Altered Mental Status Flashcards
Arousal
Physiologic and psychological state of being awake
. Regulated by: ascending reticular system (ARAS), ANS, endocrine system
Wakefulness regulated by ____
. ARAS
. Involves ACh, NE, dopamine, histamine, and serotonin
Locus coeruleus
. Fibers to limbic system
. Release of NE causes wakefulness
Pons and basal forebrain
. Activate ACh neurons
Midbrain and substantiated Nigra
. Release of dopamine coordinating excitement and arousal
Raphe nuclei
. Release of serotonin causing cortical arousal
Hypothalamus
. Stimulates release of ACh to cerebral cortex
What causes altered mental status (AMS)
. Disruption in brain function that causes a change in behavior or responsiveness
. Range from slight confusion to total disorientation and coma
Causes of AMS
. Hypoxia/hypoxemia . Trauma (subdural.epidural hematoma, intracranial hemorrhage, sub-arachnoid hemorrhage) . Nutrition deficiencies (thiamine) . Med interactions/poisons . Encephalopathy Electrolyte abnormalities (uremia/renal failure) . Infection . Stroke . Pain . Seizure (post ictal state) . Drug overdose . Temperature (hypothermia/hyperthermia) . Insulin issues . Space occupying lesions/ Shunt (VP) malfunction (tumors, patients w/ ventricular shunt) . Mnemonic: AEIOU TIPS
Causes of fluctuating AMS
. Alcohol/hepatic encephalopathy (underlying liver disease/ ammonia build up causing encephalopathy)
. Acidosis/metabolic disorders (inc. anion gap acidosis)
. Cardiac arrhythmia
. Endocrine/electrolyte derangement
Risk factors for hepatic encephalopathy
. TIPs, portal vein thrombosis . Infections (spontaneous bacterial pericarditis from ascitis getting infected) . AKI, electrolyte derangement (dec. K) . GI bleed . Hypoxemia, hypercapnia
Wernicke-Korsakoff’s psychosis
. Wernicke’s encephalopathy: confusion, ophthalmoplegia, ataxia, thiamine deficiency
. Korsakoff’s psychosis/stage 2: retrograde amnesia, anterograde amnesia, confabulation, Korsakoff’s psychosis
. Treated w/ thiamine supplements
Glasgow coma scale
. Eyes opening: 1 (none), 2(to pain) 3(voice) 4(spontaneously)
. Verbal response 1 (none) 2 (incomprehensible sound) 3. (Inappropriate words) 4 (confused) 5 (oriented)
. Motor: 1(none) 2 (abnormal extension) 3 (abnormal flexion) 4(withdraws from pain) 5(localized to pain) 6(obeys commands)
Dementia
. Decline in memory, language, problem solving, and thinking skills
. Usually occurs slowly
. Affect’s a person’s ability to perform tasks
. Causes: Alzheimer’s, Levy body, vascular, frontotemporal, alcohol-related
. Reversible causes: hematoma, hypothyroid, B12 deficiency, syphilis, normal pressure hydrocephalus (gait instability, bladder incontinence)
. Labile/irritated to normal mood
Delirium
. Abrupt change in brain that causes mental confusion and emotional disruption
. Causes: metabolic, infection, CNS issues, post-concussive, auto-antibody (tumors, hashimotos)
Symptoms: emotional dysregulation, psychomotor disturbance, circadian rhythm disturbance, impairment of consciousness
. Flat and depressed mood
Psychosis
. Severe, disconnection form reality
. Delusions, hallucinations, incoherency, agitation
. Causes: organic and psychotic causes
Mental status evaluation
. Orientation to person, place, and time
. Affect: labile (unstable) or blunt/depressed
. Appearance and behavior: level of consciousness (GCS), gross motor function, personal hygiene
. Speech
. Thought and perception: obsessions, phobias, anxieties, feelings of unreality, abnormalities of perception (illusions/hallucinations)
. Cognitive function: attention span, learning ability (remembering items, counting)
MMSE components and scoring
. Orientation . Memory . Language . Visual-spatial skills . Highest score 30 . Score 20-24: mild cognitive deficit . Less than 12: severe cognitive deficit
Trauma primary survey
. Identifies immediate life-threatening injuries
. Check airway, breathing, circulation, disability, and exposure
Airway etiologies and management
. Obstruction or injury
. Chin lift, suction, surgical airways/intubation
Breathing etiology and management
. Tension or open pneumo
. Tracheobronchial injury w/ air leak
. Flail chest
. Manage: listen for breath sounds, inspect for wounds, palpate for crepitus, consider needle thoracotomy
Circulation etiology and management
. Hemorrhage, pelvic fracture w/ bleeding, extremity blood loss, cardiogenic tamponade
. Manage: 2 large bore IV, start fluids, consider central access, pericardiocentesis or paracentesis
Disability etiology and management
. Intracranial hemorrhage, cervical spine injury
.manage: pupil size, GCS, strength and grip testing
. Exposure etiology and management
. Spinal fracture, puncture wounds
. Manage: disrobe and look at skin, logroll patient for spine exam
Secondary survey
. Brief history and head to toe
. AMPLE (allergies, meds, past med history, last meal, events leading to injury)
General categories of AMS
. Acute global confusion w/ psychomotor activity
. Delirium
. Dementia
. Psychosis
Medical diseases assoc. w/ acute global confusion w/ hypoactivity
. Salt (hyper/hypoNA)
. Sugar (glycemic)
. Septic (UTI, infection in elderly, only if they have other health problems too)
. Solid organ stupors (4 S’s)
Drugs/meds assoc. w/ acute global confusion w/ hypoactivity
. Opiates . Anticholinergics . Sedatives . Steroids . Weed . Psychotropics . Toxic alcohols . Dopa/serotonin agents . Antibiotics or chemotherapy
CNS diseases assoc. w/ acute global confusion w/ hypoactivity
. Store, tumor, or abscess in R parietal, L temporal . Subdural hematoma . Encephalitis . Cerebral vasculitis . Hypertensive encephalopathy . Nonconvulsive status epilepticus
1st step in hepatic encephalopathy
. Reversal of sleep/wake cycle (sleep during day, awake at night)
Labs and diagnostic for AMS
. CBC/BMP/LFTs for bleeding, uremia, liver failure
. UA, urine, blood culture: infections
. ABG: hypercapnia
. U tox: opiates, PCP, BZDs
. CT/MRI: subdural, strokes, lesions
. LP: encephalitis, meningitis, autoimmune
. B12, RPR(syphilis), HIV, thyroid function: reversible dementia causes
