ALTERED MENTAL STATUS Flashcards
KEY STEPS
Immediate stabilization
Differential diagnosis and initial diagnostics based on history, exam, and ancillary sources of information (eg, family, friends, emergency medical services [EMS]).
Definitive treatment is disease-specific.
MANAGEMENT
- PRIMARY SURVEY
A - CHECK
Stridor
Maintain C-Spine Precautions
B - CHECK:
RESPIRATORY RATE for respiratory depression
02 Sats for hypoxia
Air entry and wheezing
C - CHECK:
HR, BP
Check for Cushing’s Reflex: HTN bradycardia
MOTTLING
Cap Refill. Distal Pulses.
Pallor.
Palpate Abdomen.
D - CHECK:
POC GLUCOSE.
GCS
PERRLA,
lateralizing signs
Posturing
Plantar Reflex
E - CHECK:
Temperature
Trauma
Track Marks
TAKE DOWN DRESSINGS
- UNIVERSAL ANTIDOTES
1 Amp D50 (50 mL (25g)) OR 1 mg glucagon
Oxygen
Narcan (0.4 mg IV / IN / IM up to 2 mg, up to 10 mg if fentanyl or methadone)
Thiamine (100 mg but make sure to give with the dextrose
- POCUS: RUSH EXAM
- HISTORY & PHYSICAL
- INVESTIGATIONS
CBC
Electrolytes
Extended Lytes
Cr
Urea
LFTs
Ammonia
TSH
Cortisol
VBG
Acetaminophen level
Salycilate Level
Ethanol Level
Carboxyhemoglobin
Blood Cultures
U/A
Urine Cultures
Urine Tox
CT Head
Lumbar Puncture
MRI ahead
EEG
- DEFINITIVE TREATMENT
See Critical Diagnosis
DDx: CRITICAL DIAGNOSIS OF AMS & IMMEDIATE TREATMENT
TRAUMATIC BRAIN INJURY (SDH, EDH)
OPIOID OVERDOSE
respiratory rate <12 per minute, miotic pupils
Consider naloxone 0.04-0.4 mg intravenous, repeat dosing or increase dose to 2 mg if the initial response is inadequate
MENINGITIS / ENCEPHALITIS
Complete blood count
Complete chemistry
Blood cultures
Lumbar puncture
CSF analysis
ACUTE HYPONATREMIA
Complete chemistry
Urine electrolytes
Urine osmolarity
100 mL bolus of 3% saline over 10 minutes (may repeat × 2 as needed) to prevent herniation
For other symptomatic patients: increasing sodium concentration by 4-6 mmol/L in the first 6 hours
CARBON MONOXIDE
Serum carboxyhemoglobin
ECG
Non-rebreather or high-flow oxygen if no indications for intubation
RESPIRATORY FAILURE
Pulse oximetry
Blood gas
Hypoxemia
If intubated, start with 100% FiO2 and titrate down
Set a sufficiently high positive end-expiratory pressure
Hypercapnia: Optimize minute ventilation via mechanical ventilation
Avoid breath stacking in patients with obstructive lung disease
HYPERTENSIVE ENCEPHALOPATHY
Non-contrast head CT
Diagnosis is confirmed only after improvement of altered mental status with lowering of blood pressure
Labetalol 20 mg, then 40-80 mg bolus every 10 minutes if needed
Hydralazine 5-10 mg intravenous, may repeat to achieve goal in 20-40 minutes
Goal: Lower blood pressure by no more than 20% within 2 hours
BASILAR ARTERY OCCLUSION
CT angiography/perfusion
SPONTANEOUS INTRACRANIAL HEMORRHAGE
Non-contrast head CT
Manage intracranial pressure
Elevate head of bed >30°
Mannitol 0.5-1 g/kg intravenous
3% hypertonic saline 100 mL intravenous
Lower blood pressure (goal <140 mm Hg)
Anticoagulant reversal
Neurosurgical consult
With or without surgery
DDx: AMS
MNEMONIC: AEIOUTIPS
A: Alcohol (intoxication or withdrawal)
E: Endocrine (hypo- or hyperthyroidism, hypo- or hyperglycemia), electrolytes (hypo- or hypernatremia, hypo- or hypercalcemia), encephalopathy (hepatic, hypertensive)
I: Infection
O: Overdose (opioid, prescription or nonprescription medications)
U: Uremia
T: Trauma/tumor
I: Ischemia (cardiac, central nervous system)
P: Pulmonary (hypoxia or hypercarbia), poisoning, psychosis (diagnosis of exclusion)
S: Seizures
ALCOHOL WITHDRAWL
ENDOCRINE / ELECTROLYTE / ENCEPHALOPATHY:
Hyper/ Hyponatremia
Hypercalcemia
Hypoglycemia
Hyperosmolar State
Hypothyroidism
Addison’s Disease
Metabolic Encephalopathy
Hypertensive Encephalopathy
Hepatic Encephalopathy
Wernicke’s Encephalopathy
INFECTION:
CNS: Meningitis, Encephalitis, Abscess
Systemic:
Sepsis, UTI, PNA, Soft Tissue, Bone / Joint
OVERDOSE:
Opioids, Benzodiazepines, Barbituates, EtOH;
CO, CN;
B-Blockers, TCA, ASA, Acetaminophen, Digoxin
Withdrawal: Benzodiazepines, EtOH, SSRI
UREMIA
TRAUMA:
Diffuse axonal injury
subdural hematoma
Epidural hematoma
ISCHEMIA
Stroke: both hemispheres (decorticate) brainstem (decerebrate)
MI
PULMONARY
Hypoxic Encephalopathy, Hypercarbia
SEIZURE
, Hemorrhage, ), Hydrocephalus, Neoplasm.
DOCUMENTATION
HISTORY
Ask about:
Baseline
Last time seen normal
Events leading up to the change
Trauma
Intoxication
Preceeding Illness
Exposure
Travel
PMHx
New Medications / Medication Compliance
PHYSICAL EXAM
GCS
Pupillary Response
Lateralizing Signs
Reflex
Posturing
CVS
Pulm
Exposure
CLINICAL FEATURES: TOXIC METABOLIC COMA
Lack of focal neurological findings
Pupillary responses equal
Spontaneous movement OR reflex posturing
Movements are symmetric with NO hemiparesis
Symmetric muscle stretch reflexes
CLINICAL FEATURES: SUPRATENTORIAL
Progressive hemiparesis
asymmetric muscle tone
Asymmetric stretch reflexes
Asymmetric extensor or flexor postures
CLINICAL FEATURES: INCREASED ICP:
Cushing’s Reflex: hypertension and bradycardia in a comatose patient
CLINICAL FEATURES: INFRATENTORIAL LESIONS
Abrupt coma
Abnormal extensor posturing
Loss of pupillary reflex
Loss of EOM
