23

Altered Mental Status:

Labs:

Answer 23

VBG w co-ox, CBC, BMP, LFT, lipase, coags, EtOH, NH3, lactate, TSH, T&C/S, ASA, APAP, drug levels, UA, hCG, UDS. CSF: cell counts, GS/Cx, prot/gluc, HSV PCR, crypto antigen

Question 24

Altered Mental Status:

Rads:

Answer 24

CXR, FAST, CT head non-con (before LP!)

Question 25

Altered Mental Status:

Tx:

Answer 25

Supportive, guided by clinical picture