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Altered Mental Status

Altered Mental Status. PI Project 2011. Mnemonic: AEIOU TIPS. A lcohol intoxication/withdrawal, elevated a mmonia (hepatic encephalopathy) E lectrolyte abnormalities, especially hypoglycemia and severe hypoNa, hyperCa. E ndocrine – severe hyper/hypothyroidism, Addisonian crisis, DKA/HHNS

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Altered Mental Status

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  1. Altered Mental Status PI Project 2011

  2. Mnemonic: AEIOU TIPS Alcohol intoxication/withdrawal, elevated ammonia (hepatic encephalopathy) Electrolyte abnormalities, especially hypoglycemia and severe hypoNa, hyperCa. Endocrine – severe hyper/hypothyroidism, Addisonian crisis, DKA/HHNS Iatrogenic – i.e. steroid psychosis, anticholinergics in elderly, opiates, benzos O – HypOxemia – pneumonia, PE, carbon monoxide etc. CO2 narcosis

  3. Mnemonic: AEIOU TIPS Uremic encephalopathy Trauma (concussion, subdural or epidural hematoma), TIA/CVA Infection – sepsis, encephalitis, meningitis, UTI, pneumonia (elderly are especially prone to AMS with infection) Poisons/toxins – including intoxication or withdrawal from drugs of abuse Seizures – ictal (including nonconvulsive) or post-ictal

  4. Other causes of AMS not mentioned in mnemonic • Constipation. Common in elderly!! • Hydrocephalus • complicated migraine • CNS vasculitis • Hypertensive encephalopathy • Wilson’s disease

  5. Delerium is common! • Affects 10-20% of all hospitalized adults, 30-40% of elderly hospitalized patients, 60% to 80% of mechanically ventilated medical and surgical ICU patients and 50% to 70% of non-ventilated medical ICU patients

  6. Delerium vs Dementia Delerium: • Disturbance of consciousness (reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention) • Change in cognition (e.g., problem-solving impairment or memory impairment) or a perceptual disturbance • Onset of hours to days, and tendency to fluctuate (as opposed to dementia)

  7. Pointers on Treatment • ABCs and vitals first! • Remember to get head CT before LP if there is possibility of increased ICP • If pt is alcoholic, remember to give thiamine 100mg IV PRIOR to any dextrose to prevent exacerbation of Wernicke’s encephalopathy • Indication for Narcan: acute narcotic overdose and respiratory rate <8. Do not give simply for drowsiness! Discuss with your senior resident. • Indication for Flumazenil: acute benzo overdose and respiratory rate <8. Be extremely cautious when giving to patients with long-standing benzo use, as giving flumazenil may induce seizure.

  8. Pointers on Treatment • Make sure pain is adequately treated, lytes are repleted, no constipation, nutrition is optimized • Talk to patient, frequent re-orientation (i.e. tell them where they are, what time/day it is etc), family at bedside (familiar faces) are helpful. Consider placing clock in patient’s room. • Minimize intrusive procedures or exams to the extent possible • Medication of choice is Haldol • check baseline EKG for prolonged QT • if giving frequently/regularly, monitor periodic EKG or tele

  9. Pointers on Treatment • Do NOT give IV haldol to patient’s on a ward (non-ICU) bed. Can only give IM. • Watch for extrapyramidal side effects, especially with prolonged use • Neuroleptic malignant syndrome is a rare complication • Typical dosing: Initial: 2-10 mg depending on degree of agitation; may repeat bolus dose (with sequential doubling of initial bolus dose) every 15-30 minutes until calm achieved, then administer 25% of the last bolus dose every 6 hours. • After the patient is controlled, haldol should be tapered over several days. Note: QTc prolongation may occur with cumulative doses ≥35 mg and torsade de pointes has been reported with single doses of ≥20 mg

  10. Pointers for Neuro Exam • pupil size and reactivity: • pinpoint: suspect opiates • midposition and fixed: midbrain lesion • fixed and dilated: severe anoxic injury or herniation • signs of increased ICP: papilledema, pronator drift, unilateral dilated pupil. Cushing’s response causes HTN and bradycardia • Brainstem reflex testing: • Oculocephalics (“Doll’s eye”): moving head eyes should move in opposite direction • Oculovestibular (“cold calorics”)  inject cold water into ear  eyes should move toward lavaged ear. Mnemonic: COWS (COld Water Same side)

  11. Diagnostic Testing to Consider In addition to the routine tests (use the mnemonic to help you): • ammonia, LFTs • Lytes • EtOH level, urine toxicology, salicylates • Infectious workup, including u/a, CXR, pancultures • KUB (for constipation/ileus) • TSH • ABG • CT of head • EEG • Lumbar puncture

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