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Altered Mental Status

Tony Suharsono

Definition
Altered mental status (AMS) is failure

to respond to the external environment after appropriate stimulation


The spectrum of AMS ranges from

confusion to lethargy, stupor, and coma

Level of Conciousness
Alert: Follows commands in a timely

fashion Lethargic: Appears drowsy, may drift off to sleep during examination Stuporous: Requires vigorous stimulation (shaking, shouting) for a response Comatose: Does not respond appropriately to either verbal or painful stimuli

Etiology
AEIOU TIPS A: Alcohol, other toxins, drugs E: Endocrine, electrolytes I: Insulin (diabetes) O: Oxygen, opiates U: Uremia (renal, including HTN) T: Trauma, temperature I: Infection P: Psychiatric, porphyria S: Subarachnoid hemorrhage, spaceoccupying lesion

Clinical Manifestation
Pathologic conditions can be divided

into supratentorial lesions, subtentorial lesions, and metabolic dysfunction Supratentorial lesions present with focal motor abnormalities Subtentorial lesions produce rapid loss of consciousness, cranial nerve abnormalities, abnormal breathing patterns, and asymmetric or fixed pupils Metabolic dysfunction produces decreased level of consciousness before exhibiting motor signs

Diagnostic testing
Diagnostic

adjuncts should be guided by the clinical situation include analysis of blood, gastric fluid, urine, stool, cerebrospinal fluid (CSF), electrocardiography, or selected radiographic studies Rapid bedside glucose determination is a universally accepted standard If meningitis or encephalitis is suspected, lumbar puncture and CSF analysis should be done as rapidly as possible after initial resuscitation and stabilization A 12-lead electrocardiogram should be

obtained in cases where there are pathologic auscultatory findings or rhythm disturbances

Approach in AMS
A thorough history and physical

are paramount to determining the diagnosis The examination should look for signs of occult infection, trauma, toxicity, or metabolic disease. Aggressive resuscitation, stabilization, diagnosis, and treatment must occur simultaneously to prevent morbidity and death

Approach in AMS
AMS is a medical emergency. No time

should be wasted. It is often necessary to perform the phisical examination while obtaining the history
At least two individuals are needed in

caring AMS. One can be obtaining a medical history while the other performs resuscitation, followed by a more thorough physical examination

Management AMS
As with all ED patients, treatment begins

with the airway, breathing and circulation (ABCs). The main goals of treatment are physiologic stabilization, symptom relief and specific diagnosis-driven treatment plans. The first four recommendations are commonly referred to by the acronym DONT (dextrose, oxygen, naloxone and thiamine).

Management AMS
Airway, breathing, and circulation must be

ensured Continuous pulse oximetry and supplemental oxygen as needed to correct hypoxia should be provided, including bagvalve mask and intubation when appropriate Fluid resuscitation with 20-mL/kg fluid boluses of isotonic crystalloid is gven for hypotension

Management AMS
Perform bedside glucose testing and

administer glucose if indicated Control core body temperature to minimize metabolic demands If seizures are present, control with benzodiazepines Restore acid-base balance

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