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ALTERED MENTAL STATUS. DAN MUSE, MD. AMS. ALTERED MENTAL STATUS IS A SYMPTOM AND NOT THE DIAGNOSIS CAUSES: INFECTION: MENINGITIS, SEPSIS STRUCTURAL: STROKE, TRAUMA METABOLIC: HYPOGLYCEMIA INGESTIONS: NARCOTICS, ALCOHOL. AMS PNEUMONIC. A – ALCOHOL E – EPILEPSY I - INSULIN
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ALTERED MENTAL STATUS DAN MUSE, MD
AMS ALTERED MENTAL STATUS IS A SYMPTOM AND NOT THE DIAGNOSIS CAUSES: • INFECTION: MENINGITIS, SEPSIS • STRUCTURAL: STROKE, TRAUMA • METABOLIC: HYPOGLYCEMIA • INGESTIONS: NARCOTICS, ALCOHOL
AMSPNEUMONIC • A – ALCOHOL • E – EPILEPSY • I - INSULIN • O - OPIOIDS • U - UREMIA • T – TRAUMA, TEMPERATURE • I – INFECTION • P – POISONINGS • P – PSYCHIATRIC • S – STROKE, SHOCK
AMS • ALTERED MENTAL STATUS MAY BE INTERTWINED WITH OTHER CAUSES. • ALCOHOL CAN CAUSE TRAUMA WHICH COULD CAUSE A SEIZURE.
AMSALCOHOL • CAUSES AMS BY ITSELF • CAN CAUSE TRAUMA AND SECONDARY AMS • DROPS IN ALCOHOL MAY RESULT IN SEIZURES AND DELIRIUM IN CHRONIC ALCOHOLICS • ACUTE INTOXICATION CAN CAUSE DROPS IN BLOOD SUGAR ESP IN CHILDREN. • RESULTS IN MALNUTRITION AND THIAMINE DEFICIENCY IN CHRONIC ALCOHOLICS
AMSALCOHOL GUINNESS ADVERTISED THAT IT WAS GOOD TO DRINK IN PREGNANCY BECAUSE IT CONTAINED THIAMINE
AMSEPILEPSY (SEIZURE) • INTRINSIC SEIZURES • SEIZURES CAUSED BY SPACE OCCUPYING LESION; TUMOR, BLEED • POISONINGS: INH • METABOLIC: HYPOGLYCEMIA • INFECTION: MENINGITIS; FEBRILE SEIZURES • PSYCHIATRIC: PSEUDOSEIZURES
AMSINSULIN (DIABETES) • HYPOGLYCEMIA • HYPERGLYCEMIA: NONKETOTIC HYPERGLYCEMIA • HYPERGLYCEMIA CAUSE DEHYDRATION WHICH WORSENS AMS • DKA: HIGH OR LOW BLOOD SUGAR, ACIDOSIS AND…….AMS
AMSOPIOIDS • POTENTIAL FOR TRAUMA • HYPOXIA • INFECTION WITH IVDA
UREMIA • ELEVATED BUN IN THE BODY RESULTS IN ACIDOSIS, SYSTEMIC POISONING AND AMS
AMSTRAUMA • HEAD INJURIES • HYPOTENSION/BLOOD LOSS • HYPOXIA/ANOXIA
AMSTEMPERATURE HYPERTHERMIA • CONFUSION • COMA • SEIZURES HYPOTHERMIA • CONFUSION • COMA
AMSINFECTION • MENINGITIS • SEPSIS • PNEUMONIA AND HYPOXIA • FEVER AND CONFUSION FROM THE INFECTION
AMSPOISONINGS • NARCOTICS • BENZODIAZEPINES…PCP…SPICE……………. • PSYCHIATRIC MEDICATIONS • GLYCOL • METHANOL • …………….IN THE RIGHT DOSAGE OR IN THE RIGHT COMBINATION, ALMOST ANYTHING CAN CAUSE AMS
AMSPSYCHIATRIC • MAY BE DUE TO MEDICATIONS TAKEN BY THE PATIENT • CATATONIA; DEPRESSION; DELERIUM • PSEUDOSEIZURES • HIGHER PROPENSITY TO SUBSTANCE ABUSE • SUICIDE ATTEMPT
PSYCHIATRIC SYNDROMESDELUSION OF GRANDEUR DELUDE THEMSELVES INTO BELIEVING THEY ARE SOMETHING THEY ARE NOT
PSYCHIATRIC SYNDROMESDELUSION OF GRANDEUR THIS MAN BELIEVES HE IS A DOCTOR
AMSSHOCK • SEPSIS • CARDIOGENIC • TRAUMATIC • SPINAL
AMSSTROKE • STROKES VARY IN TYPE AND LOCATION • TYPES: HEMORRHAGIC, THROMBOTIC AND EMBOLIC • LOCATION: ANY PART OF THE BRAIN.
AMSHEMORRHAGIC STROKE • OFTENTIMES DUE TO CHRONIC HYPERTENSION • SMALL VESSEL DISEASE • BASAL GANGLIA OFTEN INVOLVED • LOCATION OF THE BLEED WILL DICTATE THE SYMPTOMS
AMSISCHEMIC STROKE • MOST COMMONLY THROMBOTIC BUT ALSO CAN BE EMBOLIC • SYMPTOMS CAN RELIABLY DETERMINE THE LOCATION OF THE STROKE
AMSANTERIOR CEREBRAL ARTERY • CONTRALATERAL PARESIS; LEGS WEAKER THAN ARMS AND FACE • CONTRALATERAL SENSORY LOSS. • GAIT DISTURBANCE
AMSMIDDLE CEREBRAL ARTERY • CONTRALATERAL PARALYSIS; ARMS AND FACE WEAKER THAN LEGS • CONTRALATERAL SENSORY LOSS • APHASIA OR HEMINEGLECT. WHICH OCCURS IS DETERMINED BY THE EXACT LOCATION OF THE STROKE AND THE WHETHER THE PERSON IS RIGHT OR LEFT SIDED DOMINANT.
AMSPOSTERIOR CEREBRAL ARTERY • SUPPLIES CEREBRAL CORTEX • HOMONYMOUS HEMIANOPSIA (contralateral) • VISUAL AGNOSIA (can’t recognize objects) • CORTICAL BLINDNESS (e.g. after CPR) • MOTOR INVOLVEMENT MINIMAL
AMS VERTBROBASILAR ARTERY • SUPPLIES BRAINSTEM, CEREBELLUM, VISUAL CORTEX • VERTIGO, NYSTAGMUS • VISUAL FIELD DEFICITS, DIPLOPIA • DYSARTHRIA, DYSPHAGIA • QUADRIPLEGIA • SYNCOPE, COMA
AMS VERTBROBASILAR ARTERY WALLENBERG’S SYNDROME • Vertebral artery thrombosis • Ataxia, vertigo, nystagmus, nausea, vomiting. • Decreased pain and temperature sensation, ipsilateral face and contralateral body • Ipsilateral Horner’s Syndrome. (ptosis, miosis, anhydrosis
AMS VERTBROBASILAR ARTERY “LOCKED IN” SYNDROME • Basilar artery occlusion at pons • Seen with pontine hemorrage, central pontine myelinolysis • Patient is awake and lucid, able to feel and understand • No motor activity except diaphragmatic breathing. • Vertical eye movement is spared
AMSCEREBELLAR INFARCT • SUDDEN INABILITY TO WALK AND STAND • HEADACHE, DIZZINESS, NYSTAGMUS, ATAXIA, NAUSEA, VOMITING • CAN PRESENT WITH ONLY NAUSEA AND VOMITING • RAPID DETERIORATION WITH HEMORRHAGE AND EDEMA
AMSTREATMENT DON’T FORGET THE OBVIOUS • HYPOXIA….0XYGEN • OVERDOSE…..NARCAN • HYPOTENSION…..FLUID BOLUS • HYPOGLYCEMIA….D50
AMSTREATMENT • DETERMINATION OF THE CAUSE AND THE TREATMENT OFTENTIMES IS BASED ON THE HISTORY OF WHAT OCCURRED. • YOUR FINDINGS OF THE EVENTS MAY BE THE ONLY CLUES WE HAVE ESPECIALLY FOR QUESTIONS OF SEIZURES • BE ACCURATE AND COMPLETE IN YOUR REPORTS.
AMSTREATMENT • STROKES COME IN VERY MANY FORMS • IF YOU THINK YOU HAVE A POTENTIAL STROKE….CALL IT IN AS SUCH
AMSTREATMENT • TIME IS THE LIMITING FACTOR IN A STROKE • IT IS IMPERATIVE WE KNOW WHEN THE SYMPTOMS BEGAN
AMSTREATMENT IT IS CRITICAL THAT YOU FIND OUT WHETHER FROM THE PATIENT OR FAMILY WHEN THE SYMPTOMS STARTED.
CASE #1 • 29 y/o who fell down some stairs. • Had been drinking and felt that he was intoxicated by family/friends • Opted to observe the patient for a couple of hours before calling 911.
CASE #1 • Normal vitals • Obtunded • No head trauma • GCS: 6 • What is the differential?
CASE #1 • Toxicology Screen: negative • ETOH: 261 • Glucose: 266