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Altered Mental Status. Susan Schayes, MD, M.P.H Program Director Emory Family Medicine Residency Program Adapted from Dr. Eddie Needham. As life happens. You’re an Emory Family Medicine Resident at EUHM…at 4pm. You get the call from the ER that you

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altered mental status

Altered Mental Status

Susan Schayes, MD, M.P.H

Program Director

Emory Family Medicine Residency Program

Adapted from Dr. Eddie Needham

as life happens
As life happens
  • You’re an Emory Family Medicine Resident at EUHM…at 4pm.
  • You get the call from the ER that you

Have a patient with altered mental status in the ER for admission. He was “not right at home”, and brought by ambulance to the ER.

slide3
… you arrive to find a 63 year old male ESRD pt on HD who is not quite conscious.
  • You attempt to get a history – he’s not responsive enough. No one came with him by ambulance.
  • You do a cursory exam…hum…ABCs okay, lungs…heart…abd…okay, legs and arms attached and moving 
slide4
Your nurse is drawing your usual rainbow tubes while putting in an IV…
  • That’s when you notice the vital signs…
  • Pulse 68
  • RR 14
  • BP 110/58
  • Temp 100.5
today s goals
Today’s Goals
  • Define “Altered Mental Status” (AMS)
  • Create an algorithm for the work up of AMS
  • List ten causes of AMS using the

A-E-I-O-U-T-I-P-S mnemonic

  • Use the MMSE, and the above mnemonic to evaluate patient cases
slide7
AMS
  • No clear definition
  • Delirium
    • Acute vs chronic
    • Fluctuating level of consciousness
    • Impaired attention/concentration
    • Disorientation, hallucinations
    • Incoherent speech
    • Agitation
  • Coma
    • Complete behavioral unresponsiveness to external stimulus
    • Patient lies still with the eyes closed
diagnosis and treatment
Diagnosis and Treatment
  • What exam features and tests are routinely performed for AMS?
    • ABC’s, etc…
    • Finger stick blood sugar
    • Finger stick hemoglobin
    • ABG, pulse ox
    • Routine labs … like …
      • CMP, CBC, UA
      • Drug levels – acetaminophen, ASA, etc…
      • UDS
diagnosis and treatment9
Diagnosis and Treatment
  • Other labs:
    • Anion gap
    • Osmolality
  • Procedures/tests
    • Head CT
    • Lumbar puncture
    • CXR/radiology as indicated
mnemonic
A Alcohol, Alzheimer's

E Endocrine, Environmental

I Infection

O Opiates, Overdose

U Uremia

T Tumor, Trauma

I Insulin

P Poisonings, Psychosis

S Stroke Seizures Syncope

Mnemonic
mnemonic11
A Alcohol, Alzheimer's

E Endocrine, Environmental

I Infection

O Opiates, Overdose

U Uremia

T Tumor, Trauma

I Insulin

P Poisonings, Psychosis

S Stroke Seizures Syncope

Mnemonic
clinical tests that are helpful to evaluate ams
Clinical tests that are helpful to evaluate AMS
  • Glascow Coma Scale (GCS)
  • Mini-Mental State Exam (MMSE)

MOCA

common causes of ams on fms
Common causes of AMS on FMS
  • Hypoglycemia
  • Infection
  • Head injury
  • Stroke
  • Tumor/mets in brain
  • Undiagnosed dementia
  • Electrolyte imbalance
  • Overdose
  • Psychiatric causes
case 1
Case 1
  • 29 year old male training outside for the Peachtree Road race :
    • 100 push ups
    • 100 sit ups
    • Runs for one hour at 6 minutes/mile
    • Repeats above
  • Is drinking water as he is training
case 1 continued
Case 1 continued
  • After the second round, he then stands in the swimming pool at his sports complex at Lake Lanier to cool off
case 1 continued16
Case 1 continued
  • After 10 minutes, he goes down.
  • He is rescued by his neighbors.
  • At this point, he is combative and unresponsive.
  • He is being brought to your ER.
slide19

DDx?

Group 1 first

case 1 cont d
Case 1 cont’d
  • In the ER, he has already rec’d 3 mg Ativan to sedate him.
  • VS: Temp 100.5 RR 16 P 84 BP 100/60 Wt 90 Kg
  • Lungs/CV/Abd normal
  • Neck – moving without apparent discomfort
  • Neuro – no focal deficits, PERRL
  • GCS – Opens eyes to pain, nonspecific cuss words, tries to knock your hand away on sternal rub
  • GCS = 10 (E2, V3, M5)
case 1 cont d21
Hg/Hct 12.5/39

Plt Ct and WBC normal

Na 117

K 3.8

Cl 89

HCO3 25

BUN 10

Creatinine 1.0

Glucose 200

AST 100

ALT 87

Albumin 4.2

T Bili 1.3

Ammonia 37

UA – normal with spec. grav. 1.005, no blood

Case 1 cont’d
case 1 cont d23
Hg/Hct 12.5/39

Plt Ct and WBC normal

Na 117

K 3.8

Cl 89

HCO3 25

BUN 10

Creatinine 1.0

Glucose 200

AST 100

ALT 87

Albumin 4.2

T Bili 1.3

Ammonia 37

UA – normal with spec. grav. 1.005, no blood

Case 1 cont’d
case 1 teaching point
Case 1 teaching point
  • Acute exertional hyponatremia
    • Consider treating with 3% NaCl
    • Imperative to calculate sodium deficit
    • (Desired sodium – measured sodium) x 0.6 x weight in Kg = (140-117)x0.6x90 = 1242 mEq
    • 3% NaCl has 513 mEq/L of Na+
    • Correct half the deficit over 8–12 hours, and the remainder over 16-24 hours.
    • Goal is to raise the plasma sodium 1-2 mEq/L/hr, no more than 8 mEq/L in the first 24 hours (Wash. Manual)
    • Your drip rate will be?
3 saline
3% Saline

Your drip rate will be?

  • 1242/2 = 620mEq. Over 8-12 hours (say 10) = 62 mEq per hour
  • This is 62/513 = 120cc/hour.
  • I always take this corrected number and divide in 2 to make sure I go slow  rate = 60cc/hr and check the sodium on the hour.
case 2
Case 2
  • 35 yo AAM male is found semi-conscious in the street after he has been at a party with some friends.
  • He has the smell of alcohol on his breath.
  • Because he is not easily arousable, he is brought to the ER.
case 229
Case 2
  • Hx – are you kidding? Difficult to ascertain.
  • Exam – VSS
  • Gen – not tremulous, GCS 13
  • Neuro – nonfocal
  • Lungs/CV/Abd/Extremities – normal, no trauma.
case 2 labs
Hg 13

Hct 40

Plt Ct 117

WBC 3.2

MCV 102

Na 137

K 3.8

HCO3 15

Cl 100

BUN/Cr 28/1.5

Glucose 180

AST 52

ALT 48

T. Bili 1.7

Albumin 3.9

Case 2 labs
case 2 labs32
Hg 13

Hct 40

Plt Ct 117

WBC 3.2

MCV 102

Na 137

K 3.8

HCO3 15

Cl 100

BUN/Cr 28/1.5

Glucose 180

AST 52

ALT 48

T. Bili 1.7

Albumin 3.9

Case 2 labs
more info
More info
  • ABG: pH 7.32/pO2 88/pCO2 36/HCO3 16, on room air
  • Anion Gap = Na – (Cl + HCO3) = ?
  • 137 – (100+15) = 22, high.
  • DDx from the PGY 1 class?
mudpiles memorize this
MUDPILESMemorize this!
  • M - Methanol
  • U - Uremia
  • D - DKA
  • P – Paraldehyde (more of historical note)
  • I – (Ischemia - lactic acidosis, not INH)
  • L – lactic acidosis
  • E – Ethylene glycol
  • S - Salicylates
ddx in this patient
DDx in this patient?
  • Methanol or ethylene glycol?
  • How can you tell in the ER?
  • Urine – calcium oxalate crystals with?
    • Ethylene Glycol
  • It’s the middle of the night and the lab won’t look at the urine until the morning
  • What now?
osmolar gap
Osmolar Gap
  • Measured - Calculated osmoles
  • Calculated osmoles – does that hurt to do?
  • 2(Na) + BUN/2.8 + Glucose/18
  • 2(137) + 28/2.8 + 180/18 = 294
  • Measured osmoles = 328
  • Osmolar gap = 328-294 = 34 (normal <10)
treatment
Treatment?
  • Fomepizole (expensive- $1000 a vial)
  • Alcohol drip
  • Get nephrology on board ASAP
  • Emergency dialysis
  • Critical care medicine/ICU
  • Poison control/toxicology consult
case 3
Case 3
  • 43 yo African female is brought to the ER because she her speak is incoherent and she is hot, per her family.
  • She recently immigrated from Kenya.
case 3 exam
Case 3 - Exam
  • Pt is gently rolling around in the bed, mumbling.
  • Hx is as above
  • VSS – Temp 104.5, RR 24, Pulse 110, BP 108/54, pulse ox on RA 99%
  • Skin quite warm
  • Otherwise unremarkable exam
case 3 ddx
Case 3 DDx
  • Meningitis – bacterial and others
  • Malaria, especially falciparum - deadly
  • HIV CNS infections – Toxoplasmosis, cryptococcus, HSV, others
another classic case of ams
Another classic case of AMS
  • Middle-aged male alcoholic is found down and brought to the ER.
  • Head CT shows …
case 5
Case #5
  • 57 yo male presents to clinic with progressive dyspnea and mental sluggishness x 1 week.
  • PMHx – HTN – stable, no HF/CAD/CRF
  • Meds – occasional albuterol
  • ROS – no fevers, no chest pain, no cough, no recent falls
case 552
Case #5
  • VS: Pulse 80 sitting, BP 120/75, T 98.9, RR 22
  • Pulse Ox on RA = 93-94%
  • Gen – speaking in 3-5 word sentences with lips pursed
  • Exam normal except for:
  • Lungs – decreased breath sounds bilateral but moving air, E>I, no rales
case 553
Case #5
  • Pt walked 30 feet
  • Repeat VS: P 120, BP stable, RR 26, Pulse Ox 93%
  • Repeat after 3 minutes: P 90, RR 26, Pulse Ox 84%
  • Home O2 ordered urgently for patient
helpful things not usually done
Helpful things not usually done
  • Peak Flow
  • Pulsusparadoxus
  • Exercise challenge – assess ADLs
summary
Summary
  • List ten causes of AMS
  • Stabilize the patient
    • ABCs
    • Labs – the usual rainbow
    • X-rays – strongly consider a head CT
    • Don’t miss the uncommon things
  • Put the MMSE/GCS on your blackberry
  • Put the AEIOUTIPS on your blackberry