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Altered Mental Status

Altered Mental Status. Susan Schayes, MD, M.P.H Program Director Emory Family Medicine Residency Program Adapted from Dr. Eddie Needham. As life happens. You’re an Emory Family Medicine Resident at EUHM…at 4pm. You get the call from the ER that you

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Altered Mental Status

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

  2. As life happens • You’re an Emory Family Medicine Resident at EUHM…at 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.

  3. … you arrive to find a 63 year old male ESRD pt on HD who is not quite conscious. • You attempt to get a history – he’s not responsive enough. No one came with him by ambulance. • You do a cursory exam…hum…ABCs okay, lungs…heart…abd…okay, legs and arms attached and moving 

  4. Your nurse is drawing your usual rainbow tubes while putting in an IV… • That’s when you notice the vital signs… • Pulse 68 • RR 14 • BP 110/58 • Temp 100.5

  5. Today’s 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

  6. Define AMS

  7. 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

  8. Diagnosis and Treatment • What exam features and tests are routinely performed for AMS? • ABC’s, etc… • Finger stick blood sugar • Finger stick hemoglobin • ABG, pulse ox • Routine labs … like … • CMP, CBC, UA • Drug levels – acetaminophen, ASA, etc… • UDS

  9. Diagnosis and Treatment • Other labs: • Anion gap • Osmolality • Procedures/tests • Head CT • Lumbar puncture • CXR/radiology as indicated

  10. 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

  11. 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

  12. Clinical tests that are helpful to evaluate AMS • Glascow Coma Scale (GCS) • Mini-Mental State Exam (MMSE) MOCA

  13. Common causes of AMS on FMS • Hypoglycemia • Infection • Head injury • Stroke • Tumor/mets in brain • Undiagnosed dementia • Electrolyte imbalance • Overdose • Psychiatric causes

  14. 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

  15. Case 1 continued • After the second round, he then stands in the swimming pool at his sports complex at Lake Lanier to cool off

  16. 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.

  17. Divide into teams and formulate a differential diagnosis

  18. DDx? Group 1 first

  19. Case 1 cont’d • In the ER, he has already rec’d 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)

  20. 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 Case 1 cont’d

  21. Refine your DDx and initial treatment plans as a group

  22. 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 Case 1 cont’d

  23. DDx and Rx? Group 2

  24. 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 8–12 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?

  25. 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.

  26. Take a breather

  27. 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.

  28. 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.

  29. Hg 13 Hct 40 Plt Ct 117 WBC 3.2 MCV 102 Na 137 K 3.8 HCO3 15 Cl 100 BUN/Cr 28/1.5 Glucose 180 AST 52 ALT 48 T. Bili 1.7 Albumin 3.9 Case 2 labs

  30. Formulate a DDx and Rx plan

  31. Hg 13 Hct 40 Plt Ct 117 WBC 3.2 MCV 102 Na 137 K 3.8 HCO3 15 Cl 100 BUN/Cr 28/1.5 Glucose 180 AST 52 ALT 48 T. Bili 1.7 Albumin 3.9 Case 2 labs

  32. DDx? Any other info requested? Group 3

  33. 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?

  34. MUDPILESMemorize 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

  35. DDx in this patient? • Methanol or ethylene glycol? • How can you tell in the ER? • Urine – calcium oxalate crystals with? • Ethylene Glycol • It’s the middle of the night and the lab won’t look at the urine until the morning • What now?

  36. Can you prevent this?

  37. 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)

  38. Danger, Will Robinson, Danger

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

  40. Relax with the mist …and the critters

  41. 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.

  42. 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

  43. DDx and Rx?

  44. Ddx and Rx? Group ?

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

  46. Another classic case of AMS • Middle-aged male alcoholic is found down and brought to the ER. • Head CT shows …

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