Understanding Altered Mental Status: Symptoms & Causes

1. ALTERED MENTAL STATUS DAN MUSE, MD

2. AMS ALTERED MENTAL STATUS IS A SYMPTOM AND NOT THE DIAGNOSIS CAUSES: • INFECTION: MENINGITIS, SEPSIS • STRUCTURAL: STROKE, TRAUMA • METABOLIC: HYPOGLYCEMIA • INGESTIONS: NARCOTICS, ALCOHOL

3. AMSPNEUMONIC • A – ALCOHOL • E – EPILEPSY • I - INSULIN • O - OPIOIDS • U - UREMIA • T – TRAUMA, TEMPERATURE • I – INFECTION • P – POISONINGS • P – PSYCHIATRIC • S – STROKE, SHOCK

4. AMS • ALTERED MENTAL STATUS MAY BE INTERTWINED WITH OTHER CAUSES. • ALCOHOL CAN CAUSE TRAUMA WHICH COULD CAUSE A SEIZURE.

5. AMSALCOHOL • CAUSES AMS BY ITSELF • CAN CAUSE TRAUMA AND SECONDARY AMS • DROPS IN ALCOHOL MAY RESULT IN SEIZURES AND DELIRIUM IN CHRONIC ALCOHOLICS • ACUTE INTOXICATION CAN CAUSE DROPS IN BLOOD SUGAR ESP IN CHILDREN. • RESULTS IN MALNUTRITION AND THIAMINE DEFICIENCY IN CHRONIC ALCOHOLICS

6. AMSALCOHOL GUINNESS ADVERTISED THAT IT WAS GOOD TO DRINK IN PREGNANCY BECAUSE IT CONTAINED THIAMINE

7. AMSEPILEPSY (SEIZURE) • INTRINSIC SEIZURES • SEIZURES CAUSED BY SPACE OCCUPYING LESION; TUMOR, BLEED • POISONINGS: INH • METABOLIC: HYPOGLYCEMIA • INFECTION: MENINGITIS; FEBRILE SEIZURES • PSYCHIATRIC: PSEUDOSEIZURES

8. AMSINSULIN (DIABETES) • HYPOGLYCEMIA • HYPERGLYCEMIA: NONKETOTIC HYPERGLYCEMIA • HYPERGLYCEMIA CAUSE DEHYDRATION WHICH WORSENS AMS • DKA: HIGH OR LOW BLOOD SUGAR, ACIDOSIS AND…….AMS

9. AMSOPIOIDS • POTENTIAL FOR TRAUMA • HYPOXIA • INFECTION WITH IVDA

10. UREMIA • ELEVATED BUN IN THE BODY RESULTS IN ACIDOSIS, SYSTEMIC POISONING AND AMS

11. AMSTRAUMA • HEAD INJURIES • HYPOTENSION/BLOOD LOSS • HYPOXIA/ANOXIA

12. AMSTEMPERATURE HYPERTHERMIA • CONFUSION • COMA • SEIZURES HYPOTHERMIA • CONFUSION • COMA

13. AMSINFECTION • MENINGITIS • SEPSIS • PNEUMONIA AND HYPOXIA • FEVER AND CONFUSION FROM THE INFECTION

14. AMSPOISONINGS • NARCOTICS • BENZODIAZEPINES…PCP…SPICE……………. • PSYCHIATRIC MEDICATIONS • GLYCOL • METHANOL • …………….IN THE RIGHT DOSAGE OR IN THE RIGHT COMBINATION, ALMOST ANYTHING CAN CAUSE AMS

15. AMSPSYCHIATRIC • MAY BE DUE TO MEDICATIONS TAKEN BY THE PATIENT • CATATONIA; DEPRESSION; DELERIUM • PSEUDOSEIZURES • HIGHER PROPENSITY TO SUBSTANCE ABUSE • SUICIDE ATTEMPT

16. PSYCHIATRIC SYNDROMESDELUSION OF GRANDEUR DELUDE THEMSELVES INTO BELIEVING THEY ARE SOMETHING THEY ARE NOT

17. PSYCHIATRIC SYNDROMESDELUSION OF GRANDEUR THIS MAN BELIEVES HE IS A DOCTOR

18. AMSSHOCK • SEPSIS • CARDIOGENIC • TRAUMATIC • SPINAL

19. AMSSTROKE • STROKES VARY IN TYPE AND LOCATION • TYPES: HEMORRHAGIC, THROMBOTIC AND EMBOLIC • LOCATION: ANY PART OF THE BRAIN.

20. AMSHEMORRHAGIC STROKE • OFTENTIMES DUE TO CHRONIC HYPERTENSION • SMALL VESSEL DISEASE • BASAL GANGLIA OFTEN INVOLVED • LOCATION OF THE BLEED WILL DICTATE THE SYMPTOMS

21. AMSISCHEMIC STROKE • MOST COMMONLY THROMBOTIC BUT ALSO CAN BE EMBOLIC • SYMPTOMS CAN RELIABLY DETERMINE THE LOCATION OF THE STROKE

22. AMSBRAIN AND BLOOD FLOW

23. AMSCIRCLE OF WILLIS

24. AMSANTERIOR CEREBRAL ARTERY • CONTRALATERAL PARESIS; LEGS WEAKER THAN ARMS AND FACE • CONTRALATERAL SENSORY LOSS. • GAIT DISTURBANCE

25. AMSMIDDLE CEREBRAL ARTERY • CONTRALATERAL PARALYSIS; ARMS AND FACE WEAKER THAN LEGS • CONTRALATERAL SENSORY LOSS • APHASIA OR HEMINEGLECT. WHICH OCCURS IS DETERMINED BY THE EXACT LOCATION OF THE STROKE AND THE WHETHER THE PERSON IS RIGHT OR LEFT SIDED DOMINANT.

26. AMSPOSTERIOR CEREBRAL ARTERY • SUPPLIES CEREBRAL CORTEX • HOMONYMOUS HEMIANOPSIA (contralateral) • VISUAL AGNOSIA (can’t recognize objects) • CORTICAL BLINDNESS (e.g. after CPR) • MOTOR INVOLVEMENT MINIMAL

27. AMSHOMONYMOUS HEMIANOPSIA

28. AMS VERTBROBASILAR ARTERY • SUPPLIES BRAINSTEM, CEREBELLUM, VISUAL CORTEX • VERTIGO, NYSTAGMUS • VISUAL FIELD DEFICITS, DIPLOPIA • DYSARTHRIA, DYSPHAGIA • QUADRIPLEGIA • SYNCOPE, COMA

29. AMS VERTBROBASILAR ARTERY

30. AMS VERTBROBASILAR ARTERY WALLENBERG’S SYNDROME • Vertebral artery thrombosis • Ataxia, vertigo, nystagmus, nausea, vomiting. • Decreased pain and temperature sensation, ipsilateral face and contralateral body • Ipsilateral Horner’s Syndrome. (ptosis, miosis, anhydrosis

31. AMS VERTBROBASILAR ARTERY “LOCKED IN” SYNDROME • Basilar artery occlusion at pons • Seen with pontine hemorrage, central pontine myelinolysis • Patient is awake and lucid, able to feel and understand • No motor activity except diaphragmatic breathing. • Vertical eye movement is spared

32. AMSCEREBELLAR INFARCT • SUDDEN INABILITY TO WALK AND STAND • HEADACHE, DIZZINESS, NYSTAGMUS, ATAXIA, NAUSEA, VOMITING • CAN PRESENT WITH ONLY NAUSEA AND VOMITING • RAPID DETERIORATION WITH HEMORRHAGE AND EDEMA

33. AMSMCA CT STROKE

34. AMSHEMORRHAGIC CT STROKE

35. AMSHEMORRHAGIC CT STROKE

36. AMSHEMORRHAGIC CT STROKE

37. AMSCEREBELLAR CT STROKE

38. AMSPONTINE “LOCK IN” STROKE

39. AMSPCA CT STROKE

40. AMSTREATMENT DON’T FORGET THE OBVIOUS • HYPOXIA….0XYGEN • OVERDOSE…..NARCAN • HYPOTENSION…..FLUID BOLUS • HYPOGLYCEMIA….D50

41. AMSTREATMENT • DETERMINATION OF THE CAUSE AND THE TREATMENT OFTENTIMES IS BASED ON THE HISTORY OF WHAT OCCURRED. • YOUR FINDINGS OF THE EVENTS MAY BE THE ONLY CLUES WE HAVE ESPECIALLY FOR QUESTIONS OF SEIZURES • BE ACCURATE AND COMPLETE IN YOUR REPORTS.

42. AMSTREATMENT • STROKES COME IN VERY MANY FORMS • IF YOU THINK YOU HAVE A POTENTIAL STROKE….CALL IT IN AS SUCH

43. AMSTREATMENT • TIME IS THE LIMITING FACTOR IN A STROKE • IT IS IMPERATIVE WE KNOW WHEN THE SYMPTOMS BEGAN

44. AMSTREATMENT IT IS CRITICAL THAT YOU FIND OUT WHETHER FROM THE PATIENT OR FAMILY WHEN THE SYMPTOMS STARTED.

45. CASE #1 • 29 y/o who fell down some stairs. • Had been drinking and felt that he was intoxicated by family/friends • Opted to observe the patient for a couple of hours before calling 911.

46. CASE #1 • Normal vitals • Obtunded • No head trauma • GCS: 6 • What is the differential?

47. CASE #1 • Toxicology Screen: negative • ETOH: 261 • Glucose: 266

48. CASE #1

49. CASE #1

50. CASE #1