Altered mental status medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]

Overview

The emergency department plays a critical role in the evaluation and management of older patients with altered mental status. The emergency department is often the initial point of entry for geriatric hospital admissions, and it is tasked with rapidly identifying those who are critically ill, while efficiently diagnosing the underlying etiology, and promptly initiating life saving therapies. The concepts pertinent to delirium can be generalized to stupor and coma, because there is significant overlap. Although altered mental status is common in presentation, its workup is challenging because the potential causes are vast, and they vary from nonserious to life-threatening. Therefore, a thoughtful, comprehensive approach is essential, which involves clarifying the history and onset of symptoms with the patients and/or caregivers, and localizing specific signs or symptoms to narrow the differential.

Medical Therapy

Evaluating a patient with altered mental status is difficult because obtaining a reliable history is often impossible. Initially, it is imperative to establish basic life support. Once the patient's airway, breathing, and circulation have been secured, a secondary emergency survey should be conducted. This includes securing adequate intravenous access, providing oxygen, and obtaining important vitals (e.g., temperature, respiratory rate, heart rate, BP, oxygen saturation, and blood sugar).

Pre-Hospital Care

Emergency medical services are often first to provide care for the patients with altered mental status. Initial goal of the management by an emergency medical services is stabilization of the patient, and prevent further nervous system damage. The following conditions must be identified and corrected promptly,

  • Hypotension
  • Hypoglycemia
  • Hypoxia
  • Hypercapnia, and
  • Hyperthermia

Airway

  1. Breathing spontaneous on initial assessment and adequate ventilation present,
    • Maintain oxygenation with cannula
    • Mask if oxygen saturation is below 94% titrate to 94%-99%
  2. Breathing spontaneous on initial assessment without adequate ventilation present:
    • Check airway for obstruction and clear if needed
    • After airway is clear, assist ventilation with an appropriate adjunct and oxygen
    • If adequate ventilation is not maintained, proceed to an advanced airway
  3. Not breathing on initial assessment:
    • Open airway with head tilt chin lift. If successful, assist ventilation at an adequate rate and depth then reassess
    • If head tilt chin lift is not successful, check airway for obstruction and clear if needed
    • After airway is clear, assist ventilation
    • If adequate ventilation is not maintained, proceed to an advanced airway[1]
  4. Mechanical ventilation if,
    • Hypoventilation
    • If increased intracranial pressure- to induce hypocapnia.
    • Immobilization of cervical spine is crucial and must not be ignored in suspected cervical fractures, especially during intubation and oculocephalic response evaluation.

IV Access

Establish IV access and

  1. Measure glucose level,
    • If blood glucose level is <60 mg/dl: administer oral glucose 15mg, only if there is no risk of aspiration and the patient is able to swallow.
    • 50% Dextrose in adults
    • 10% Dextrose in children
    • Thiamine is given with dextrose to avoid precipitation of Wernicke’s encephalopathy
    • If IV access can not be established, give IM Glucagon
  2. If patient does not recover, and respiration is depressed, administer IV Naloxone
  3. If no recovery, consider head trauma, stroke, intoxication, hypoxia, hypothermia
  4. Determine cardiac rhythm by 12 lead ECG
  5. If dehydration is suspected, or if blood sugar level is >250mg/dl, give IV fluid bolus once.[2]
Mental Status Consider following possibilities Management
Unarousable/difficult to arouse
  • Cerebrovascular events
  • Sepsis
  • Infections of nervous system
  • Space occupying lesion of CNS
  • Metabolic disturbance like hypoxia, hypoglycemia, hypercalcemia
  • Electrolyte disturbances
  • Uremia
  • Hepatic encephalopathy
  • Wernicke’s encephalopathy.
  • Intoxication
  • Endocrine disturbances
  • Decreased cerebral perfusion states like anemia, decreased cardiac output
  • Establish IV access
  • Cardiac monitor
  • Secure airway and maintain oxygen saturation
  • Rapid glucose administration
  • Check for increased intracranial pressure
  • Cold calorics
  • Electrolytes
  • Serum calcium level
  • Renal function tests
  • Thyroid scan
  • Workup for sepsis
  • Complete blood count
  • Head CT
  • EEG
  • EKG
  • Follow ACEP guidelines for intoxication
  • Thiamine
  • Naloxone
  • Immobilie cervical spine
Lethargy and decreased level of consciousness Check blood sugar level and administer glucose accordingly
  • Mental status examination
  • Confusion assessment methord exam
  • Oxygen saturation and administration if required
  • Electrolytes
  • Serum calcium level
  • Renal function tests
  • Complete blood count
  • Head CT
  • EEG
  • EKG
  • Thiamine
Hyperalert/agitation
  • Intoxication
  • Drug withdrawal
  • Alcohol withdrawal
  • Psychiatric causes
  • Hypoglyemia
  • Hypoxia
  • Hyperthyroidism
  • Blood glucose level assessment and IV dextrose
  • Anticipate disruptive behavior *from patient and treat agitation with restrains or pharmacologically if needed
  • Maintain oxygen saturation
  • Thyroid function tests
  • Minimental status examination
  • CAM
  • Toxicology workup
  • Thiamine
Acute cognitive impairment like disorientation, language difficulties, memory and learning disturbances
  • Intoxication
  • Psychiatric causes
  • CNS inections
  • Cerebrovascular events
  • Space occupying lesions
  • Minimental status examination
  • CAM
  • Electrolytes
  • Renal function test
  • Complete blood count
  • Head CT
  • LP if CT not available or nonconclusive
  • Sepsis workup
  • EKG
  • Thiamine

Hospital care

After emergency treatment and stabilization of the patient, a directed differential diagnosis should be considered. Directing the differential may be even more problematic in older patients, who often present with relatively common conditions in uncommon, subtle manners. For example, they may present with infections without fever or leukocytosis, or a perforated viscus without abdominal pain or tenderness. It is therefore important to tailor a thoughtful approach specific to individual patients. The use of a logical and stepwise approach is preferred to one that relies on broad testing, which can predispose to iatrogenesis.

Pupil Suspect Management
New asymmetry
  • Cerebrovascular accident
  • Space occupying lesion

Head CT

Bilaterally pin point
  • Opiods
  • Cholinergics
  • Head CT
  • Naloxone
  • Toxicology workup
Bilaterally dilated
  • Brain death
  • Anticholinergics
  • Sympathetic drugs

Toxicology workup



History and presenting symptoms Consider following possibilities Management
Intoxication Carbon monoxide poisoning
  • Carboxyhemoglobin level
  • 100% Oxygen
  • Follow ACEP guidelines
Opioid

Naloxone

Chronic drug use Withdrawal Supportive
Drug overdose
  • Drug specific antidotes, and
  • Supportive
Chronic alcohol use
  • Withdrawal
  • Subdural hematoma
  • Wernicke’s encephalopathy
  • Hepatic encephalopathy
  • Infection / Sepsis
  • Septic workup
  • Ammonia level
  • Complete blood Count
  • Head CT
  • Thiamine
  • Mg
  • Glucose
Trauma Intracranial hemorrhage Head CT

Headache

  • Intracranial hemorrhage
  • Intoxication
  • CNS infections
  • Space occupying lesion
Head CT
Seizure
  • Intoxication or withdrawal symptoms
  • Hypoglycemia
  • Cerebrovascular event
  • CNS infections
Follow ACEP guidelines to manage patient of seizures
Past history of seizure disorder
  • Status epilepticus- non convulsive
  • Antiepileptic medication overdose
  • Antiepileptic drug levels
  • EEG
  • Neurological consult
Immunocompromised or HIV positive

Space occupying lesion in brain

  • MRI
  • CT with and without contrast
  • Lumbar puncture and CSF fluid analysis for syphilis, fungal infections, mycobacterial infections
Taking anticoagulants

Bleeding in brain

  • Lab studies of coagulation like PT, PTT, INR
  • Head CT
Significant hypertension
  • Hypertensive encephalopathy
  • Intoxication
  • Thyroticosis
  • Hypertention related to pregnancy
  • Raised intracranial pressure
  • Intracerebral hemorrhage
  • Fundoscopy
  • Check for end organ damage
  • Thyroid function tests
  • Workup for toxicology
  • Head CT
  • LP if CT nonconclusive or not available
  • Treat hypertension
Heartbeat<60 *Intoxication
  • ICP
  • Hypothyroidism
  • Cardiac monitoring
  • Maintain airway
  • Oxygen if necessary
  • Thyroid function tests
  • EKG
  • Manage bradycardia
  • Toxicology workup
Heartbeat >100
  • Intoxication
  • Sepsis
  • Decreased cardiac output
  • Hypoglyemia
  • Hypoxia
  • Withdrawal syndrome
  • Thyrotoxicosis
  • Cardiac monitoring
  • Maintain airway
  • Oxygen if necessary
  • EKG
  • Toxicology workup
  • Thyroid function tests
  • Crystalloid challenge
  • Complete blood count
Compromised respiratory function
  • Intoxication
  • Cerebrovascular accident
  • Increased intracranial pressure
  • Maintain airway
  • Oxygen if necessary
  • Naloxone
  • Head CT
  • Arterial blood gas
  • Toxicological workup
Fever
  • CNS infections
  • Neuroleptic malignant syndrome
  • Seratonin syndrome
  • Intoxication
  • Cerebrovascular accident
  • Withdrawal syndrome
  • Thyrotoxicosis
  • Investigate source of infection
  • Sepsis workup
  • Thyroid function test
  • Complete blood count
  • Antibiotics
  • Control temperature
Hypothermia
  • Hypoglycemia
  • Intoxication
  • Sepsis
  • Hypothyroidism
  • Sepsis workup
  • Thyroid function tests
  • Toxicology workup
  • Complete blood count
Neurological deficit
  • Cerebrovascular accident
  • Space occupying lesion
  • Hypoglycemia
  • Todds paralysis
  • Uremia
  • Wernicke’s encephalopathy
  • Metabolic disorders
  • Measure and maintain blood glucose levels
  • Head CT
  • Thiamine
  • Platelate count
Asterixis
  • Hepatic encephalopathy
  • Uremia
  • Renal function test
  • Liver function tests
  • Arterial blood gases
  • Electrolyte
  • Investigate gastrointestinal bleeding
Icterus

Hepatic encephalopathy

  • Liver function tests
  • Serum ammonia
Papilloedema
  • Malignant Hypertension
  • Increased intracranial pressure
  • Head CT
Breath odor: fruity
  • Ketoacidosis
  • Serum Glucose
  • Serum ketone
  • Isopropanol levels
  • Electrolytes
  • Arterial blood gases
Nuchal rigidity
  • Meningeal irritation secendory to infections
  • Subarachnoid hemorrhage
  • Head CT
  • Lumbar puncture if not contraindicated
  • Antibiotics and steroids bacterial meningitis is suspected

[3]

  • Physostigmine for anticholinergictype drug overdose, mostly recommended to treat anticholinergic overdose associated with cardiac arrhythmias.
  • Use of benzodiazepine antagonists offers some prospect of improvement after overdose of soporific drugs and has transient benefit in hepatic encephalopathy.

References

  1. "http://www.idph.state.ia.us/ems/common/pdf/ems_protocols.pdf" (PDF). External link in |title= (help)
  2. "http://www.ncems.org/pdf/Pro17-AlteredMentalStatus.pdf" (PDF). External link in |title= (help)
  3. "Clinical policy for the initial approach to pa... [Ann Emerg Med. 1999] - PubMed - NCBI".




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