Altered mental status resident survival guide

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Altered mental status Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D.

Synonyms and Keywords: approach to delirium, approach to encephalopathy, encephalopathy workup, delirium workup

Overview

Altered mental status can result from a variety of factors, including alterations in the chemical environment of the brain, insufficient oxygen or blood flow in the brain, and excessive pressure within the skull. The level of consciousness may decline abruptly or slowly, or it may increase and decrease intermittently. Life threatening causes of altered mental status include malignant hypertension, myocardial infarction, rabies and sepsis. Other common causes of altered mental status include alcohol withdrawal, dehydration, electrolyte disturbance and hypoglycemia.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of altered mental status according to the the American Academy of Neurology guidelines.[1][2][3][4]


 
 
 
Patient with altered mental status (Amnesia, confusion, loss of alertness, disorientation, disruption of judgement, behavior and perception)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate ABCDEF
Airway
Breathing
Circulation
Disability (Glasgow coma scale)
• Exposure (Rapid head to toe revision)
Fingerstick blood glucose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check vital signs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable?
 
Yes
 
Stabilize
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Combative?
 
Yes
 
Apply physical or chemical restrain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Alcoholism and thiamine deficiency suspected?
 
Yes
 
Administer thiamine
 
Improvement
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hypoglicemic?
 
Yes
 
Administer dextrose
 
Improvement?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Opioid intoxication suspected?
 
Yes
 
Administer naloxone
 
Improvement?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform physical examination with full neurologic evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order CBC, electrolyte panel, liver and kidney function tests (including albumin), urinalysis, urine culture, urine toxicology screen, chest x-ray, EKG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspected neurodegenerative disease?
 
Yes
 
Perform minimental exam
 
Positive for neurodegenerative disease?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for neurodegenerative disorder, electrolyte imbalance, hepatic encephalopathy, urinary infection, pneumonia, drug intoxication?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform non-contrasted CT scan of the brain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for stroke or structural causes (hidrocephalus, neoplasms)?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform lumbar puncture
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for neuro infection or subarachnoid hemorrhage?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspicious for status epilepticus?
 
Yes
 
Perform EEG
 
Positive for status epilepticus?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order the following tests guided by findings of the evaluation:

Serum ammonia, thyroid function tests, morning cortisol, vitamin B12, arterial blood gas analysis, sedimentation rate, autoimmune serologies including antinuclear antibodies, thyroperoxidase

and thyroglobulin antibodies, blood cultures, extended toxicology screen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive for sepsis, intoxication, overdose, withdrawal, concusion, Hashimoto encephalopathy, hypothyroidism, uremic encephalopathy, porphyria, B12 deficiency, autoimmune encephalitis, carbon monoxide intoxication?
 
Yes
 
End
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform a thorough psychiatric evaluation to rule out psychiatric conditions
 
 
 


Do's

Don'ts

References

  1. "www.loyolamedicine.org" (PDF).
  2. Walker HK, Hall WD, Hurst JW, Tindall SC. PMID 21250221. Missing or empty |title= (help)
  3. . doi:10.5847/wjem.j.1920-8642.2012.04.006. Missing or empty |title= (help)
  4. Han JH, Wilber ST (February 2013). "Altered mental status in older patients in the emergency department". Clin. Geriatr. Med. 29 (1): 101–36. doi:10.1016/j.cger.2012.09.005. PMC 3614410. PMID 23177603.
  5. Lee B, Newberg A (April 2005). "Neuroimaging in traumatic brain imaging". NeuroRx. 2 (2): 372–83. doi:10.1602/neurorx.2.2.372. PMC 1064998. PMID 15897957.
  6. "Central Pontine Myelinolysis Information Page | National Institute of Neurological Disorders and Stroke".
  7. Gankam Kengne, Fabrice; Decaux, Guy (2018). "Hyponatremia and the Brain". Kidney International Reports. 3 (1): 24–35. doi:10.1016/j.ekir.2017.08.015. ISSN 2468-0249.
  8. Merlin MA, Carluccio A, Raswant N, Dossantos F, Ohman-Strickland P, Lehrfeld DP (November 2012). "Comparison of Prehospital Glucose with or without IV Thiamine". West J Emerg Med. 13 (5): 406–9. doi:10.5811/westjem.2012.1.6760. PMC 3556948. PMID 23359624.