Altered Mental Status

Susan Schayes, MD, M.P.H Program Director Emory Family Medicine Residency Program
Adapted from Dr. Eddie Needham

As life happens
Youre an Emory Family Medicine Resident at EUHMat 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.

 you arrive to find a 63 year old male ESRD pt on HD who is not quite conscious. You attempt to get a history hes not responsive enough. No one came with him by ambulance. You do a cursory examhumABCs okay, lungsheartabdokay, legs and arms attached and moving

Your nurse is drawing your usual rainbow tubes while putting in an IV Thats when you notice the vital signs Pulse 68 RR 14 BP 110/58 Temp 100.5

Todays 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

Define AMS

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

What exam features and tests are routinely performed for AMS?
ABCs, 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 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
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

Clinical tests that are helpful to evaluate AMS

Glascow Coma Scale (GCS) Mini-Mental State Exam (MMSE)
MOCA

Common causes of AMS on FMS

Hypoglycemia Infection Head injury Stroke Tumor/mets in brain Undiagnosed dementia Electrolyte imbalance Overdose Psychiatric causes

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
After the second round, he then stands in the swimming pool at his sports complex at Lake Lanier to cool off

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.

Divide into teams and formulate a differential diagnosis

DDx?
Group 1 first

Case 1 contd
In the ER, he has already recd 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 contd
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

Refine your DDx and initial treatment plans as a group

Case 1 contd
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

DDx and Rx?

Group 2

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 812 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
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.

Take a breather

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 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 Hct Plt Ct WBC MCV Na K HCO3 Cl BUN/Cr 13 40 117 3.2 102 137 3.8 15 100 28/1.5 Glucose AST ALT T. Bili Albumin 180 52 48 1.7 3.9

Formulate a DDx and Rx plan

Hg Hct Plt Ct WBC

Case 2 labs

13 40 117 3.2

Glucose AST ALT

180 52 48

MCV Na K HCO3 Cl BUN/Cr

102 137 3.8 15 100 28/1.5

T. Bili Albumin

1.7 3.9

DDx? Any other info requested?

Group 3

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!

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?

Methanol or ethylene glycol? How can you tell in the ER? Urine calcium oxalate crystals with?
Ethylene Glycol

Its the middle of the night and the lab wont look at the urine until the morning What now?

Can you prevent this?

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)

Danger, Will Robinson, Danger

Treatment?
Fomepizole (expensive- $1000 a vial) Alcohol drip Get nephrology on board ASAP Emergency dialysis Critical care medicine/ICU Poison control/toxicology consult

Relax with the mist and the critters

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
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

DDx and Rx?

Ddx and Rx?

Group ?

Case 3 DDx
Meningitis bacterial and others Malaria, especially falciparum - deadly HIV CNS infections Toxoplasmosis, cryptococcus, HSV, others

Another classic case of AMS

Middle-aged male alcoholic is found down and brought to the ER. Head CT shows

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 #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 #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

Peak Flow Pulsus paradoxus Exercise challenge assess ADLs

Summary
List ten causes of AMS Stabilize the patient
ABCs Labs the usual rainbow X-rays strongly consider a head CT Dont miss the uncommon things

Put the MMSE/GCS on your blackberry Put the AEIOUTIPS on your blackberry