Altered mental status medical therapy: Difference between revisions
No edit summary |
No edit summary |
||
| Line 7: | Line 7: | ||
The ED plays a critical role in the evaluation and management of older patients with altered mental status. The ED 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. | The ED plays a critical role in the evaluation and management of older patients with altered mental status. The ED 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== | ==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). | 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). | ||
| Line 27: | Line 26: | ||
Mechanical ventilation if, | Mechanical ventilation if, | ||
:*Hypoventilation | :*Hypoventilation | ||
:*If increased intracranial pressure- to induce hypocapnia. | :*If increased intracranial pressure- to induce hypocapnia. | ||
===IV Access=== | ===IV Access=== | ||
Establish IV access | Establish IV access and measure glucose level, | ||
:* If blood glucose level is <60 mg/dl: administer oral glucose 15mg, if there is no risk of aspiration and the patient is able to swallow. | :* If blood glucose level is <60 mg/dl: administer oral glucose 15mg, if there is no risk of aspiration and the patient is able to swallow. | ||
:* 50% Dextrose in adults 12.5 -25 gm IV | :* 50% Dextrose in adults 12.5 -25 gm IV | ||
| Line 40: | Line 37: | ||
*If no recovery, consider Head trauma, stroke, intoxication, hypoxia, hypothermia | *If no recovery, consider Head trauma, stroke, intoxication, hypoxia, hypothermia | ||
*Determine cardiac rhythm by 12 lead ECG | *Determine cardiac rhythm by 12 lead ECG | ||
*If dehydration is suspected, or if blood sugar level is >250 give IV fluid bolus once. | *If dehydration is suspected, or if blood sugar level is >250 give IV fluid bolus once. | ||
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. | 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. | ||
Revision as of 03:29, 3 March 2014
|
Altered mental status Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Altered mental status On the Web |
|
American Roentgen Ray Society Images of Altered mental status |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]
Overview
The ED plays a critical role in the evaluation and management of older patients with altered mental status. The ED 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).
First goal in the management of altered mental status is stabilization of the patient, prevent nervous system damage. The following conditions must be identified and corrected promptly,
- Hypotension
- Hypoglycemia,
- Hypercalcemia
- Hypoxia
- Hypercapnia, and
- Hyperthermia
Airway
Oropharyngeal airway is established if the patient is breathing spontaneously. Tracheal intubation if,
- Apnea
- Upper airway obstruction
- Hyperventilation
- Emesis, or there is a risk of aspiration.
Mechanical ventilation if,
- Hypoventilation
- If increased intracranial pressure- to induce hypocapnia.
IV Access
Establish IV access and measure glucose level,
- If blood glucose level is <60 mg/dl: administer oral glucose 15mg, if there is no risk of aspiration and the patient is able to swallow.
- 50% Dextrose in adults 12.5 -25 gm IV
- 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 Glucagone
- If patient does not recover, administered IV Naloxone if respiration is depressed.
- If no recovery, consider Head trauma, stroke, intoxication, hypoxia, hypothermia
- Determine cardiac rhythm by 12 lead ECG
- If dehydration is suspected, or if blood sugar level is >250 give IV fluid bolus once.
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.
| History | Consider following possibilities | Management | ||
| Intoxication | Carbon monoxide poisoning |
| ||
| Opioid | Naloxone | |||
| Chronic drug use | Withdrawal | Supportive | ||
| Drug overdose |
| |||
| Chronic alcohol use |
|
| ||