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2. Overview
Altered mental status: It Could Be [almost] Anything! requires a
thorough work-up
What is the differential for altered mental status?
What is the type of problem that could cause it?
What is the organ system(s) that could be involved?
3. Example
63 yo female found down next to park bench.Bystander called EMS who
are now moving patient from gurney onto bed.
You ask for history: There is none
You ask for ROS: There is none
You ask for PMH, Meds, Anything!: There is none
WELCOMETO EMERGENCY MEDICINE
4. What Could Be Wrong With Her?
Tramua: Brain laceration/injuryConcussionDepressed skull
fractureHead traumaBrain, contusionBrain injury, massiveDiffuse
axonal injury/Acute brain traumaShaken Baby
SyndromeElectromagnetic, Physics, trauma, Radiation
CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea
waterDrowning/Near- drowningHeat exhaustion/prostrationHeat
strokeEncephalopathy/postanoxicHypoxiaHypoxic
environmentHypothermia, accidental/exposureElectrocution/lightning
strikeHigh altitude cerebral edemaDecompression sicknessHigh
altitude pulmonary edemaIatrogenic, Self Induced DisordersWater
intoxicationHypothermic anesthesiaHyponatremia correction,
rapidSurgical, Procedure ComplicationAnesthesia, generalBrain
surgeryInfectious Disorders (Specific Agent)Pneumonia,
bacterialAIDS MeningoencephalitisEncephalitis, herpes
simplexEncephalitis, secondary viralEncephalitis, viralMeningitis
BacterialMeningitis, aseptic/viralMeningitis, HemophilusMeningitis,
pneumococcalMeningococcal
meningitisPneumonia/BronchopneumoniaPneumonia, acute
lobarPneumonia, pneumococcalTyphoid feverMeningitis,
tuberculosisAmebic (Naegleria) meningoencephalitisBacterial
overwhelming sepsisCandidiasis systemicChickenpox
encephalitisEncephalitis, bacterial/cerebritisEncephalitis,
Dawsons/inclusion bodyEncephalitis, Eastern equineEncephalitis,
mumpsEncephalitis, Murray valleyEncephalitis,
non-viralEncephalitis, St Louis BEncephalitis, Western equineGram
negative (e coli) meningitisHistoplasmosis meningitisKunjin viral
encephalitisLa Crosse viral encephalitisLegionella
meningoencephalitisLeptospiral meningitisLeptospirosis/severe
(Weils) typeListeria meningitisLyme meningoencephalitisMalaria,
cerebralMeningitis, candidaMeningitis, Coxacki viralMeningitis,
echo viralMeningitis, staphylococcus aureusMononucleosis
encephalitisPlague meningitisPost-viral/infectious
encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes
syndromeRussian tick-bourne encephalitisToxic shock
syndromeTrichinella meningoencephalitisTyphus, acute/epidemicWest
Nile fever/encephalitisBrucellosisLegionaires diseaseListeria
monocytogenes/listeriosisMeningitis, fungalRocky mountain spotted
feverToxoplasma meningoencephalitisCreutzfeld-Jakob
diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleeping
sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis,
CaliforniaEncephalitis, equine, VenezuelanEncephalitis, Japanese
BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah
virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis,
acuteFungus brain abscessLeptospirosis IctohemorrhagicaInfected
organ, AbscessesInfectionsAbscess,
intracranialBacteremia/SepticemiaBrain abscessEmbolism, septic,
cerebralEndocarditis, infectiveMeningoencephalitisPneumonia,
aspirationSepsisSepsis, overwhelmingSeptic
shockUrosepsis/septicemiaEncephalomyelitis,
acuteEncephalopathy/secondary/toxic/sepsisNecrotizing
fasciitis/mixedBrain stem
encephalitisEncephalitisMeningitisPneumoniaGranulomatous,
Inflammatory DisordersHemorrhagic pancreatitis,
necrotizingPancreatitis/resp distress syndromeNeoplastic
DisordersHypercalcemia of malignancyMetastatic brain diseaseBrain
stem tumorBrain tumorFrontal lobe tumorMedulloblastomaMeningeal
carcinomatosisParietal lobe tumorPrimary CNS lymphomaTemporal lobe
tumorBrain tumor , malignant
(astrocytoma)CraniopharyngiomaGlioblastoma
multiformeInsulinoma/Islet cell tumorMeningiomaPontine
gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune
DisordersEncephalitis, hemorrhagic, acuteEncephalitis, post
viralEncephalomyelitis, necrotizing hem. ac.Encephalomyelitis,
post-infectiousStevens-Johnson syndromeTransfusion reaction,
hemolyticLupus cerebritisPolyarteritis nodosaBehcet's
syndromeHashimotos EncephalitisMetabolic, Storage
DisordersHypoglycemia, reactive diabeticDiabetic
ketoacidosis/comaHyperosmolar hyperglycemic coma, nonketNeonatal
hyperbilirubinemiaMetabolic disordersMethemoglobinemia,
HereditaryPorphyria, acute intermittentGlutaric
aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia,
acquired/toxicBiochemical DisordersEncephalopathy,
hypoglycemicHypoglycemia, infantileAcid/Base
derangementAcidosisHypercalcemiaHypercapnea
HypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic
acidosisMetabolic encephalopathyHypoxia, systemic,
chronicHypoglycemiaPontine myelinolysis, centralDeficiency
DisordersDehydration and feverDehydrationWernicke's
encephalopathyMalnutrition/StarvationPellagra/niacin
deficiencyMarchiafava-Bignami syndromeCongenital, Developmental
DisordersNephrogenic diabetes insipidusHereditary, Familial,
Genetic DisordersMELAS EncephalopathyVan Bogaert encephalitisUsage,
Degenerative, Necrosis, Age Related DisordersAlzheimer's
syndromeDementia, Lewy-body typeMultiple sclerosisRelational,
Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia,
factitiousCatatoniaManic deleriumAnatomic, Foreign Body, Structural
DisordersAcute subdural hematoma/hemorrhageBrain
compressionEpidural hematomaIntracerebral hematomaIntraventricular
brain hemorrhageSubdural hematomaTamponade, cardiacBrain stem
herniation/peduncle/tonsilsFat embolismSuperior vena cava
syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous
DisordersCerebral vascular accidentCerebral embolismCerebral
hemorrhageCerebral vein thrombosis/phlebitisIntracerebral
hemorrhageMyocardial infarction, acuteSubarachnoid
hemorrhageTransient cerebral ischemia attackCerebral
infarct/EncephalomalaciaBrain stem infarctCavernous sinus
thrombosisCerebral/Venous sinus thrombophlebitisSuperior sagittal
sinus thrombosisVertebrobasilar artery dissectionFunctional,
Physiologic Variant DisordersHyperpyrexiaSleep
deprivationVegetative, Autonomic, Endocrine DisordersCardiac
arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic
shockConvulsion/grand mal seizureEpilepsyHypoglycemia,
functionalIncreased intracranial pressureSeizure
disorderHyperthermiaHypotensionOrthostatic hypotensionPost-ictal
statusThyrotoxicosis (Graves disease)Hypothyroidism
(myxedema)Encephalopathy, hypertensiveHypertension,
malignantMalignant hyperthermiaMyxedema comaMyxedema
madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete
heart blockInappropriate ADH secretionVertebrobasilar migraine
syndromeHypothyroidism, juvenileNarcolepsyPickwick's
syndromeReference to Organ SystemShockCerebral edemaDisseminated
intravascular coagulopathyHepatic encephalopathyHypovolemic
shockRenal Failure AcuteRespiratory distress (adult) syndromeBrain
disordersRespiratory failure/Pulmonary
insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic
thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremic
encephalopathyEncephalopathyHyperviscosity syndromePernicious
anemiaPontine lesion/disorderThrombotic thrombocytopenic
purpuraCombined system disease/pernicious an.Fever Unknown
OriginReversable Posterior Encephalopathy
SyndromePathophysiologicSepsis encephalopathy/elderlyCardiac output
reductionCerebral depressed
functionsDrugsMedication/drugsBenzodiazepines
Administration/ToxicitySedative drugs
Administration/ToxicityDigitalis toxicity/poisoningHypoglycemia,
diabetic/treatmentInsulin overdose/exogenousIntoxication/overdose
syndromeSalicylate intoxication/overdoseTricyclic
overdoseBarbiturate/sedative abuse/dependentDrug induced
Hypoglycemia.Oral hypoglycemic
Administration/Toxicity/effectInsulin (Humulin/Novulin)
Administration/ToxicityIsoniazid (INH/Nydrazid)
Administration/ToxicityErgot toxicityIsoniazid hepatitisMilk-alkali
syndromePoisoning (Specific Agent)Opiate overdose toxidromeKitchen
gas/propane exposureAlcohol/Ethanol ingestion/intakeAlcohol
amnestic disorderAlcohol induced hypoglycemiaAlcohol intoxication,
acuteAlcohol seizure (rum fits)Cholinergic crisis toxidromeDelirium
tremensInsecticide/organophosphate typeOverdose,
drug/alcoholPoisoningSnakebite (neurotoxic/coral/cobra
type)Snakebite (rattlesnake/pit viper type)Alcohol
withdrawalHallucinogen abuseLead poisoning in childrenSmoke
inhalationHeroin/morphine usage/addictionCyanide/Hydrogen cyanide
exposure/poisoningVomiting CBW agent (Dm/Da/Dc) Weapon
exposureArsine gas (Hydrogen arsenide) poisoningCarbon monoxide
poisoning/exposureDiethylene Glycol poisoningEthylene glycol
[Antifreeze] ingestionInsecticide/pesticide poisoningIntentional
poisoningIsopropyl alcohol ingestion/poisoningMustard gas
exposure/poisoningNerve gas exposureAluminum
toxicity/syndromeAmmonia exposure/inhalationHydrogen sulfide
poisoning/inhalationInsecticide/chlorinated/non-ester's inhLead
poisoningLead encephalopathyNitrogen narcotic actionCarbon
disulfide inhalant/poisoningChlorine gas poisoningMethane gas
poisoning/asphyxiaCarbon dioxide gas inhalation/asphyxiaOrgan
Poisoning (Intoxication)Neuroleptic malignant syndrome
5. From Vertebrobasilar migraine syndrome to HyponatremiaIts TOO
MUCH
You need a clue:
-EMS report
-Cell phone (call family members)
-Bystander account
-PMH from meds, alert bracelet, wallet, PhysEx (e.g fistula)
-Phys Examfor current physiological state of patient
-Labs
-Imaging
6. PhysiologicReserveDeterminesHowReadily the PatientWillHave
AMS!
Frail Old Patient: A simple Urinary Tract Infection can put this
patient in a coma.
Young Healthy Patient: Likely to be something significant that has
gone wrong
Patient With Obvious Comorbidities:Other causes (than primary
medical problem) will more readily alter this patient (less
reserve!)
7. YouMayGetFrustrated at thisPatient and Say (ddx):
M: MetabolicB12 or thiamine deficiency, serotonin syndrome
O: Hypoxemia (pulmonary, cardiac, anemia);high CO2
V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA,
vasculitis, MI
E: Electrolytes and endocrine
S: Seizures / status epilepticus, post-ictal
T: Tumor, trauma, temperature, toxins ( lead, mercury, CO,
toxidromes )
U: Uremia. Renal or hepatic dysfuction with hepatic
encephalopathy
P: Psychiatric, porphyria
I: Infection (inflammatory-see vasculitis above)
D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs,
BZDs, barbiturates, alcohol)
8. M: MetabolicB12 or thiamine deficiency, serotonin syndrome
Glucose metabolism uses up even more thiamine
Serotonin syndrome=serotonin toxicity and caused by various drugs,
medicines and combinations thereof
-increased heart rate, shivering, sweating, dilated
pupils,myoclonus, as well as overresponsive reflexes
9. O: Hypoxemia (pulmonary, cardiac, anemia);high CO2
Purely Hypoxic patient is anxious/agitated
-PE
Purely Hypercarbic patient is sleepy
-Jet Insufflation in kids or bad COPDer
10. V: Vascular causeshypertensive emergency, ischemic/hemorrhagic
CVA, vasculitis, MI
All of these cause poor perfusion of the brain either focally or
globally through local effects (CVA) or through loss of forward
flow to brain (MI)
11. E: Electrolytes and endocrine
Electrolyte shifts can cause swelling in the brain
High Na or Ca global depression (any electrolyte involved in
ion-channel transmission in the brain can cause a problem)
Hypoglycemia most common cause of endocrine-related MS
depression
12. S: Seizures / status epilepticus, post-ictal
Post-ictal state typically resolves in 20-40minutes
Non-epileptiform seizures can be cause of depressed mental
status
-No tonic-clonic activity
-Ultimately diagnosed with EEG
-Eye movement, hx, trial of Ativan may give clue
13. T: Tumor, trauma, temperature, toxins (lead, mercury, CO,
toxidromes )
Tumor causes compression or diffuse edema
Hypothermia: Global depression of ion-channels
Toxins: Wide range of responses depending on individual and their
reserve
Look for Toxidromes- A symptom constellation specific to a given
toxin (e.g. Slurred speech, B lateral-gaze nystagmus, cerebellar
deficits, altered mood is the toxidrome for Ethanol)
14. U: Uremia. Renal or hepatic dysfuction with hepatic
encephalopathy
Electrolyte Abnormalities
Uremia-Urea build-up AND electrolyte abnormalities
Hepatic Encephalopathy- elevated Ammonia (level should be high but
poorly correlated with actual degree of AMS)
15. P: Psychiatric, porphyria
Catatonia: no focal neurological deficits but unresponsive
(responds to Ativan!)
Porphyria: A group of enzyme deficiencies in hematologic
biosynthesis pathway that results in accumulation of Porphyrins (or
precursors): Multiple s/sx including various MS effects
16. I: Infection (inflammatory-see vasculitis above)
Meningitis (A constant concern in all patient, esp at extremes of
age)
Cerebritis
17. D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs,
BZDs, barbiturates, alcohol)
Learn and look for Toxidromes (withdrawal states are usually
essentially opposite in symptoms)
18. In Summary:It ALL Boils Down to One of TwoThings
Both cerebral hemispheres are depressed
The Reticular Activating System is not functioning.
19. In Summary:It ALL Boils Down to One of TwoThings
Both cerebral hemispheres are depressed
The Reticular Activating System is not functioning.
Diffuse Process most of
the cases arise from this
20. In Summary:It ALL Boils Down to One of TwoThings
Both cerebral hemispheres are depressed
The Reticular Activating System is not functioning.
Diffuse Process most of
the cases arise from this
?
21. In Summary:It ALL Boils Down to One of TwoThings
Both cerebral hemispheres are depressed
The Reticular Activating System is not functioning.
Diffuse Process most of
the cases arise from this
Stroke, Seizure or Trauma to this region
22. Approach the PatientCoveringMostUrgentBasesFirst
ABCs
Intravenous access, oxygen therapy, cardiac monitoring with pulse
oximetry
Accu-check / glucose / thiamine
Cervical spine precautions
Naloxone
23. Approach the PatientCoveringMostUrgentBasesFirst
EKG / cardiac monitoring
ABG with carboxyhemoglobin
CBC, electrolytes, Ca, Mg
Drug screen, EtOH, serum osmolarity
Urinalysis
Imaging
lumbar puncture
liver, thyroid
24. Approach the PatientCoveringMostUrgentBasesFirst
EKG / cardiac monitoring
ABG with carboxyhemoglobin
CBC, electrolytes, Ca, Mg
Drug screen, EtOH, serum osmolarity
Urinalysis
Imaging
lumbar puncture
liver, thyroid
Frail Old Patient: A simple Urinary Tract Infection can put this
patient in a coma.
25. 63 yo female found down next to park bench
You have no information: You do a physical exam
-A: Breath sounds CTAB,+gag, trachea midline, no pooling of
secretions,
-B: Spontaneous respirations
-C: Regular rhythm , tachycardia, B femoral pulses, diminished DP
pulses (but present)
-VS:101,88/45, T- 35.6, 92% RA
26. 63 yo female found down next to park bench
-HEENT: PERRL, TMs clear, MM slightly dry
-Neck: Supple, no JVD
-Chest: no crepitus, atraumatic
-GI: soft, BS present/normal; rectal no gross blood, NL tone
-Extrem: UE and LE with no clubbing, cyanosis, edema pulses present
except as noted in ABCs
-Back: Atraumatic, no step-offs
-Neuro: CN grossly intact, MAE, withdraws to pain, no gross focal
neurol deficits, reflexes symmetrical, does not answer Qs or follow
commands, moaning
-Skin: well perfused
-GU: Perineum atraumatic, no discharge or lesions
27. What Was Abnormal?What Could It Mean?
28. What Was Abnormal?What Could It Mean?
You have no information: You do a Physical Exam
-A: Breath sounds CTAB,+gag, trachea midline, no pooling of
secretions,
-B: Spontaneous Respirations
-C: Regular rhythm , tachycardia, B Femoral pulses, diminished DP
pulses (but present)
-VS:101,88/45, T- 35.6, 92% RA
29. 63 yo female found down next to park bench
-HEENT: PERRL, TMs clear, MM slightly dry
-Neck: Supple, no JVD
-Chest: no crepitus, atraumatic
-GI: soft, BS present/normal; rectal no gross blood, NL tone
-Extrem: UE and LE with no clubbing, cyanosis, edema, pulses
present except as noted in ABCs
-Back: Atraumatic, no step-offs
-Neuro: CN grossly intact, MAE, withdraws extrem to pain,no gross
focal neurol def, reflexes symmetrical, does not answer Qs or
follow commands, moaning
-Skin: well perfused
-GU: Perineum atraumatic, no discharge or lesions
30. Putting the PhysicalExamFindingsTogether:
Do you think this is a Global or a Focal Process?
How would you summarize the state of the patient based on
PEX?
What could cause this state?
31. What is more likely now?
M: MetabolicB12 or thiamine deficiency, serotonin syndrome
O: Hypoxemia (pulmonary, cardiac, anemia);high CO2
V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA,
vasculitis, MI
E: Electrolytes and endocrine
S: Seizures / status epilepticus, post-ictal
T: Tumor, trauma, temperature, toxins (lead, mercury, CO,
toxidromes)
U: Uremia. Renal or hepatic dysfuction with hepatic
encephalopathy
P: Psychiatric, porphyria
I: Infection (inflammatory-see vasculitis above)
D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs,
BZDs, barbiturates, alcohol)
32. What is more likely now?
M: MetabolicB12 or thiamine deficiency, serotonin syndrome
O: Hypoxemia (pulmonary, cardiac, anemia);high CO2
V: Vascular causeshypertensive emergency, ischemic/hemorrhagic CVA,
vasculitis, MI
E: Electrolytes and endocrine
S: Seizures / status epilepticus, post-ictal
T: Tumor, trauma, temperature, toxins ( lead, mercury, CO,
toxidromes )
U: Uremia. Renal or hepatic dysfuction with hepatic
encephalopathy
P: Psychiatric, porphyria
I: Infection (inflammatory-see vasculitis above)
D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs,
BZDs, barbiturates, alcohol)
33. Next Step: Diagnostic Studies
Prioritize acute life threats first
Get high-yield, easy items first: Glc, EKG
Keep modifying testing as DDX changes with results
Shotgun Approach (parallel processing)
Is patient stable to go to imaging or to wait for lab result before
making treatment decision?
34. How Do I Know What to Order?
Balance these two things to determine what tests/priority:
-Shotgun approach (intended to move things along quickly and cast
wide net)
-What youve learned from your H&P
35. LABS
141
101 26
101
4.1
17 1.1
UA:
Spec grav 1.026
pH 6.0
Ketones +
Glucose
Bile
Blood +
Bacteria ++
WBC ++
Nitrite +
Leuk. Est +
14.4
41.9
14.5380
LFTs- Normal
ASA, APAP, Coags Normal
36. LABS
141
101 26
101
4.1
17 1.1
UA:
Spec grav 1.026
pH 6.0
Ketones +
Glucose
Bile
Blood +
Bacteria ++
WBC ++
Nitrite +
Leuk. Est +
14.4
41.9
14.5380
LFTs- Normal
ASA, APAP, Coags Normal
37. Do We Know Whats Going On?
We know the patient has a UTI
Is this enough to explain the patients sepsis?
Can we stop our work-up?
Could the UTI be a red herring?
38. Do We Know Whats Going On?
We know the patient has a UTI
Is this enough to explain the patients sepsis? YES
Can we stop our work-up?
Could the UTI be a red herring?
39. Do We Know Whats Going On?
We know the patient has a UTI
Is this enough to explain the patients sepsis? YES
Can we stop our work-up? NO
Could the UTI be a red herring?
40. Do We Know Whats Going On?
We know the patient has a UTI
Is this enough to explain the patients sepsis? YES
Can we stop our work-up? NO
Could the UTI be a red herring?YES
41. What Else Should We Do?
Pt does have Sepsis and a UTI, this could be Urosepsis.HOWEVER, it
could also be something else (and there just happens to be a
UTI)
42. What Else Should We Do?
EKG MI, Intervals (Toxins), Other-
CXR PNA (Sepsis), Edema, Trauma-
Head CT Bleed, Swelling, Mass -
Lumbar Puncture Bleed, Infection -
Urine Drug Screen Drugs of Abuse -
43. What Else Should We Do?
EKG MI, Intervals (Toxins), Other- NORMAL
CXR PNA (Sepsis), Edema, Trauma- NORMAL
Head CT Bleed, Swelling, Mass - NORMAL
Lumbar Puncture Bleed, Infection - NORMAL
Urine Drug Screen Drugs of Abuse - NORMAL
44. We THINK We Know the Cause
Urosepsis
45. We THINK We Know the Cause
Urosepsis
Re-Examine the patient and make sure nothing has changed and that
the exam is consistent w Dx
Dont become emotionally attached to a Dx,as the clinical picture
can change and start looking like something else
The only atypical presentation is a typical presentation
46. CONCLUSION
Maintain a wide differential
Get a Grip on the Diagnosis through systematic clue finding
Remember: Its focal in the RAS, or diffuse in the Bilateral
Hemispheres
Re-evaluate patient frequently and do frequent hypothesis-testing
in your mind