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Altered Mental Status and Coma November 15, 2005 Tintinalli Chapter 229 Dr. Hadcock Slides by Scott...
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Transcript of Altered Mental Status and Coma November 15, 2005 Tintinalli Chapter 229 Dr. Hadcock Slides by Scott...
Altered Mental Status Altered Mental Status and Comaand Coma
November 15, 2005November 15, 2005
Tintinalli Chapter 229Tintinalli Chapter 229
Dr. HadcockDr. Hadcock
Slides by Scott GundersonSlides by Scott Gunderson
Altered Mental StatusAltered Mental Status
Arousal FunctionArousal Function Content of ConsciousnessContent of Consciousness Or bothOr both
Arousal FunctionArousal Function
Reticular activating systemReticular activating system MidbrainMidbrain PonsPons MedullaMedulla
Content of ConsciousnessContent of Consciousness
Cerebral cortexCerebral cortex EmotionsEmotions ReasoningReasoning Self-awarenessSelf-awareness Spatial relationshipsSpatial relationships
DeliriumDelirium
DeliriumDelirium
Acute confusional state with impaired Acute confusional state with impaired alertnessalertness Alerting functionsAlerting functions
Overworking or underworkingOverworking or underworking Difficulty focusing, shifting or sustaining attentionDifficulty focusing, shifting or sustaining attention
Formal definition includes:Formal definition includes: Fluctuating confusionFluctuating confusion Disturbed sleep wake cycleDisturbed sleep wake cycle
PathophysiologyPathophysiology
4 general causes4 general causes
1.1. Primary intracranial diseasePrimary intracranial disease
2.2. Systemic disease affecting CNSSystemic disease affecting CNS
3.3. Exogenous toxinsExogenous toxins
4.4. Drug withdrawalDrug withdrawal
Clinical FeaturesClinical Features
Onset is within daysOnset is within days 3 general variants of activity and alertness3 general variants of activity and alertness
1.1. Hypoalert-hypoactiveHypoalert-hypoactive
2.2. Hyperalert-hyperactiveHyperalert-hyperactive
3.3. MixedMixed– May cycle rapidly between hyperactive and May cycle rapidly between hyperactive and
hypoactive.hypoactive.
Clinical FeaturesClinical Features
Altered sleep wake cyclesAltered sleep wake cycles ““Sundowning”Sundowning” Tremor, tachycardia, diaphoresis, outbursts, Tremor, tachycardia, diaphoresis, outbursts,
delusions, hallucinations may occurdelusions, hallucinations may occur
DiagnosisDiagnosis
Diagnosis primarily by historyDiagnosis primarily by history Physical exam to look for causesPhysical exam to look for causes Additional testing to identify a causeAdditional testing to identify a cause
Labs: CMP, CBC, UALabs: CMP, CBC, UA +/- lumbar puncture+/- lumbar puncture
Radiology: CXR and head CTRadiology: CXR and head CT MMSEMMSE
TreatmentTreatment
Treat the underlying cause (Table 229-5)Treat the underlying cause (Table 229-5) Infections: pneumonia, UTI, meningitis, sepsisInfections: pneumonia, UTI, meningitis, sepsis Metabolic: hypoglycemia, electrolytes, hepatic, Metabolic: hypoglycemia, electrolytes, hepatic,
thyroid disorders, ETOH, or drugsthyroid disorders, ETOH, or drugs Neurologic: CVA, TIA, seizure, intracranial Neurologic: CVA, TIA, seizure, intracranial
hemorrhage or masshemorrhage or mass Cardiopulmonary: CHF, MI, PE, hypoxiaCardiopulmonary: CHF, MI, PE, hypoxia Drug related: Narcotics, sedatives, muscle Drug related: Narcotics, sedatives, muscle
relaxants, antiemetics, digoxinrelaxants, antiemetics, digoxin
TreatmentTreatment
SedationSedation HaloperidolHaloperidol LorazepamLorazepam
Confinement or restraints as appropriateConfinement or restraints as appropriate
Admit unless rapidly reversible cause is Admit unless rapidly reversible cause is identifiedidentified
DementiaDementia
DementiaDementia
2 main types2 main types Dementia of Alzheimer diseaseDementia of Alzheimer disease Vascular dementiasVascular dementias
Insidious loss of mental capacityInsidious loss of mental capacity Rapidly progressing or abrupt onset indicates Rapidly progressing or abrupt onset indicates
another organic causeanother organic cause Behavior problems are commonBehavior problems are common
PathophysiologyPathophysiology
Majority of causes are from Alzheimer’sMajority of causes are from Alzheimer’s Etiology is poorly understoodEtiology is poorly understood Reduced number of neurons in the cortexReduced number of neurons in the cortex Amyloid depositionAmyloid deposition Neurofibrillary tangles and plaquesNeurofibrillary tangles and plaques
Vascular DementiaVascular Dementia Multiple infarctionsMultiple infarctions
http://www-medlib.med.utah.edu/WebPath/CINJHTML/CINJ034.html
http://www-medlib.med.utah.edu/WebPath/CNSHTML/CNS178.html
http://www-medlib.med.utah.edu/WebPath/CNSHTML/CNS092.html
Clinical FeaturesClinical Features
Memory impairment gradual & progressiveMemory impairment gradual & progressive Recent memory affected greatestRecent memory affected greatest Impairment of memory and orientation with Impairment of memory and orientation with
preserved motor and speech is characteristicpreserved motor and speech is characteristic 3 stages3 stages
Mild–minor memory lossMild–minor memory loss Moderate–memory now affecting social lifeModerate–memory now affecting social life Severe–affecting ADL’sSevere–affecting ADL’s
Clinical FeaturesClinical Features
Vascular dementiaVascular dementia Similar insidious onsetSimilar insidious onset May also have exam findings of exaggerated May also have exam findings of exaggerated
DTR’s or weakness that AD will not have.DTR’s or weakness that AD will not have.
DiagnosisDiagnosis
Diagnosis primarily by historyDiagnosis primarily by history Usually no one specific eventUsually no one specific event If single or multiple distinct events more likely to If single or multiple distinct events more likely to
be vascular dementiabe vascular dementia Labs to rule out other causesLabs to rule out other causes
CBC, CMP, Thyroid, B12, RPR, +/- LPCBC, CMP, Thyroid, B12, RPR, +/- LP RadiologyRadiology
CT or MRICT or MRI
DiagnosisDiagnosis
Exacerbating factorsExacerbating factors UTIUTI CHFCHF HypothyroidismHypothyroidism Many othersMany others
TreatmentTreatment
Primarily environmental or psychosocialPrimarily environmental or psychosocial
PharmacologicPharmacologic AntiphychoticsAntiphychotics Mood stabilizersMood stabilizers Cholinesterase inhibitorsCholinesterase inhibitors All have little use in the ED except to manage an All have little use in the ED except to manage an
acute exacerbation acute exacerbation
DispositionDisposition
New diagnosis entertained in the ED but New diagnosis entertained in the ED but further testing is neededfurther testing is needed
Admit vs. outpatient follow up after treatable Admit vs. outpatient follow up after treatable causes ruled out or addressedcauses ruled out or addressed
Must consider safety of there environment Must consider safety of there environment when discharging.when discharging.
ComaComa
ComaComa
State of reduced alertness and responsiveness State of reduced alertness and responsiveness from which you cannot be arousedfrom which you cannot be aroused
Glasgow Coma ScaleGlasgow Coma Scale Motor, verbal, eye openingMotor, verbal, eye opening
Motor Motor ResponseResponse ExampleExample ScoreScore
CommandsCommands Follows simple commandsFollows simple commands 66
Localizes Localizes PainPain
Pulls examiner's hand away Pulls examiner's hand away when pinchedwhen pinched 55
Withdraws Withdraws from Painfrom Pain
Pulls a part of body away when Pulls a part of body away when pinchedpinched 44
Abnormal Abnormal FlexionFlexion
Flexes body inappropriately to Flexes body inappropriately to painpain 33
Abnormal Abnormal ExtensionExtension
Body becomes rigid in an Body becomes rigid in an extended position when extended position when examiner pinches himexaminer pinches him 22
No ResponseNo Response Has no motor response to pinchHas no motor response to pinch 11
Eye-OpeningEye-Opening ..
SpontaneousSpontaneous Opens eyes on ownOpens eyes on own 44
To VoiceTo VoiceOpens eyes when asked to Opens eyes when asked to in a loud voicein a loud voice 33
To PainTo Pain Opens eyes when pinchedOpens eyes when pinched 22
No ResponseNo Response Does not open eyesDoes not open eyes 11
Verbal Response Verbal Response (Talking)(Talking) ..
OrientatedOrientated
Carries on a conversation Carries on a conversation correctly and tells examiner correctly and tells examiner where he is, who he is, and where he is, who he is, and the month and yearthe month and year 55
Confused Confused ConversationConversation
Seems confused or Seems confused or disorienteddisoriented 44
Inappropriate WordsInappropriate Words
Talks so examiner can Talks so examiner can understand him but makes understand him but makes no senseno sense 33
SoundsSounds
Makes sounds that Makes sounds that examiner cannot examiner cannot understandunderstand 22
No ResponseNo Response Makes no noiseMakes no noise 11
PathophysiologyPathophysiology
GlobalGlobal Hypoglycemia, hypoxiaHypoglycemia, hypoxia
CNSCNS Brainstem diseaseBrainstem disease Bilateral cortical diseaseBilateral cortical disease
Unilateral should not present as comaUnilateral should not present as coma
Mass Lesions Causing ComaMass Lesions Causing Coma
Secondary to compression of the brainstemSecondary to compression of the brainstem
Primarily uncal vs. centralPrimarily uncal vs. central
Uncal herniationUncal herniation
Medial temporal lobe compresses brainstemMedial temporal lobe compresses brainstem
Decreased responsiveness going into a comaDecreased responsiveness going into a coma
Ipsilateral pupil dilated and nonreactiveIpsilateral pupil dilated and nonreactive
Central HerniationCentral Herniation
Progressive loss of consciousnessProgressive loss of consciousness
Decorticate posturingDecorticate posturing
Irregular respirationsIrregular respirations
Increased Intracranial PressureIncreased Intracranial Pressure
Localized vs. generalizedLocalized vs. generalized Cerebral blood flow constant with MAP of 50-Cerebral blood flow constant with MAP of 50-
100 mm of Hg100 mm of Hg CPP = MAP – ICPCPP = MAP – ICP Cushing reflex of hypertension and Cushing reflex of hypertension and
bradycardiabradycardia
Clinical FeaturesClinical Features
Coma secondary to hemispheric hemorrhage Coma secondary to hemispheric hemorrhage may still have localizing featuresmay still have localizing features
Pupillary, muscle, and cranial nerve exam to Pupillary, muscle, and cranial nerve exam to determine central vs. focaldetermine central vs. focal
Pupillary response generally preserved in toxic Pupillary response generally preserved in toxic metabolic comametabolic coma
DiagnosisDiagnosis
Stabilization diagnosis and treatment overlapStabilization diagnosis and treatment overlap ABC’sABC’s Lab,+/- LPLab,+/- LP CT headCT head ExaminationExamination
Focal vs. diffuseFocal vs. diffuse
Specific IssuesSpecific Issues
C-spine immobilization if trauma suspectedC-spine immobilization if trauma suspected Pediatric coma commonly ingestion, infection, Pediatric coma commonly ingestion, infection,
or abuseor abuse SeizuresSeizures
Coma s/p seizure activityComa s/p seizure activity ““electromechanical dissociation of the brain and body”electromechanical dissociation of the brain and body”
TreatmentTreatment
Reverse identifiable causesReverse identifiable causes GlucoseGlucose
Thiamine prior if alcoholicThiamine prior if alcoholic NaloxoneNaloxone
If signs or history of opioid useIf signs or history of opioid use FlumazenilFlumazenil
Only recommended if history of benzo use not as Only recommended if history of benzo use not as routine.routine.
DispositionDisposition
Most cases will be admittedMost cases will be admitted Discharge rapidly reversible causes such as Discharge rapidly reversible causes such as
insulin induced hypoglycemiainsulin induced hypoglycemia Admit if unclear cause or poor follow-upAdmit if unclear cause or poor follow-up
ReferencesReferences Tintinalli, Judith E., Tintinalli, Judith E., Emergency Medicine a Comprehensive Study Guide.Emergency Medicine a Comprehensive Study Guide. Sixth edition. McGrw-Hill Sixth edition. McGrw-Hill
Companies, Inc. 2004. Chapter 229. Altered Mental status and Coma. Huff, J. Stephen. Pages 1390-1397.Companies, Inc. 2004. Chapter 229. Altered Mental status and Coma. Huff, J. Stephen. Pages 1390-1397.
Boon, Rosemary. “Sleeping Disorders.” http://home.iprimus.com.au/rboon/SleepingDisorders.htm. Boon, Rosemary. “Sleeping Disorders.” http://home.iprimus.com.au/rboon/SleepingDisorders.htm. Accessed 11/14/05.Accessed 11/14/05.
Klatt, Edward C. University of Utah Webpath. http://www.medlib.med.utah.edu/WebPath/ Accessed Klatt, Edward C. University of Utah Webpath. http://www.medlib.med.utah.edu/WebPath/ Accessed 11/14/05.11/14/05.
QuestionsQuestions
1.1. All of the following are features of delirium except:All of the following are features of delirium except:a.a. Fluctuating courseFluctuating courseb.b. Disordered attentionDisordered attentionc.c. Visual and/or auditory hallucinationsVisual and/or auditory hallucinationsd.d. Insidious onset over yearsInsidious onset over years
2.2. A fluctuating stepped course of mental impairment with A fluctuating stepped course of mental impairment with focal neurologic signs is suggestive of:focal neurologic signs is suggestive of:
a.a. Vascular dementiaVascular dementiab.b. Alzheimer’s dementiaAlzheimer’s dementiac.c. DeliriumDeliriumd.d. Parkinson’s diseaseParkinson’s disease
3.3. A patient arrives to the ED with an altered mental status. A patient arrives to the ED with an altered mental status. On examination he responds only to painful stimuli by On examination he responds only to painful stimuli by withdrawing, opens his eyes only with pain, and only withdrawing, opens his eyes only with pain, and only audible noises are moans. His GCS score is?audible noises are moans. His GCS score is?
a.a. 1212
b.b. 1010
c.c. 88
d.d. 44
4.4. (T/F) The reticular activating system responsible for arousal (T/F) The reticular activating system responsible for arousal functions is located in the midbrain, pons, and medulla.functions is located in the midbrain, pons, and medulla.
5.5. (T/F) Delirium always has an organic cause.(T/F) Delirium always has an organic cause.
Answers: 1-d, 2-a, 3-c, 4-T, 5-TAnswers: 1-d, 2-a, 3-c, 4-T, 5-T