Approach to Altered Mental Status

1. Sean Wilde MargrietGreidanus March 29 2012 Approach to Altered Mental Status

2. Outline: • Practical ED based Approach • Some important keys and pearls • Discuss thinking about altered MS in presentation categories • Practice it with cases • Discussion of selected diagnoses • Important not to miss • Not covered in other topics

3. Disorders of Consciousness Hypervigilent Confused Obtunded Drowsy/Lethargic Stupor Coma

4. Look ‘em up • Dementia • Chronic, slowly progressive, non-emergent • Delerium • Acute, fluctuating, **investigate** • 25% hyperactive • 50% hypoactive • 25% mixed • Assessment Tools: • GCS • AVPU • ACDU • Simplified Motor Scale • Confusion Assessment Method (CAM)

5. CAM for Delerium Acute onset and/or Fluctuating Course AND Inattention WITH EITHER Disorganized thinking OR Altered Level of Consciousness 91-97% sensitivity 85-94% specificity J Am Geriatr Soc. 2008 May ; 56(5): 823–830

6. Beware: “Grandpa’s just a little confused today”

7. Approach to the Clearly Altered

8. 2 Causes of altered LOC Behavior (Cerebral activity) Arousal (R.A.S.)

9. Bihemispheric dysfunction • Usually metabolic • Diffuse cerebral disease (infection, edema) • Brainstem dysfunction • Reticular activating system • Brainstem lesions • Herniation

10. Step 1: Unleash the A(BC)-Team

11. Unclear history? C-spine

12. Step 2: Absent an emergent A or B… Look for neurological findings before you sedate/paralyze

13. Step 3: Emergent Interventions The Coma Cocktail:Do DON’T, or don’t DON’T? • Dextrose • Only if glucose < 4 • 1 amp (25g) D50 • Oxygen • Narcan • Reasonable if any clinical/historical suspicion of narcotic use • 0.4-2mg IV/SC • Start small, increase. Full dose in code. • Response? Ongoing boluses vs infusion (2/3 effective dose) • Thiamine • If worried about nutritional deficiency • Q- Before or after glucose? • A- In the ED, who cares • No Flumazenil • Risk of seizure induction

14. GCS < 8: When Wouldn’t I Intubate? • If the airway is acutely threatened, or oxygenation/ventilation poor, then yes. • Otherwise, the indication for intubation is urgent, but not emergent. • Look first for rapidly reversible or self-limited causes of decreased LOC • Hypoglycemia, opioid overdose • Post-ictal, EtOH intoxication

15. Step 4: Full vitals with ACURATE temperature • Temperature can quickly direct your differential • Rectal most accurate • Can still trick you. • Rechecks

16. Emergent Temperature Control • Think of it like Blood Pressure • Healthy body can autoregulate • Thermal damage occurs when regulation fails Hypo/Hyperthermia in an altered patient is a critical finding requiring emergent correction!

17. Other emergent considerations • Treat shock state • Antibiotics • Sepsis, meningitis • Often indicated empirically • Steroids • Meningitis • Adrenal crisis • Benzos • Seizures, agitation

18. Step 5: Details • Evidence of trauma • Evidence of infection • Signs of shock • Toxidromes • Focal neuro symptoms • Brainstem reflexes • Seizure related injuries • Onset, course, symptoms • Meds/substance use • Medical history • Trauma Secondary Survey History

19. Step 6: Work-up • CBC, ERChem, LFTs, INR, PTT • Calcium, TSH • ABG • EKG • Blood cultures • Urinalysis/culture/tox • CT head • EtOH, ASA, apap, osm, toxic alcohols • Trauma films/CT • Chest x-ray • Lumbar Puncture • MRI • EEG Most of the Time When Indicated

20. Step 7: Diagnosis and Management • Supportive Care • Correct physiologic abnormalities • Treat underlying cause • Antidote?

21. Think in presenting Categories… Focal and Altered Hot and Altered Cold and Altered Trauma and Altered Shock and Altered Bradycardic and Altered Sudden vs. progressive But don’t fixate or exclude too early

22. So, what should I memorize?

23. Common Causes Rare Dangerous Treatable X

24. Most Common Causes • CNS infections • Trauma • Toxic ingestions • DKA • Severe dehydration • Congenital malformations • Metabolic disorders • Prolonged seizures • Infections / sepsis • Trauma • Intoxication/Withdrawal • Toxic ingestions • Seizures • Hypoglycemia • Intracranial bleeding • Hypoxia/CO2 narcosis • Electrolyte abnormalities Pediatrics Adults

25. Cases

26. The Hot and Altered Patient • Infectious • Toxidromes • Sympathomimetic, anti-cholinergic • Psychotropic meds • Environmental • Exertional or exposure Heat Stroke • Other Febrile illnesses • Thyrotoxicosis, thyroid storm • Neoplasms • Inflammatory conditions

27. Toxidrome differentiation Look at the Skin • Diaphoretic: sympathomimetic • Dry: anti-cholinergic • decreased bowel sounds • urinary retention

28. Serotonin Syndrome • Rapid onset • Myoclonus • Ocular clonus • Increased reflexes (hyperkinesia) • Difference b/wn upper and lower extremities • Neuromuscular Malignant Syndrome • Onset over days • Bradykinesia • Lead pipe rigidity (think Parkinson’s) • Extremity exam: upper = lower.

29. Heat Illnesses • Spectrum from mild (cramping, rash) to severe (coma and death) • Exertional heat stroke • Young, healthy athletes • Acute onset, exertion in high heat • Non-Exertional heat stroke • Typically young or elderly in heat waves • Slow onset, abnormal lytes common.

30. Water Intoxication • Acute Hyponatremia (<125) • N&V, malaise, dizziness, fatigue • Peripheral edema • Progression to cerebral edema • Risk Factors: • Exercise > 4hours • Female • Low body mass index • Free water consumption

31. Non-Convulsive Status Epilepticus • Persistent neurological seizure activity without obvious visible seizure activity • Difficult diagnosis • Controversial and developing clinical and EEG criteria • Add to DDx of “Altered/Comatose/Bizarre behavior of no obvious cause”

32. Non-Convulsive Status Epilepticus

33. Non-Convulsive Status Epilepticus

34. NCSE- Risk Factors • Known epilepsy • Even remote • Under-medicated • CNS infections (all types) • Any recent or remote seizure risk factors • Stroke, tumor, neurosurg, CNS catastrophe/trauma • Drug intoxication/withdrawal • Recent witnessed convulsive seizure

35. NCSE- When to suspect • Altered MS with no other obvious cause • Prolonged post-ictal period • >1-2 hours • Subtle motor activity • Minor tremors, twitching or eye deviations • Awake but altered with: • Slowing, disorientation • Somatomotor symptoms • Automatisms • Sensory hallucinations • Prolonged prodromal aura • New confusion or abnormal behavior in the elderly

36. J NeurolNeurosurg Psychiatry 2003;74:189–191 Most predictive Clues • Ocular movement abnormalities • History of seizures • Remote seizure risk factors: • Stroke • Neoplasia • Dementia • Previous neurosurgery Small study Poor design Not much else out there

37. NCSE- Management approach • Urgent EEG/Neurology to confirm/categorize if at all unclear of dx. • Treatment less urgent than convulsive • NCSE still probably damages neurons, but not nearly as much as convulsive • Mostly from animal studies and case series • Benzos are first line for all types • 4mg IV lorazepam X 2. • Treatment diverges then if it is Absence

38. NCSE- If Benzo’s fail… Comatose (esp post grand mal) Altered but preserved consciousness Impaired Consciousness Could be Absence Full standard status Tx Rapid progression to GA (midaz, propofol) Phenytoin Phenobarb VPA (std Status tx) VPA Phenobarb Avoid: Phenytoin Carbamazapine

39. Case #2Altered Elderly

40. Salicylate Toxicity • Early signs • Hearing changes, tinnitus • Tachypnea • Can be febrile • Late • CNS toxicity • AG Metabolic acidosis • Consider in: • Septic appearing elderly (most common misdiagnosis) • Herbal OD (wintergreen) • Any sick pt with AG metabolic acidosis and resp alkalosis.

41. Suspected Meningitis Approach • Blood cultures during ABCs • Antibiotics and dexamethasone • Ceftriaxone 2g IV • Vancomycin 1g IV • CT • LP • Antivirals • Acyclovir 10mg (0.15-0.3mg/kg)

42. CT before LP if: • Age > 60 • Immunocompromised • Altered or decreasing LOC • Seizure within 1 week • Known CNS disease • AVN, tumor, stroke • Malignancy Hx • Papilledema • Focal neurological finding (incl. aphasia) 97% negative predictive value for abnormal CT N Engl J Med 2001, Hasbun et al.

43. Steroids in meningitis • Bacterial lysis increases CNS inflammation • Steroids attenuate if given before/concurrently • Demonstrated benefit in Strep Pneumo (adults) and H. Influenza (Peds) • Probably no harm in others • Only Dexamethasone studied • Caution in overtly immunocompromised

44. Viral or Bacterial? Gaham, Can J Emerg Med 2003;5(5):348-9

45. Viral or Bacterial? • Caution in interpreting CSF • Significant overlap of findings • Normal is not always reassuring • Gram stain – 80% sensitive at best • Organism in blood culture: 50-91% of time • Empiric Acyclovir? • No good guidelines • Reasonable if high viral suspicion • Probably not as urgent as antibiotics

46. Case #3Cold and Altered

47. Adrenal Crisis • Severe hypotension • Fluid/pressor refractory • Dehydration and hypoglycemia • Abdominal Pain / GI symptoms • CNS disturbance • Confusion, disorientation, lethargy • Sepsis • With or without fever • Can be hypothermic

48. Myxedema Coma • Metabolic, multi-organ dysfunction • Features: • Mental status changes • Hypotension • Hypothermia (<35.5) • Clues • 90% elderly women in winter • Bradycardia, hypoventilation • Hypothyroid body habitus • Pleural/cardiac effusions • Absence of shivering • Delayed reflexes (esp relaxation phase)

49. Some definitions • Meningitis: • Infection/inflammation in subarachnoid space • Meningeal signs and symptoms • Encephalitis: • Infection and inflammation in brain parenchyma • Distinct neurologic abnormalities • Encephalopathy: • Global brain dysfunction • Altered LOC as primary feature • Movement disorders and eye findings prominent • Multiple forms/causes

50. Viral Encephalitis: Suspect in • New psychiatric symptoms • Cognitive deficits • Aphasia • Amnesia • Acute confusional state • Seizures • Movement Disorders • Often fever and meningeal signs