1、David T. Matero, M.D. Assistant Professor Emergency Medicine University of Colorado Denver,Altered Mental Status,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 i
2、t? What is the organ system(s) that could be involved?,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,WELCOME T
3、O EMERGENCY MEDICINE,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/suffocationDrowni
4、ng, fresh waterDrowning, sea waterDrowning/Near- drowningHeat exhaustion/prostrationHeat strokeEncephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposureElectrocution/lightning strikeHigh altitude cerebral edemaDecompression sicknessHigh altitude pulmonary edemaIatrogenic, S
5、elf Induced DisordersWater intoxicationHypothermic anesthesiaHyponatremia correction, rapidSurgical, Procedure ComplicationAnesthesia, generalBrain surgeryInfectious Disorders (Specific Agent)Pneumonia, bacterialAIDS MeningoencephalitisEncephalitis, herpes simplexEncephalitis, secondary viralEncepha
6、litis, viralMeningitis BacterialMeningitis, aseptic/viralMeningitis, HemophilusMeningitis, pneumococcalMeningococcal meningitisPneumonia/BronchopneumoniaPneumonia, acute lobarPneumonia, pneumococcalTyphoid feverMeningitis, tuberculosisAmebic (Naegleria) meningoencephalitisBacterial overwhelming seps
7、isCandidiasis systemicChickenpox encephalitisEncephalitis, bacterial/cerebritisEncephalitis, Dawsons/inclusion bodyEncephalitis, Eastern equineEncephalitis, mumpsEncephalitis, Murray valleyEncephalitis, non-viralEncephalitis, St Louis BEncephalitis, Western equineGram negative (e coli) meningitisHis
8、toplasmosis meningitisKunjin viral encephalitisLa Crosse viral encephalitisLegionella meningoencephalitisLeptospiral meningitisLeptospirosis/severe (Weils) typeListeria meningitisLyme meningoencephalitisMalaria, cerebralMeningitis, candidaMeningitis, Coxacki viralMeningitis, echo viralMeningitis, st
9、aphylococcus aureusMononucleosis encephalitisPlague meningitisPost-viral/infectious encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes syndromeRussian tick-bourne encephalitisToxic shock syndromeTrichinella meningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisL
10、egionaires diseaseListeria monocytogenes/listeriosisMeningitis, fungalRocky mountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleeping sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, CaliforniaEncephalitis, equine,
11、VenezuelanEncephalitis, Japanese BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acuteFungus brain abscessLeptospirosis IctohemorrhagicaInfected organ, AbscessesInfectionsAbscess, intracranialBacteremia/SepticemiaB
12、rain abscessEmbolism, septic, cerebralEndocarditis, infectiveMeningoencephalitisPneumonia, aspirationSepsisSepsis, overwhelmingSeptic shockUrosepsis/septicemiaEncephalomyelitis, acuteEncephalopathy/secondary/toxic/sepsisNecrotizing fasciitis/mixedBrain stem encephalitisEncephalitisMeningitisPneumoni
13、aGranulomatous, Inflammatory DisordersHemorrhagic pancreatitis, necrotizingPancreatitis/resp distress syndromeNeoplastic DisordersHypercalcemia of malignancyMetastatic brain diseaseBrain stem tumorBrain tumorFrontal lobe tumorMedulloblastomaMeningeal carcinomatosisParietal lobe tumorPrimary CNS lymp
14、homaTemporal lobe tumorBrain tumor , malignant (astrocytoma)CraniopharyngiomaGlioblastoma multiformeInsulinoma/Islet cell tumorMeningiomaPontine gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune DisordersEncephalitis, hemorrhagic, acuteEncephalitis, post viralEncephalomyelitis, necrotiz
15、ing hem. ac.Encephalomyelitis, post-infectiousStevens-Johnson syndromeTransfusion reaction, hemolyticLupus cerebritisPolyarteritis nodosaBehcets syndromeHashimotos EncephalitisMetabolic, Storage DisordersHypoglycemia, reactive diabeticDiabetic ketoacidosis/comaHyperosmolar hyperglycemic coma, nonket
16、Neonatal hyperbilirubinemiaMetabolic disordersMethemoglobinemia, HereditaryPorphyria, acute intermittentGlutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical DisordersEncephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHyperca
17、lcemiaHypercapnea HypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontine myelinolysis, centralDeficiency DisordersDehydration and feverDehydrationWernickes encephalopathyMalnutrition/StarvationPellagra/niaci
18、n deficiencyMarchiafava-Bignami syndromeCongenital, Developmental DisordersNephrogenic diabetes insipidusHereditary, Familial, Genetic DisordersMELAS EncephalopathyVan Bogaert encephalitisUsage, Degenerative, Necrosis, Age Related DisordersAlzheimers syndromeDementia, Lewy-body typeMultiple sclerosi
19、sRelational, Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia, factitiousCatatoniaManic deleriumAnatomic, Foreign Body, Structural DisordersAcute subdural hematoma/hemorrhageBrain compressionEpidural hematomaIntracerebral hematomaIntraventricular brain hemorrhageSubdural hematomaTa
20、mponade, cardiacBrain stem herniation/peduncle/tonsilsFat embolismSuperior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolismCerebral hemorrhageCerebral vein thrombosis/phlebitisIntracerebral hemorrhageMyocardial infarcti
21、on, acuteSubarachnoid hemorrhageTransient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosisCerebral/Venous sinus thrombophlebitisSuperior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexi
22、aSleep deprivationVegetative, Autonomic, Endocrine DisordersCardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shockConvulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotensionOrthostatic hypotensionPost-ictal statusThy
23、rotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignantMalignant hyperthermiaMyxedema comaMyxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart blockInappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, ju
24、venileNarcolepsyPickwicks syndromeReference to Organ SystemShockCerebral edemaDisseminated intravascular coagulopathyHepatic encephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndromeBrain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung di
25、seaseCerebral thrombotic thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremic encephalopathyEncephalopathyHyperviscosity syndromePernicious anemiaPontine lesion/disorderThrombotic thrombocytopenic purpuraCombined system disease/pernicious an.Fever Unknown OriginReversable Posterior Enceph
26、alopathy SyndromePathophysiologicSepsis encephalopathy/elderlyCardiac output reductionCerebral depressed functionsDrugsMedication/drugsBenzodiazepines Administration/ToxicitySedative drugs Administration/ToxicityDigitalis toxicity/poisoningHypoglycemia, diabetic/treatmentInsulin overdose/exogenousIn
27、toxication/overdose syndromeSalicylate intoxication/overdoseTricyclic overdoseBarbiturate/sedative abuse/dependentDrug induced Hypoglycemia.Oral hypoglycemic Administration/Toxicity/effectInsulin (Humulin/Novulin) Administration/ToxicityIsoniazid (INH/Nydrazid) Administration/ToxicityErgot toxicityI
28、soniazid 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 tremensI
29、nsecticide/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
30、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 ga
31、s exposureAluminum toxicity/syndromeAmmonia exposure/inhalationHydrogen sulfide poisoning/inhalationInsecticide/chlorinated/non-esters inhLead poisoningLead encephalopathyNitrogen narcotic actionCarbon disulfide inhalant/poisoningChlorine gas poisoningMethane gas poisoning/asphyxiaCarbon dioxide gas
32、 inhalation/asphyxiaOrgan Poisoning (Intoxication)Neuroleptic malignant syndrome,From Vertebrobasilar migraine syndrome to Hyponatremia Its 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 Exam fo
33、r current physiological state of patient-Labs-Imaging,Physiologic Reserve Determines How Readily the Patient Will Have 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 O
34、bvious Comorbidities: Other causes (than primary medical problem) will more readily alter this patient (less reserve!),You May Get Frustrated at this Patient and Say (ddx):,M: MetabolicB12 or thiamine deficiency, serotonin syndrome O: Hypoxemia (pulmonary, cardiac, anemia); high CO2 V: Vascular caus
35、eshypertensive 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, por
36、phyria I: Infection (inflammatory-see vasculitis above) D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol),M: MetabolicB12 or thiamine deficiency, serotonin syndrome,Glucose metabolism uses up even more thiamine Serotonin syndrome=serotonin toxicity and caus
37、ed by various drugs, medicines and combinations thereof-increased heart rate, shivering, sweating, dilated pupils, myoclonus, as well as overresponsive reflexes,O: Hypoxemia (pulmonary, cardiac, anemia); high CO2,Purely Hypoxic patient is anxious/agitated-PE Purely Hypercarbic patient is sleepy -Jet
38、 Insufflation in kids or bad COPDer,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),E: Electrolytes and endocrine,Ele
39、ctrolyte 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,S: Seizures / status epilepticus, post-ictal,Post-ictal state typi
40、cally 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,T: Tumor, trauma, temperature, toxins (lead, mercury, CO, toxidromes ),Tumor causes compression or d
41、iffuse 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 toxidr
42、ome for Ethanol),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),P: Psychiatric, porphyria,C
43、atatonia: 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,I: Infection (inflammatory-see vasculit
44、is above),Meningitis (A constant concern in all patient, esp at extremes of age) Cerebritis,D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRIs, BZDs, barbiturates, alcohol),Learn and look for Toxidromes (withdrawal states are usually essentially opposite in symptoms),In Summary: It ALL B
45、oils Down to One of Two Things,Both cerebral hemispheres are depressed The Reticular Activating System is not functioning.,In Summary: It ALL Boils Down to One of Two Things,Both cerebral hemispheres are depressed The Reticular Activating System is not functioning.,Diffuse Process most of the cases
46、arise from this,In Summary: It ALL Boils Down to One of Two Things,Both cerebral hemispheres are depressed The Reticular Activating System is not functioning.,Diffuse Process most of the cases arise from this,?,In Summary: It ALL Boils Down to One of Two Things,Both cerebral hemispheres are depresse
47、d The Reticular Activating System is not functioning.,Diffuse Process most of the cases arise from this,Stroke, Seizure or Trauma to this region,Approach the Patient Covering Most Urgent Bases First,ABCs Intravenous access, oxygen therapy, cardiac monitoring with pulse oximetry Accu-check / glucose
48、/ thiamine Cervical spine precautions Naloxone,Approach the Patient Covering Most Urgent Bases First,EKG / cardiac monitoring ABG with carboxyhemoglobin CBC, electrolytes, Ca, Mg Drug screen, EtOH, serum osmolarity Urinalysis Imaging lumbar puncture liver, thyroid,Approach the Patient Covering Most
49、Urgent Bases First,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.,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,
