RRT – Mental Status Change Workshop

1. RRT – Mental Status Change Workshop Joseph Silberfarb, PA-C Theresa Rohrs, PA-C

2. Approach to Mental Status Change ABCs Identify life-threatening conditions Establish a baseline Past Medical History Review Medications / Mind-altering drugs Bedside evaluation Differential diagnosis Appropriate testing

3. Always airway first Blood pressure Pulse / rhythm Oxygen saturation Blood Glucose Temperature

4. Life Threatening Conditions & Responses Arrhythmia – ACLS Hypoxia/apnea/airway protection – intubate / ventilate & oxygenate Hypoglycemia – D50 Hypotension – IV access

5. Level of Consciousness Alert - awake Drowsy – asleep, but easy to arouse Lethargic – arousable, but not for long Stuporous – partially or almost completely unconscious Obtunded – very dulled response to stimuli; near comatose; not able to be awakened Comatose – no response to stimuli

7. Mental Status Appropriate – alert, cooperative Anxious - uncertainty, fear, restlessness Confused - disturbed orientation Agitated - restless with ↑activity, uncooperative, combative Psychotic - loss of contact with reality, delusions, hallucinations

8. Delerium v. Dementia Delerium Dementia A reversible state of cognitive impairment and confusion Sudden onset Usually toxic or metabolic Affects 30% of older hospitalized patients An irreversible state of cognitive impairment and short term memory loss Slow & progressive Sundowning–established behavior; usually late day confusional state, associated with behavioral changes

9. *The diagnosis of delirium requires the presence of features of 1 and 2 plus either 3 or 4.

11. AEIOU TIPS A – Alcohol E - Electrolyte disturbances I – Infection O – Overdose U – Uremia T – Trauma I – Insulin (hypoglycemia) P – Psychomotor disturbance S – Space occupying lesion (mass, bleed, infarcts, etc.)

12. Differential Diagnosis - Extensive Neurological: Respiratory: • Ischemic stroke – aphasia • Hypertensive encephalopathy • Seizures • Generalized • Complex partial • Post-ictal • Non-convulsive status epilepticus • Structural • Intracranial hemorrhage • Subdural hematoma • Hydrocephalus • Cerebral edema • Head trauma • Tumors Hypoxemia Hypercapnia Gastrointestinal: Hepatic encephalopathy Obstipation Genitourinary: Urinary obstruction Retention Renal failure / uremia

13. Fluid & Electrolytes: Infectious: • Dehydration • Hyponatremia • Hypernatremia • Hypoglycemia • Uremia • Thyrotoxicosis • Wernickes encephalopathy (thiamine deficiency) • Diabetic states: • Ketosis • Hyperosmolar hyperglycemia Miscellaneous: • Sleep deprivation • Psychiatric • SIRS • Sepsis • Meningitis • UTI • Pneumonia • Anything that can cause fever • The higher the fever, the more MS∆ • Elderly patients may be hypothermic Cardiovascular: Low perfusion state: • MI w/cardiogenic shock • Heart failure • Cardiac tamponade • Arrhythmias

16. Drugs, drugs, drugs Withdrawal: Initiation of Medications: • Benzodiazepines • SSRIs • Barbiturates • Psychotropics • Alcohol: • Seizures (12-48 hrs) • Alcoholic hallucinosis (12-48 hrs) • Delerium tremens (48-96 hrs) • Narcotics • Benzodiazepines • Steroids • Sleepers (Ambien) • Anticholinergics: • Reglan • Diphenhydramine • Oxybutynin

17. Physical Exam - Clues Dusky appearance Jaundice Needle tracks Smell of alcohol or ketones Trauma Bitten tongue Incontinence Tachycardia, flushing, sweating and dilated pupils (withdrawal from alcohol or sedatives) Peritoneal signs Asymmetry or localizing signs

18. Case Presentations

19. Acute Stroke Evaluate: 1-ABCs 2-Onset / LKW 3-NIHSS 4-Inclusion/Exclusion tPA 5-CT Head 6-Labs: CBC, Coags, BMP, cardiac enzymes Treat: Thrombolytics Aspiration Precautions VTE Prophylaxis Early Antithrombotics if no tPA Diagnostics: Customize to patient MRI/MRA, carotid ultrasound, echo, Lipids

20. NIH Stroke Scale 6 – motor legs 7 – limb ataxia 8 – sensory 9 – best language 10 – dysarthria 11 – extinction / inattention Score: 0-42 Severity of stroke Prognosis 1a – level of consciousness 1b – answers questions accurately 1c – follows commands 2 – best gaze 3 - visual fields 4 – facial palsy 5 – motor arms

21. Seizure – Initial Assessment • ABCs • Neurologic exam • Oxygenation • Mechanical ventilation • Cardiac monitor • Pulse oximetry • Frequent vital signs • Protect against injury temperature Fingerstick glucose Electrolytes Toxicology CBC LFTs CA & Mg ABG

22. Seizure Management #1 – STOP the SEIZURE: Benzodiazepines: • Diazepam – onset 10-20 seconds; terminates 50-80% of seizures; may only be effective 20 minutes • Lorazepam – longer onset 2 minutes but duration 4-6 hours #2 – PREVENT the next SEIZURE: Phenytoin – 15-20 mg/kg; infused 50mg/minute; cardiac brady-arrhythmias, hypotension risk; cardiac monitoring required; prevents recurrence Fosphenytoin – pro-drug of phenytoin; less local irritation at infusion site than phenytoin allows faster infusion rate (150mg/min); less cardiovascular effects; still requires cardiac monitoring Barbiturates (Phenobarbital / Pentobarbital) effective but not first-line; slow infusion rate and prolonged sedation; useful in refractory seizures

23. Seizures & Epilepsy in Elderly • 25% new seizures occur in > 65 year old patients • Seizure is a provoked event not expected to recur without a trigger (fever, alcohol withdrawal) • Epilepsy is recurrent unprovoked seizures expected to recur without treatment • Complex Partial – most common; may appear as episodic confusion, sleepiness, clumsiness, prolonged postictal state • Non-convulsive status epilepticus – confusion, psychosis, lethary or coma

24. Seizure Etiology: Acute Stroke - 50% (> hemorrhage, size & corticol) Metabolic – up to 30% - hypo / hyperglycemia - hyponatremia < 120 - hypocalcemia ~ 7 - uremia - hepatic encephalopathy Drugs – 10% - poly-pharmacy - impaired clearance - benzos, barbs & alcohol withdrawal Trauma 5-20% Epilepsy Etiology: Stroke 30-50% Cryptogenic 30-50% Dementia 15% Other: 5-15% Tumors, Trauma & Obstructive Sleep Apnea Seizure/Epilepsy Etiology

25. Tramadol or Ultracet

26. Right way eyes & Wrong way eyes Right way Wrong way Gaze preference TOWARD the side of the lesion – away from the side of the weakness STROKE Gaze preference AWAY from the side of the lesion – look toward the side of the weakness SEIZURE

27. Delirium Management Identify causes Treat the underlying illness Avoid drugs which increase delirium risk Familiar faces offer reassurance Sitter for safety Cautious trial of antipsychotics for severe agitation or psychosis with potential for harm (haloperidol 0.5 – 1 mg PO/IM/IV) Benzos can worsen confusion / sedation Avoid physical restraints