Approach to altered mental status Flashcards
What cause does delirium always have?
Organic
Define delirium
difficulty in focusing, shifting or sustaining attention
Describe confusion of delirium
fluctuating
4 causes of delirium
- Primary intracranial dz
- Systemic dz
- Exogenous toxins
- Drug withdrawal
Delirium characteristics:
Slide 13-note that visual hallucinations are associated
What must be present to diagnose delirium?
Findings in history and PE
6 Elements of MSE
Appearance, behavior, and attitude Disorders of thought Disorders of perception Mood and affect Insight and judgment Sensorium and intelligence
MMSE elements
Orientation Registration Attention and calculation Recall Language
What does MMSE not detect?
Mild impairment
Quick confusion scale
Year Month Present memory phrase Time Count backward Reverse month Repeat memory phrase
Advantage of quick confusion scale over MMSE
Quicker-no reading, drawing, writing
Correlates well with MMSE
Tx of delirium
Consider sedation
-Haldol
-Lorazepam
(Reduce haldol if given with benzo)
Disposition for delirium
- Admit majority
- Must call internal med
Define dementia
*Loss of mental capacity
Slow, insidious onset*
2 Categories of dementia
Idiopathic
Vascular
Characteristics of dementia
Slide 29
Memory features of dementia
Recent affected > long term
Exaggerated or Asymmetric DTRs, Gait Disturbance, Extremity Weakness =
Vascular dementia
What does not determine presence of dementia?
General PE
Remember, delirium is determined by PE and hx
What must you remember to consider in dementia?
Co-existing causes of delirium
What must be r/o with dementia?
Treatable cause or delirium
When might you be able to discharge dementia?
Stable, reliable caregivers, and prompt f/u AFTER life-threats excluded
Definition of coma
Pt cannot be aroused
GCS
Slide 41
What condition CANNOT cause coma?
Stroke (unilateral hemispheric dz) except uncal herniation
Toxic metabolic coma findings (4)
- Diffuse CNS function
- Lacks focal findings
- Symmetrical findings
- Pupillary response preserved
What is an ominous finding of CNS malfunction?
Abnormal flexion and extension
Which type of posturing is worse?
Decerebrate worse than decorticate (know positions of limbs; term not important)
Decorticate posture
arms adducted and flexed, wrists and fingers flexed on chest, legs may be internally rotated and stiffly extended, plantar flexion of the feet
Decerebrate posture
arms adducted and extended, wrists pronated and fingers flexed, legs may be internally rotated and stiffly extended, plantar flexion of the feet
Decerebrate posturing indicates injury where?
Brain stem
Decorticate posturing indicates injury where?
Corticospinal tract
Supratentorial mass has what finding?
Progressive ipsilateral hemiparesis
What does uncal herniation cause?
Medial temporal lobe shift-compresses upper brain stem
What leads to abrupt coma?
Posterior fossa & infratentorial lesions: Cerebellar hemorrhage & infarction
What is a unique sign of pontine hemorrhage?
Pinpoint pupils
What imaging is best for abrupt coma and pinpoint pupils?
MRI-everything else is CT first
What are findings of pseudocoma or psychogenic coma?
Pupillary, EOMs, Muscle Tone, Reflexes ALL intact & symmetric
Patient will resist manual eye opening
“Drop arm” test is positive
Avoidance gaze
Nystagmus with caloric vestibular testing
Abrupt onset of coma is caused by:
trauma, stroke, seizures, cardiac
Slow onset of coma caused by:
progressive CNS lesion (tumor, SDH), hyperglycemia
PE for diagnosis of coma:
Assess vital signs: oxygen saturation & temperature
Look for signs of trauma, toxidrome, etc.
Bedside glucose
Neurological exam
What is the goal of coma diagnosis?
rapid determination of diffuse vs focal cause of CNS dysfunction
Study of choice for coma:
CT-bleeding shows white
If you think there’s a bleed, but CT is negative, you must do:
LP (also when infection suspected)
Airway issues when treating coma:
Don’t forget to protect the C-spine!
ICP:RSI and maintenance sedation indicated
For status epilepticus, what should you do if not better after 30 min or if subtle?
Urgent EEG and/or neuro consult
What should your treatment for coma be aimed at?
Underlying cause-*MUST focus on reversible causes
-Hypoxia, hypoglycemia, hypo-hypertension, hypo-hyperthermia
What steps should be performed while taking diagnostic steps?
Brain-saving:
Sedate, paralyze and intubate
Elevate head of bed 30 degrees
Mannitol
Hyperventilate-last resort (only in herniation)!
Steroids for tumors, septic shock, spinal cord injury
Coma cocktail:
D-50% Dextrose (D50) 1 amp IVP after finger stick
O-Oxygen at high flow
N-Naloxone (Narcan) 0.4 to 2 mg IV initially
T-Thiamine 100mg IV: prevents Wernicke’s
For suspected seizures when treating coma, give what?
Lorazepam or diazepam
If head bleed, who do you refer to?
Neurosurgery
If ischemic stroke, who do you refer to?
Neurology
