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Altered Mental Status (AMS)University of Utah Medical Center
Division of Emergency Medicine
Student Orientation
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Case 1
• 78 yo male
• CC: Unresponsive
• HPI: Arrives by EMS who state he was found in bed this morning by his wife, unresponsive. Usual state of health last night. No complaints. No recent illnesses. No signs of trauma
• PMHx: CAD, PAF, HTN, cholesterol
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Case 1
• All: PCN
• Meds: metoprolol, Lipitor, coumadin, nitro
• Surg Hx: appendectomy, L inguinal hernia repair
• Soc Hx: remote tobacco use, 2 drinks per evening, married, 3 children, retired police officer.
• FHx: CAD, HTN
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Case 1• Vitals: T 38 HR 56 RR 10 BP 210/100
SpO2 94% RA• HEENT: pupils sluggish, equal• Chest: CTA, heart RRR• Abd: soft NT/ND• Ext: scattered healing ecchymoses, 2+
pulses• Neuro: unresponsive, decerebrate
posturing to painful stimulus
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What’s going on? Diagnosis?
Hint: that’s your job
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Altered Mental Status
• Up to 40% of geriatric population
• Metabolic vs. structural– 80% metabolic
• Multifactorial
• May have more than one etiology at a time
• You need to be a (medical) detective
Naughton, Bruce et al. “Delerium and Other Cognitive Impairment in Older Adults in an Emergency Department: Ann of EM 1995(25): 751-5.
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Altered Mental Status
• Inattention• Confusion
– Intact mental status with misinterpretation of external stimuli
• Lethargy– Wakefulness with depressed awareness of self and environment
• Stupor– Unresponsiveness from which the pt. may be aroused with
vigorous noxious stimuli w/o achieving the normal baseline
• Coma– Unresponsiveness from which the patient cannot be aroused by
verbal or physical stimuli
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Mechanism• Cerebral cortex disruption
– must be BIHEMISPHERIC• Diffuse axonal injury• Toxins (drugs, EtOH)• Metabolic toxins (ammonia, urea)• Deficiency of substrates (glucose, oxygen)• Infections
– Focal lesions typically do not cause AMS
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Mechanism• Disruption of the Reticular Formation
– A grouping of fibers that traverses the brainstem to the thalamus
• Mediates state of wakefulness through continuous stimulation of the cerebral cortex
• Interruption usually from structural lesions– Supratentorial pressure (mass effect)– Infratentorial pressure (compression of brainstem)– Intrinsic brainstem lesions (pontine hemorrhage)
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Midline Shift which leads to herniation
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Differential Diagnosis
• AEIOU TIPS• A - Alcohol (drugs), Ammonia• E - Electrolytes, endocrine, environment (too hot/too cold)• I - Insulin (meaning glucose. High-DKA, HHNK; low
hypoglycemia)• O - Oxygen (hypoxia), Opiates• U - Uremia• T - Trauma, toxins• I - Infection (sepsis, meningitis)• P - Psychogenic, Porphyria• S - Stroke, SAH, Space occupying lesion, Shock
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History
• Many patients with AMS are poor historians – where to look?– Wallet / belongings– Friends / family– Witnesses– EMS– Police (can go to scene)– Medical record
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History
• PMHx– Psychiatric Hx
• Medicines – recent changes– account for pills– interactions
• Allergies• Social History
– EtoH– Drug use
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Physical Exam
• Vitals– Temp– Heart rate– Respiratory rate– Blood pressure– SpO2– Glucose
• Not really a vital sign but so important it should be
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Physical Exam
• ABC’s
• Head to toe, detailed exam– Undress patient completely– Look everywhere
• Signs of trauma• Sources of infection
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Respiratory Patterns• Cheyne-Stokes: regularly increasing depth of breathing
alternating with decreasing depth followed by a short period of apnea. – Diffuse cerebral injury– Absence of forebrain breathing control in metabolic disease
• Hyperventilation: deep, rapid breathing – Midbrain lesion – Hypoxia, metabolic acidosis, pain, anxiety
• Apneustic: prolonged pause at the end of inspiration– lesion proximal to CN V in the Pons
• Cluster (Biot’s breathing): breathing in short bursts – Pontine lesion
• Ataxic: irregular breathing– Leads to agonal respirations and death– Lesions of the medulla
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Physical Exam
• Skin – Color– Temperature– Moisture– Needle tracks/scars– Ecchymosis– Pressure bullae – Signs of trauma
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Physical Exam • Eyes
– Pupil size and reactivity• Tectal: large & fixed• Midbrain: midpositioned, fixed• CN III: unilateral, dilated & fixed• Pons: pinpoint• Opiates, cholinergics, anti-adrenergics: pinpoint/small• Sympathomimetics, anti-cholinergics: dilated
– Ocular movements• Roving movement confirm cortical control• Crossing of midline – intact brainstem• Deviation is away from inactive lesion, but towards seizure focus
– Fundoscopic exam• If possible• Pappilledema
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Physical Exam
• Neuro Exam-as able– GCS– CN– Motor– Sensory– DTRs– Cerebellar Exam
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Laboratory Data
• Fingerstick Glucose!• Oxygen saturation• Consider:
– Electrolytes– ECG– Drug levels– Tox screens (need to know which drugs they
are sensitive to)– TSH
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Studies
• Dictated by physical findings/differential
• Plain films (i.e. CXR)
• CT scan (head CT)
• MRI
• US
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Management
• ABC’s
• Check Glucose
• Coma Cocktail: classic teaching/mantra– Naloxone: won’t hurt, may clear things up– Thiamine: debatable– Dextrose: if glucose low
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Management
• Supportive
• Treat underlying cause
• Continue search
• Question suicidality
• Disposition
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Case 1
Diagnosis?
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Case 2
• 67 yo female
• CC: Altered mentation, frequent falls
• HPI: Brought in by boyfriend due to changed behavior and frequent falls. Slurred speech, slow to respond. Usually “sharp as a tack”. C/o mild HA, multiple bruises from falls (head, legs, arms).
• PMHx: hypertension
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Case 2
• All: NKDA
• Meds: HCTZ
• Surgical Hx: hysterectomy
• Social Hx: lives alone. Boyfriend lives next door. 80 pk-yr tobacco, daily EtOH (last drink 2 days ago), no drugs.
• FHx: not obtained
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Case 2
• Vitals: T 37 HR 70 RR 14 BP 120/60 SpO2 94% RA• HEENT: PERRL, EOMI, TMs clear. Bruising to L cheek.
Mucous membranes dry.• Neck: supple• Lungs: diminished• Cor: S1S2 RRR without murmur• Abd: Soft NT/ND; no HSM• Ext: Large ecchymosis to L thigh; Full ROM x 4; 2+
pulses througout• Neuro: CN II-XII intact. 2+ DTRs; No focal motor or
sensory deficit.
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Case 2
• What is your differential?• AEIOU TIPS• A - Alcohol (drugs), Ammonia• E - Electrolytes, endocrine• I - Insulin (meaning glucose high-DKA, HHNK; low
hypoglycemia)• O - Oxygen (hypoxia), Opiates• U - Uremia• T - Trauma, toxins• I - Infection (sepsis, meningitis)• P - Psychogenic, Porphyria• S - Stroke, SAH, Space occupying lesion, Shock
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Case 2
• What studies would you want?– Labs– Imaging
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Case 2
• Tox– EtOH negative
• Imaging– Head CT negative– CXR unremarkable
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Case 2
• CBC– WBC 10K– Hb 10– Hct 30.2– Plts 168
• CMP– Na 120– K 3.2– CO2 18– Gluc 125– BUN 30– Cr 1.8– Ca 7.4– LFTs nml
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Rapid Cases
•Brief H&P
•You come up with most likely Dx
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Rapid Case 1
• 88 yo female with confusion• Lives at assisted living• Confusion, urinary incontinence• h/o CAD, HTN• Vitals: T 38.9 HR 100 RR 18 BP 104/54 Sat
96% RA• Exam: non focal• Glucose 140• Lytes nml, WBC 10K UA++++• UTI/Urosepsis
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Rapid Case 2
• 21 yo female• Found by friends unresponsive at a party• PMHx: none• Vitals: T 36 HR 98 RR 8 BP 90/60 Sat 90% RA• Physical: Pinpoint pupils, bilateral rales,
unresponsive.• Glucose 90• Dx: Opiate overdose (with non-cardiogenic
pulmonary edema)
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Rapid Case 3
• 5 yo male• Presents with lethargy• Recent URI• Low grade temp, decreased appetite, increased
thirst, frequent urination.• Vitals: T 38 HR 130 RR 28 BP 90/50 Sat 98%
RA• Dehydrated, lethargic, tachypneic, non-focal
neuro exam• Glucose 405• Dx: DKA
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Rapid Case 4
• 36 yo male• Presents with wife with AMS• More confused, forgetful, waxing and waning.• PMHx: Hep C s/p blood transfusion• Vitals: T 37 HR 80 RR 18 BP 110/60 Sat 98% RA• Physical Exam: Scleral icterus, multiple contusions,
hepatomegally, non-focal neuro exam• Glucose: 105• Ammonia level: 90• Dx: Hepatic encephalopathy
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Rapid Case 5
• 90 yo female• Lethargy• Lives alone• Found unresponsive at home• Winter – using kerosene heater• Vitals T 34 HR 50 RR 10 BP 85/40 Sat 84%
RA• Glucose 90• DDx:
– Hypothermia– CO poisoning
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Rapid Case 6• 40 yo female
• MVA, low speed, confusion without signs of trauma
• PE: VSS; non-focal neuro exam, confused and mildly combative. Multiple small ecchymoses on abdomen (non-tender)
• Glucose 30
• Dx: hypoglycemia
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Rapid Case 7• 57 yo male• MVA into a tree, no seat belt, no skid marks, significant damage• Vitals: T 37 HR 120 RR 18 BP 90/50 SpO2 90% RA• Exam: Odor resembling EtOH, laceration to forehead, L chest
crepitation, +abdominal pain, multiple abrasions; neuro – intoxicated, combative, non-focal
• Glucose 90• Differential Dx:
– Head injury– Hypoxemia– Shock– EtOH intoxication– Other toxin– Suicide attempt?
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Summary
• AMS = Broad differential
• Difficult historians– When the history is suspect you must rely on
objective data i.e. physical exam, labs, imaging
• Be a detective
• Don’t forget GLUCOSE!