AMS Flashcards
% of elderly hospitalized patients with AMS % of AMS patients who are intubated % of patients who have had symptoms <24hrs
50% 12% 72%
Define Delirium =
state of disturbed consciousness associated w/ motor restlessness, transient hallucinations, disorientation, or delusions An acute confusion state, ranging from hypoactivity to hyperactivity. People who may be actively hallucinating, or intermittently exhibiting strange behaviors are also delirious Delirium always has an organic and reversible cause
Consfusion a sx or dx?
Sx
Consciousness is an interaction between…
the reticular activating system (RAS, in brainstem or medulla) and the cerebral cortex. Both must be functioning for a patient to be fully conscious.
Disorders of consciousness grouped as diseases that affect…
arousal fxn consciousness fxn or both
Coma =
any depressed LOC
A complete failure of the arousal system w/ no spontaneous eye opening caused by…
brainstem dysfxn and/or bilateral cortical disease
Minimally conscious state =
inconsistent but discernable evidence of consciousness, an altered state, able to follow commands/purposeful behaviors, simple commands
Stupor =
patients awaken w/ stimuli but little motor/verbal activity when aroused
Obtundation =
awake but not alert, and patient exhibits psychomotor retardation
**Delirium** Reversible? Course? Onset? Difficult to distinguish from… Degree of consciousness
always has an organic and reversible cause Fluctuating course of confusion, may worsen w/ agitation, reversal of sleep-wake cycle often present Acute onset Difficult to distinguish from acute psychosis Depressed consciousness
**Dementia** Course? Onset? Reversible? Rate of progression? Degree of consciousness
stable course of confusion isidious onset Irreversible slowly progressive No impairment of consciousness
ED evaluation of patient with AMS:
Assess level of consciousness If diminished consciousness consider coma, stupor, or obtundation. If no change in consciousness look for an acute neuro deficit. If there is a deficit look for a stroke or mass If there is not a deficit look for changes in attention span or perform a mental status exam If there is a change in attention span or mental status change then consider confusion or delirium. If there isn’t a change in attention span or mental status change then consider a though disorder or possible psychiatric disorder.
HPI to get from paramedics/caretakers:
Duration of patient’s symptoms Patient’s baseline function When was patient last at baseline Any medications added or changed recently? Any empty pill/alcohol bottles noticed? Home environment?
How to evaluate delirium:
MMSE GCS
Prognosis for delirium relies most heavily on:
GCS motor response
2 broad categories of ddx for delirium:
toxic/metabolic vs. structural dz medical vs. surgical
DDx Mneumonic for Delirium:
AEIOU TIPS
- A: alcohol
- (i.e., respiratory depression, wernicke’s encephalopathy)
- E: endocrinopathy, encephalopathy, electrolytes.
- Most common cause of altered MS is hypoglycemia, extreme hypothyroidism, hyponatremia, hypercalcemia, adrenal insufficiency or adrenal crisis, severe thyroid storm
- Encephalopathy: hepatic, uremic, hypertensive
- I: insulin, infection, increased ICP
- Diabetes, systemic infections: meningitis, sepsis, urosepsis/pneumonia in elderly
- Trauma: SAH, subdural, epidural hemorrhage, hydrocephalus, tumor
- O: opiates, oxygen
- Heroin, anoxia, anemia, low cardiac output, pulmonary disease, cardiac disease
- U: uremia
- T: trauma, toxic
- alcohol, barbiturates, benzos, antidepressants, GHB), tumor, temperature (hypothermia/hyperthermia)
- I: inborn errors of metabolism
- P: psychiatric, post-ictal: Todd’s paralysis
- S: seizure, stroke, shock, space-occupying lesions
Labs + Dx Testing for AMS =
CBC
BMP
LFT
NH3 level
PT/PTT
tox screen
CXR
ECG
CT head
U/S (GB)
LP
exam (skin/soft tissues)
Tx for AMS:
disease specific, but consider empiric ABX coverage
most patients are admitted for additional tx
Do not miss conditions:
- Hypoxia/diffuse cerebral ischemia
- Respiratory failure
- Congestive heart failure
- Myocardial infarction
- Severe Anemia
- Systemic processes
- Hypoglycemia
- Hypertensive encephalopathy
- Elevated intracranial pressure of medical and surgical origin
- Systemic diseases
- Electrolyte and fluid disturbance
- Endocrine disease (e.g., thyroid, adrenal)
- Hepatic failure
- Nutrition/Wernicke’s encephalopathy
- Sepsis, infection *(occult: skin, GB, impacted stone)*
- Intoxications and withdrawal
- CNS sedatives
- Ethanol
- Other medication side effects, particularly anticholinergics
- CNS disease
- Trauma
- Infections
- Stroke
- Subarachnoid hemorrhage
- Epilepsy/seizures
- Postictal state
- Nonconvulsive status epilepticus
- Complex partial status epilepticus
- Neoplasms
