Altered Mental Status and Coma Ch 229

1. Altered Mental Status and ComaCh 229 November 3, 09

2. Delirium • Delirium, acute confusional state, acute cognitive impairment, acute encephalopathy, all refer to a transient disorder with impairment of attention and cognition • Includes difficulty in focusing, shifting or sustaining attention; and disturbed wake-sleep cycles and fluctuating course of confusion

3. Pathophysiology • ALWAYS has an organic cause • 1. Primary intracranial disease • 2. Systemic diseases secondarily affecting the CNS • 3. Exogenous toxins • 4. Drug withdrawal

4. Clinical Features • Develops quickly over days • Attention, perception, thinking, and memory are all distorted to varying degrees • These features can change quickly • “sundowning” • Tremor, asterixis, tachycardia, sweating, htn, emotional outbursts and hallucinations may be seen

5. Diagnosis and Treatment • History and physical with mini-mental status exam • Check medications and side effects • CMP, UA, CBC and CXR • Consider brain CT and LP • Treat with emotional support, appropriate lighting • Haldol PO, IM or IV • Benzodiazepines

6. Dementia • Loss of mental capacity • Typical course is slow with insidious symptom onset • Usu. a sentinel event such as caregiver burnout causes the presentation to the ED • Vascular dementia • Cerebral vascular disease with multiple infarcts • Most are due to Alzheimer • Reduction in neurons in the cerebral cortex with increased amyloid deposition and production of neurofibrillary tangles and plaques

7. Clinical Features • Impairment of recent memory, gradual and progressive with preservation of motor and speech • Then loss of reading, decreased performance in social situation and losing directions • Lastly, extreme disorientation, inability to dress, care and feed oneself with personality change • Vascular dementia may also have asymmetric DTR, gait abnormality or weakness of an extremity

8. Diagnosis • History, family history • Physical exam • CBC, BMP, Ca, glucose, LFTs • 2001 evidence review also suggested thyroid studies, serum B12 and syphilis serology • CT or MRI at some point through the course • Consider normal pressure hydrocephalus

9. Treatment • Environmental and psychosocial interventions • Antipsychotic drugs; Namenda and aricept • Treatment of risk factors such as hypertension in those with vascular disease

10. Coma • State of reduced alertness and responsiveness from which the patient cannot be aroused • Glascow Coma Scale • Causes: • Deficiency of substrates: hypoglycemia, hypoxia • Mass causing midline shift or uncal herniation syndrome • Brainstem disease: hemorrhage • Bilateral cortical dysfunction • Both the brainstem and b/l hemispheres must be impaired for unresponsiveness to occur

11. Clinical Features • Features depend on depth of coma and cause • Ocular findings: pupil size and reactive, conjugate deviation of gaze • Breathing patterns • Muscle movement, reflexes and posturing • Reflex changes in blood pressure and heart rate with increased ICP or brainstem compression • “Cushings reflex” hypertension and bradycardia

12. Diagnosis • A, B, C • Reversible causes: hypoglycemia or opiate overdose • Routine blood work, drug screen and CT • If normal head CT, consider basilar artery infarct; diagnose with MRI or angiography • Consider nonconvulsive status epilepticus

13. Treatment • Treat underlying cause • Protect the airway: intubate, keep head of bed at 30* • Mannitol for increased ICP • ? Steroids in tumor induced brain edema • Current recommendations are to avoid prophylactic hyperventilation during the first 24hrs following injury • Communicate with consultants and admitting doc

14. Sources • Tintinalli 6th edition • Rosen’s Textbook of Emergency Medicine