INTERN BOOT CAMP: Altered Mental Status
description
Transcript of INTERN BOOT CAMP: Altered Mental Status
INTERN BOOT CAMP:Altered Mental Status
Caroline Soyka PGY3
Objectives
Provide an overview of the definition of “altered mental status”
Develop reasonable differential diagnosis for acute mental status changes
Explain first steps in diagnosis and management of common causes of mental status changes
Definition
No clear definition Mental status is composed of two parts:
– Arousal: wakefulness, responsiveness– Awareness: perception of environment
Delirium (which we see a lot)
– Transient, usually reversible– Decreased attention span and waning confusion
Delirium vs. DementiaDELIRIUM DEMENTIA
Onset Acute/Subacute Insidious
Course Fluctuating Stable and progressive
Attention Fluctuates Steady
Sensorium Impaired Intact until late
Cognitive Globally impaired Poor short term memory
Perception Visual Hallucinations
Simple Delusions
Delirium
Extremely frequent– 14-56% of elderly hospitalized patients– 40% of ICU patients
In patients who are admitted with delirium, mortality rates as high as 10-26%
Development of delirium correlates with prolonged hospital stay, increased complications, increased cost, and long-term disability
McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med. Feb 25 2002;162(4):457-63.
Alertness Awareness Perform Tasks
Attention Span
“Cloudy Consciousness”
decreased retain impaired decreased
Lethargy decreased retain impaired decreased
Obtundation decreased decreased Requires stimulus
decreased
Stupor decreased decreased Requires constant stimulus
decreased
Coma Decreased Decreased None None
Epidemiology
AMS is primary reason for ED visit in 4-10% patients
ED patients > 65– 25% with AMS– 26% with minimal cognitive impairment– 34% with moderate cognitive impairment*prevalence of dementia 1% at age 60 and doubles
every 5 years until age 85 (30-50%)
So you are called for MS Δ’s…
What are the vital signs? What was the time course? What is the patient’s baseline? What medications have they received? What is the patient’s past medical history? Was there any trauma? Is there any focality to the neuro exam?
First Steps
ABCDE:– Airway– Breathing– Circulation– Disability– Exposure
Workup
HISTORY!!!!– Ask family– New meds?– Any significant PMH?
PHYSICAL– Vitals– Detailed physical WITH neurologic exam– GCS
Etiology
A alcohol, alzheimer’s E endocrine, electrolyte, encephalopathy I infection, intoxication O opiates, overdose, oxygen U uremia T tumor, trauma I insulin P poisonings, psychosis S stroke, seizures, syncope, shock, SAH,
Case #1
73 YO WM with h/o HTN and gout admitted for suspected septic arthritis of left knee. Patient had arthrocentesis this afternoon, results pending. You are called at 9pm because patient has had an acute change in mental status.
Exam
VS: T 37.5, HR 64, RR 16, BP 124/74, 96%RA Lethargic, not conversant, moaning, withdraws all 4
extremities to pain, responds to sternal rub
AEIOUTIPS
Drugs
Medications implicated in 30% of cases of delirium Common causes of mental status changes include
opioids, benzos, any anticholinergics Clues in the exam
– Opioids: miosis, decreased respirations, and hypotension – Anticholinergics: bradycardia, salivation, lacrimation, and
diaphoresis
Reversal Agents
Opioids?– Narcan (naloxone) 0.04 mg to 0.4 mg every 2-3
minutes** may need to readminister doses at a later interval (ie,
20-60 minutes) depending on type/duration of opioid – If reversal does not occur quickly or after 0.8 mg,
diagnosis should be questioned– Note: you need higher doses (0.4-2 mg) for
known/suspected opioid overdose
Reversal Agents
Benzodiazepines?– Flumazenil 0.2mg IVP, repeat every 30 seconds
up to total dose of 2mg– If reversal does not occur quickly,
diagnosis should be questioned– Beware of black box warning:
– BZP reversal may seizures especially in patients on long term BZPs or following TCA overdose. Be prepared for seizures!
A Daily J.J. Diatribe… Polypharmacy in the Elderly:
Remember to check GFR and appropriately dose medications Check for drug-drug interactions and ask about OTC’s &
herbals Avoid anything with anticholinergic properties JUST STOP UNNECCSSARY MEDS
Case #2
61 YO AAM with ESRD 2/2 poorly controlled DM2 on HD admitted to Eckel for lack of HD access due to clotted fistula. You are called at 7am with mental status changes.
VS: T 35.6, HR 88, RR 20, BP 152/86, SAT 96% RA
Exam: Moaning, incoherent, diaphoretic, drooling
Accu-check Glucose: 28 mg/dL
AEIOUTIPS
Causes of Hypoglycemia
Overly aggressive insulin regimen Renal failure Liver failure Infection/Sepsis Excessive EtOH consumption Rare Stuff
– Adrenal insufficiency– Insulinoma
Hypoglycemia Management
Is patient awake enough to drink some juice, take glucose tabs?
– Three glucose tabs will raise blood sugar by 50. If unable to take PO and has IV access, then give
use IV dextrose– 1 amp D50 = 50 grams of glucose
If patient does not have IV access and unresponsive, give Glucagon 1mg IM/SC.
Always recheck glucose 15-20 minutes later to document return to euglycemia.
Case #3
64 YO obese WF with GOLD class III COPD on 2L home O2 admitted to Wearn team with COPD exacerbation. You are called for mental status changes at 10:55 PM.
VS: T 36.4, HR 88, RR 18, BP 134/66, SAT 99% on 8L O2 via NC
Exam: Lethargic, arouses only to sternal rub, lungs with poor air exchange
ABG: 7.18 / 103 / 95 / 98% on 8L Via NC
AEIOUTIPS
Hypercapnea because of supplemental Oxygen:
1) V/Q mismatch: if a part of the lung is underventilated it should be underperfused (hypoxic pulmonary vasoconstriction)adding O2 increases perfusion but NOT ventilation
2) Haldane effect: Deoxygenated hemoglobin is able to carry more carbon dioxide than oxygenated hemoglobin
3) Respiratory homeostasis: Chronic elevation of CO2 leads to CO2 being less of a stimulant for respiratory drive and PaO2 provides stimulus, therefore supplemental O2 decreases respiratory drive leading to CO2 retention
Five Causes of Hypoxia*
1. Hypoventilation2. Shunt3. Increased Diffusion Gradient4. Decreased FiO2
5. V-Q Mismatch
* A favorite Schilz PIMP question.
Key Points to Remember
Whenever patients are requiring more FiO2, check an ABG to ensure they are not retaining CO2
Look at baseline HCO3 to have an idea of whether patient is a CO2 retainer
Elevated PaCO2 with mental status changes buys a ticket to the MICU
Case #4
62 YO WM with ischemic cardiomyopathy and HFrEF (last EF 10-15%) admitted to Hellerstein for volume overload and mental status changes
VS: T 36.4, HR 98, RR 20, BP 74/40, SAT 93% 3L
AEIOUTIPS
Hypoperfusion
Anything that decreases cerebral perfusion can alter mental status– CHF exacerbation with worsening cardiac output– Severe Sepsis– Hypovolemia– Myocardial Infarct– “Shock”
Indication for ICU transfer
A word on sepsis…
SIRS: >1 of the following manifestations: – Temperature > 38°C or < 36°C (> 100.4°F or < 96.8°F) – Heart rate > 90 beats/min – Tachypnea, as manifested by a respiratory rate > 20
breaths/min (or PaCO2 < 32 mm Hg)– White blood cell count > 12,000 cells/mm3, < 4,000
cells/mm3, or the presence of > 10% immature neutrophils Sepsis: At least two SIRS criteria caused by known
or suspected infection Severe Sepsis: Sepsis with acute organ dysfunction Septic Shock: Sepsis with persistent or refractory
hypotension or tissue hypoperfusion despite adequate fluid resuscitation
Case #5
93 YO WM with Alzheimer’s Dementia admitted for aspiration pneumonia. Patient had a PEG placed and is getting tube feeds via PEG while his pneumonia is being treated with Zosyn. Patient develops mental status changes on hospital day #4.
VS: T 36.4, HR 100, RR 22, BP 134/66, 94% on RA RFP: 158 118 27
4.8 32 1.5
AEIOUTIPS
Electrolyte Abnormalities
Hypernatremia Hyponatremia Hypercalcemia
Hypernatremia:
Signs and Symptoms: Mental status changes, hyperreflexia, seizures, and coma
Causes:-Hypovolemic: diarrhea, inadequate intake, renal losses-Euvolemic: DI (central and nephrogenic)-Hypervolemic: Hypertonic saline use, mineralcorticoid excess
Treatment: -Hypovolemic: Calculate Free H2O deficit: Replete with free H20 or D5W -Euvolemic: DI: Central: dDVAP, Nephrogenic: Treat underlying cause
-Hypervolemic: D5W and Loop Diuretic
Serum [Na] Water deficit = Current TBW x (——————— - 1) 140
Hyponatremia
Signs and Symptoms: Lethargy, seizures, mental status changes, cramps, anorexia
Diagnosis/Causes of Hyponatremia:- Hypovolemic: Diuretic use/Poor PO intake- Euvolemic: SIADH/Severe Trauma - Hypervolemic: CHF/Liver Failure/Nephrotic syndrome
Treatment:*** Only use hypertonic saline if actively seizing ***- Hypovolemic: NS- Euvolemic/Hypervolemic: water restriction
Note: SIADH which does not respond to water restriction, use a vaptan
(Vasopressin antagonist)
Hypercalcemia
Signs and symptoms– Bonesosteopenia– Stoneskidney stones and polyuria– Groansabdominal pain, anorexia, constipation, ileus, N/V– Psychiatric overtonesdepression, psychosis,
delirium/confusion Causes of Hypercalcemia
– MCC in outpatients is hyperparathyroidism– MCC in inpatients is malignancy– Other causes include vitamin A or D intoxication, sarcoid,
thiazide diuretics, immobilization, multiple myeloma
Hypercalcemia
Treatment– Hydrate the patient with NS– Calcium diuresis with furosemide– For severe hypercalcemia, calcitonin
rapidly/transiently lowers calcium in few hours– IV bisphosphonates lower further and last longer
but take for effect to kick in
Case #6
48 YO WM with h/o hepatitis C/Cirrhosis admitted for progressively worsening jaundice, weight loss, and AMS. RUQ u/s in ED, revealed a mass in liver. Pt admitted for work-up of mass and AMS. Upon arrival to room you find patient difficult to arouse.
Vitals: T 38.0 HR 66 RR 16 BP 96/60 SAT 98% RA
Exam
Gen: Stuporous, arousable but not coherentABD: Good bowel sounds, distended with moderate ascites,
diffusely tender to palpation with rebound tenderness NEURO: Diffuse hyperreflexia, + Asterixis
CT head: No hemorrhage or mass effect
Labs:- HCT 10/30 (Baseline 10.5/31)
- WBC: 18K (with left shift)
•AEIOUTIPS
Hepatic Encephalopathy
Stage Consciousness Intellect and Behavior Neurological Findings
0 Normal Normal Normal examination; impaired psychomotor testing
1 Mild lack of awareness
Shortened attention span; impaired addition or subtraction
Mild asterixis or tremor
2 Lethargic Disoriented; inappropriate behavior
Obvious asterixis;slurred speech
3 Somnolent but arousable
Gross disorientation; bizarre behavior
Muscular rigidity and clonus; Hyperreflexia
4 Coma Coma Decerebrate posturing
HE Precipitants
Infection: Infection may predispose to impaired renal function and to increased tissue catabolism, both of which increase blood ammonia levels.
Bleeding: The presence of blood in the upper gastrointestinal tract results in increased ammonia and nitrogen absorption from the gut. Bleeding may predispose to kidney hypoperfusion and impaired renal function. Blood transfusions may result in mild hemolysis, with resulting elevated blood ammonia levels.
Electrolytes: Decreased serum potassium levels and alkalosis may facilitate the conversion of NH4+ to NH3.
Med non-compliance: Ask family about lactulose use Renal failure: Renal failure leads to decreased clearance of urea,
ammonia, and other nitrogenous compounds. Medications: Drugs that act upon the central nervous system, such as
opiates, benzodiazepines, antidepressants, and antipsychotic agents, may worsen hepatic encephalopathy. Or ETOH use
Dehydration: vomiting, diarrhea, large volume para, diuretics
Management of HE
Correct the underlying cause…1st line: Lactulose
– Oral: 20 gm PO Q1-2 hrs for 3-5 BM’s/day– Enema: 300 mL in 1 L of water Q4-6 hrs – Diarrhea, flatulence, cramps
Antibiotics:- Rifaximin: 550 mg BID
helps prevent recurrent episodes of HE
Case #7
52 YO WM with h/o etoh abuse, HTN, DM2 admitted for right femoral neck fracture after falling, went to OR for pinning. Remained in house for physical therapy and placement.
You are called for headache, agitation, and visual hallucinations.
Vitals: T 38.6, HR 96, RR 20, BP 170/86, 96%RA
•AEIOUTIPS
EtOH Withdrawal
CIWA Scale
Nausea/Vomiting
Tremor
Sweats
Anxiety
Agitation
Tactile Disturbances
Auditory Disturbances
Visual Disturbances
Headache
Orientation
-symptoms treated with ativan and other prn’s
**CIWA’s > 20 consider MICU transfer**
Case #8
45 YO AAF with h/o polysubstance abuse and HTN admitted to Carpenter for fevers and HA. You are called to room by nurse soon after admission for mental status changes.
VS: T 38.6, HR 101, RR 26, BP 101/58, Sat 98%RA GEN: uncomfortable, AAO x 2 HEENT: + nuchal rigidity LUNGS: CTA b/l NEURO: no focal weakness
•AEIOUTIPS
CNS infections
Meningitis– Bacterial– Viral– Aseptic
Encephalitis Toxoplasmosis JC virus West Nile Virus
Lumbar Puncture
CT head or Ophthalmologic Exam done first to document no increase intracerebral pressure
Draw blood cultures from periphery
Do not delay giving antibiotics waiting for the CT and doing the LP
Send CSF for glucose, protein, gram stain and culture, cell count & differential, and suspected viral serologies
Treatment Antibiotic selection must be empiric
immediately after CSF is obtained
Age Common Pathogens
Antimicrobials
2-50 years N. meningitidis, S. pneumoniae
Vancomycin plus a third-generation cephalosporin
> 50 years S. pneumoniae, N. meningitidis, L. monocytogenes,
Vancomycin plus ampicillin plus a third-generation cephalosporin
> 50 years w/ suppression
Above + pseudomonas Vancomycin plus ampicillin plus meropenem/cefepime
****Add dexamethasone if suspected S. pneumo****
Seizures
Status epilepticus– Annual incidence exceeding 100,000 cases in the United
States alone, of which more than 20% result in death– Classically tonic-clonic jerking; loss of bowel/bladder;
tongue biting– Usually have post-ictal confusion
Non-convulsive status– Harder to diagnose, must always think about it– Need EEG to make diagnosis
Labs to send post-suspected seizure: CPK and Prolactin
Management of Seizures
Call Neurology Supportive care (Remember the ABC’s)
– Check fingerstick glucose/give amp D50 empirically Benzodiazepines
– Diazepam 5-10 mg per minute – Lorazepam 4-8 mg– Terminate ~75% of seizures
AED’s (Phenytoin, fosphenytoin)
} Be prepared for airway management and ICU transfer
Case #9
42 YO with DM2 and depression on SSRI’s admitted from ED for recurrent lower extremity cellulitis; patient known to be colonizer with MRSA and had severe flushing with Vancomycin last admission. Started on IV Linezolid. About 12 hours after antibiotics you are called for fevers and mental status changes.
Exam
VS: T 39.4, HR 98, RR 20, BP 104/60, SAT 98% RA GEN: Anxious, diaphoretic, A+Ox1 Neuro: Diffuse hyperreflexia with myoclonus
+ = ?
Serotonin Syndrome
Case #10
78 YO WM with h/o Stage IIB Colon Cancer admitted with SOB, found to have a PE. Patient is now on heparin drip, and he suffers a fall in his room trying to drag his IV pole to the bathroom. You are called to assess the patient.
Vitals: T 36.5, HR 52, RR 12, BP 170/88 Exam significant for new LLE weakness
•AEIOUTIPS
Intracranial Bleeding
Intraparenchymal Hemorrhage– Common after trauma or
after initiating anticoagulation in embolic stroke
– Call Neurosurgery
Intracranial Bleeding
Subdural– Subacute onset after
trauma– Crescent-shaped– Shearing of the
bridging veins– Call Neurosurgery
Intracranial Bleeding
Epidural hemorrhage– Most commonly
associated with skull fracture in area of middle cerebral artery
– Lentiform appearance– Call Neurosurgery
Intracranial Bleeding
Subarachnoid– Worst headache of on
e’s life– Usually in setting of
hypertensive emergency
– Call neurosurgery and control BP
Stroke
Embolic Stroke– Commonly in setting of
atrial fibrillation– Call Neurology and
activate the BAT pager
Case #11
93 YO AAM with HTN and vascular dementia admitted for UTI. Patient on ceftriaxone IV and awaiting placement in Brecksville. You are called at 3 AM because patient attempting to climb out of bed, very disoriented, and trying to pull out Foley.
T-37.7, HR-65, RR-16, BP-120/80PE: unrerkable
•AEIOUTIPS
Sun-Downing: Definition
Sun-downing: a group of behaviors occurring in some older patients with or without dementia at the time of nightfall or sunset.
Common Behaviors:– Confusion– Anxiety, agitation, or aggressiveness – Psychomotor agitation (pacing, wandering)– Disruptive, resistant to redirection– Increased verbal activity
Sun-Downing: Prevention
Give diuretics, laxatives early in day Discontinue any unneeded lines, catheters Ensure patient has glasses, working hearing aid Monitor amount of sensory stimulation Consider late afternoon bright light exposure Turn off lights and television during evening hours Avoid restraints if possible Attempt to re-orient patient Establish regular dose of drug for disturbing behavior
(if needed)