Altered mental status - Revision history

Danbot: Strip excess bold

2026-03-22T09:26:02Z

Strip excess bold

← Older revision		Revision as of 09:26, 22 March 2026
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	*Both cerebral cortices or the brainstem reticular activating system must be affected		*Both cerebral cortices or the brainstem reticular activating system must be affected
	*Key distinctions:		*Key distinctions:
	**~~'''~~[[Delirium]]:~~'''~~ Acute, fluctuating alteration in attention and awareness; typically reversible		**[[Delirium]]: Acute, fluctuating alteration in attention and awareness; typically reversible
	**~~'''~~[[Dementia]]:~~'''~~ Chronic, progressive cognitive decline; not typically an ED diagnosis		**[[Dementia]]: Chronic, progressive cognitive decline; not typically an ED diagnosis
	**~~'''~~Psychiatric:~~'''~~ Diagnosis of exclusion — always rule out organic causes first		**Psychiatric: Diagnosis of exclusion — always rule out organic causes first
	*Must quickly determine if the altered state is from '''diffuse''' (metabolic/toxic) or '''focal''' (structural/vascular) impairment		*Must quickly determine if the altered state is from '''diffuse''' (metabolic/toxic) or '''focal''' (structural/vascular) impairment

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	**Medical history: diabetes, liver/kidney disease, seizures, psychiatric history, substance use		**Medical history: diabetes, liver/kidney disease, seizures, psychiatric history, substance use
	*Physical exam priorities:		*Physical exam priorities:
	**~~'''~~Vital signs:~~'''~~ Fever (infection, toxidrome), hypothermia, hypo/hypertension, tachycardia, hypoxia		**Vital signs: Fever (infection, toxidrome), hypothermia, hypo/hypertension, tachycardia, hypoxia
	**'''Glucose:''' Point-of-care immediately		**'''Glucose:''' Point-of-care immediately
	**~~'''~~Neurologic exam:~~'''~~		**Neurologic exam:
	***Level of consciousness ([[Glasgow Coma Scale]])		***Level of consciousness ([[Glasgow Coma Scale]])
	***Pupil size and reactivity		***Pupil size and reactivity
	***Focal deficits (hemiparesis, facial droop, gaze preference) → suggests structural lesion		***Focal deficits (hemiparesis, facial droop, gaze preference) → suggests structural lesion
	***Diffuse findings (no lateralizing signs) → suggests metabolic/toxic cause		***Diffuse findings (no lateralizing signs) → suggests metabolic/toxic cause
	**~~'''~~Skin:~~'''~~ Needle tracks, jaundice, rash (meningococcemia, petechiae), diaphoresis, dryness		**Skin: Needle tracks, jaundice, rash (meningococcemia, petechiae), diaphoresis, dryness
	**~~'''~~Odor:~~'''~~ Alcohol, fruity (DKA), fetor hepaticus		**Odor: Alcohol, fruity (DKA), fetor hepaticus
	**~~'''~~Meningeal signs:~~'''~~ Nuchal rigidity (meningitis, SAH)		**Meningeal signs: Nuchal rigidity (meningitis, SAH)

	==Differential Diagnosis==		==Differential Diagnosis==
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	*Additional workup based on clinical suspicion:		*Additional workup based on clinical suspicion:
	**~~'''~~CT head without contrast~~'''~~ — if trauma, focal deficits, no clear metabolic cause, or concern for hemorrhage		**CT head without contrast — if trauma, focal deficits, no clear metabolic cause, or concern for hemorrhage
	**~~'''~~Lumbar puncture~~'''~~ — if meningitis/encephalitis suspected (after CT if indicated)		**Lumbar puncture — if meningitis/encephalitis suspected (after CT if indicated)
	**'''EEG''' — if nonconvulsive status epilepticus suspected (prolonged postictal state, subtle motor activity)		**'''EEG''' — if nonconvulsive status epilepticus suspected (prolonged postictal state, subtle motor activity)
	**~~'''~~CT angiography~~'''~~ — if acute stroke suspected		**CT angiography — if acute stroke suspected
	**~~'''~~Toxicology screen~~'''~~ — urine drug screen; consider serum levels (ethanol, salicylate, acetaminophen, lithium)		**Toxicology screen — urine drug screen; consider serum levels (ethanol, salicylate, acetaminophen, lithium)
	**~~'''~~Blood gas~~'''~~ (VBG/ABG) — for acid-base disturbances, CO levels		**Blood gas (VBG/ABG) — for acid-base disturbances, CO levels
	**~~'''~~Ammonia~~'''~~ — if hepatic encephalopathy suspected		**Ammonia — if hepatic encephalopathy suspected
	**~~'''~~Thyroid function~~'''~~ — if no other cause identified (myxedema coma, thyroid storm)		**Thyroid function — if no other cause identified (myxedema coma, thyroid storm)
	**~~'''~~Cortisol~~'''~~ — if adrenal crisis suspected		**Cortisol — if adrenal crisis suspected

	==Management==		==Management==
	*~~'''~~ABCs first:~~'''~~		*ABCs first:
	**Protect airway — intubate if GCS ≤8 or unable to protect airway		**Protect airway — intubate if GCS ≤8 or unable to protect airway
	**O2, IV access, continuous monitoring		**O2, IV access, continuous monitoring
	*~~'''~~Immediate interventions:~~'''~~		*Immediate interventions:
	**[[Dextrose]] (D50 50 mL IV or D10 titrated) if hypoglycemic		**[[Dextrose]] (D50 50 mL IV or D10 titrated) if hypoglycemic
	**[[Thiamine]] 100 mg IV (give before or with glucose)		**[[Thiamine]] 100 mg IV (give before or with glucose)
	**[[Naloxone]] 0.4-2 mg IV if opioid toxicity suspected		**[[Naloxone]] 0.4-2 mg IV if opioid toxicity suspected
	*Patients with ~~'''~~focal findings~~'''~~ may have a surgically treatable cause → emergent imaging		*Patients with focal findings may have a surgically treatable cause → emergent imaging
	*Treat the underlying cause once identified		*Treat the underlying cause once identified
	*Avoid sedation/restraints if possible until organic cause excluded; use the least restrictive means necessary for safety		*Avoid sedation/restraints if possible until organic cause excluded; use the least restrictive means necessary for safety

	==Disposition==		==Disposition==
	*~~'''~~Admit to ICU:~~'''~~		*Admit to ICU:
	**GCS ≤12, declining mental status		**GCS ≤12, declining mental status
	**Intubated patients		**Intubated patients
	**Hemodynamic instability		**Hemodynamic instability
	**Suspected CNS infection or stroke requiring acute intervention		**Suspected CNS infection or stroke requiring acute intervention
	*~~'''~~Admit to floor:~~'''~~		*Admit to floor:
	**AMS with identified cause requiring ongoing treatment/monitoring (e.g., metabolic correction)		**AMS with identified cause requiring ongoing treatment/monitoring (e.g., metabolic correction)
	**Elderly with new-onset delirium requiring workup		**Elderly with new-onset delirium requiring workup
	*~~'''~~Discharge:~~'''~~		*Discharge:
	**Fully resolved AMS with clearly identified and treated benign cause (e.g., hypoglycemia corrected, alcohol intoxication sobered)		**Fully resolved AMS with clearly identified and treated benign cause (e.g., hypoglycemia corrected, alcohol intoxication sobered)
	**Reliable follow-up arranged		**Reliable follow-up arranged

Danbot: Move calculators to own section with header (visible in TOC), expanded, before External Links

2026-03-21T15:07:04Z

Move calculators to own section with header (visible in TOC), expanded, before External Links

← Older revision		Revision as of 15:07, 21 March 2026
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	**Reliable follow-up arranged		**Reliable follow-up arranged
	**Safe discharge environment		**Safe discharge environment

			== Calculators ==
			{{GCS_Calculator}}

	==See Also==		==See Also==
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	==References==		==References==
	<references/>		<references/>


	~~<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">~~
	~~<div style="font-weight:bold;">📊 Glasgow Coma Scale (GCS) Calculator [show]</div>~~
	~~<div class="mw-collapsible-content">~~
	~~{{GCS_Calculator}}~~
	~~</div>~~
	~~</div>~~
	[[Category:Neurology]]		[[Category:Neurology]]
	[[Category:Symptoms]]		[[Category:Symptoms]]

Danbot: Add Glasgow Coma Scale (GCS) calculator (collapsible)

2026-03-21T13:42:32Z

Add Glasgow Coma Scale (GCS) calculator (collapsible)

← Older revision		Revision as of 13:42, 21 March 2026
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	<references/>		<references/>


			<div class="mw-collapsible mw-collapsed" style="border:1px solid #aaa; padding:5px; margin-top:10px;">
			<div style="font-weight:bold;">📊 Glasgow Coma Scale (GCS) Calculator [show]</div>
			<div class="mw-collapsible-content">
			{{GCS_Calculator}}
			</div>
			</div>
	[[Category:Neurology]]		[[Category:Neurology]]
	[[Category:Symptoms]]		[[Category:Symptoms]]

Danbot: Comprehensive expansion: EM-focused approach with structured clinical features, evaluation strategy, immediate interventions, and disposition criteria

2026-03-20T23:06:48Z

Comprehensive expansion: EM-focused approach with structured clinical features, evaluation strategy, immediate interventions, and disposition criteria

← Older revision		Revision as of 23:06, 20 March 2026
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	{{AdultPage\|altered mental status (peds)}}		{{AdultPage\|altered mental status (peds)}}
	==Background==		==Background==
	*~~Acute alteration~~ in ~~brain function~~		*Altered mental status (AMS) is one of the most common and challenging presentations in the ED
	**May include alteration of arousal or awareness, thought content, memory, or attention		*Encompasses a spectrum from mild confusion to deep [[coma]]
	*Both cerebral cortices or brainstem must be affected		*May include alteration of arousal (level of consciousness), awareness, thought content, memory, or attention
	*[[Delirium]] vs [[~~dementia~~]] ~~vs other~~ organic ~~pathology vs functional (psychiatric)~~		*Both cerebral cortices or the brainstem reticular activating system must be affected
	*Must quickly determine if ~~[[coma]]~~ is from diffuse or focal impairment		*Key distinctions:
			**'''[[Delirium]]:''' Acute, fluctuating alteration in attention and awareness; typically reversible
			**'''[[Dementia]]:''' Chronic, progressive cognitive decline; not typically an ED diagnosis
			**'''Psychiatric:''' Diagnosis of exclusion — always rule out organic causes first
			*Must quickly determine if the altered state is from '''diffuse''' (metabolic/toxic) or '''focal''' (structural/vascular) impairment

	==Clinical Features==		==Clinical Features==
	*~~Depends on cause~~		*History from family/EMS/bystanders is critical:
	**~~Diffuse brain dysfunction~~ - ~~lack~~ of ~~focal findings~~		**Baseline mental status and functional level
	**[[~~focal neuro deficits\|Focal brain dysfunction~~]] - hemiparesis, ~~loss of motor tone~~, ~~loss of ocular reflexes~~		**Onset (sudden vs gradual), preceding symptoms, recent medications/substances
	*~~Important to differentiate diffuse brain dysfunction from localized lesion as a patient may appear confused due to visual deficit~~, ~~dysphasia~~, ~~etc.~~		**Medical history: diabetes, liver/kidney disease, seizures, psychiatric history, substance use
			*Physical exam priorities:
			**'''Vital signs:''' Fever (infection, toxidrome), hypothermia, hypo/hypertension, tachycardia, hypoxia
			**'''Glucose:''' Point-of-care immediately
			**'''Neurologic exam:'''
			***Level of consciousness ([[Glasgow Coma Scale]])
			***Pupil size and reactivity
			***Focal deficits (hemiparesis, facial droop, gaze preference) → suggests structural lesion
			***Diffuse findings (no lateralizing signs) → suggests metabolic/toxic cause
			**'''Skin:''' Needle tracks, jaundice, rash (meningococcemia, petechiae), diaphoresis, dryness
			**'''Odor:''' Alcohol, fruity (DKA), fetor hepaticus
			**'''Meningeal signs:''' Nuchal rigidity (meningitis, SAH)

	==Differential Diagnosis==		==Differential Diagnosis==
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	==Evaluation==		==Evaluation==
	{{AMS workup}}		{{AMS workup}}

			*Additional workup based on clinical suspicion:
			**'''CT head without contrast''' — if trauma, focal deficits, no clear metabolic cause, or concern for hemorrhage
			**'''Lumbar puncture''' — if meningitis/encephalitis suspected (after CT if indicated)
			**'''EEG''' — if nonconvulsive status epilepticus suspected (prolonged postictal state, subtle motor activity)
			**'''CT angiography''' — if acute stroke suspected
			**'''Toxicology screen''' — urine drug screen; consider serum levels (ethanol, salicylate, acetaminophen, lithium)
			**'''Blood gas''' (VBG/ABG) — for acid-base disturbances, CO levels
			**'''Ammonia''' — if hepatic encephalopathy suspected
			**'''Thyroid function''' — if no other cause identified (myxedema coma, thyroid storm)
			**'''Cortisol''' — if adrenal crisis suspected

	==Management==		==Management==
	*~~Patients with focal findings may have surgically treatable cause~~		*'''ABCs first:'''
	*~~Coma cocktail~~		**Protect airway — intubate if GCS ≤8 or unable to protect airway
	**[[~~dextrose\|Glucose~~]], [[~~thiamine~~]], [[~~naloxone~~]]		**O2, IV access, continuous monitoring
	*Treat underlying cause		*'''Immediate interventions:'''
			**[[Dextrose]] (D50 50 mL IV or D10 titrated) if hypoglycemic
			**[[Thiamine]] 100 mg IV (give before or with glucose)
			**[[Naloxone]] 0.4-2 mg IV if opioid toxicity suspected
			*Patients with '''focal findings''' may have a surgically treatable cause → emergent imaging
			*Treat the underlying cause once identified
			*Avoid sedation/restraints if possible until organic cause excluded; use the least restrictive means necessary for safety

	==Disposition==		==Disposition==
	*~~Most frequently admission~~, ~~unless of a chronic~~ and ~~known etiology~~		*'''Admit to ICU:'''
			**GCS ≤12, declining mental status
			**Intubated patients
			**Hemodynamic instability
			**Suspected CNS infection or stroke requiring acute intervention
			*'''Admit to floor:'''
			**AMS with identified cause requiring ongoing treatment/monitoring (e.g., metabolic correction)
			**Elderly with new-onset delirium requiring workup
			*'''Discharge:'''
			**Fully resolved AMS with clearly identified and treated benign cause (e.g., hypoglycemia corrected, alcohol intoxication sobered)
			**Reliable follow-up arranged
			**Safe discharge environment

	==See Also==		==See Also==
	*[[Toxicology (Main)]]
	*[[Glasgow Coma Scale (GCS)]]
	*[[Altered mental status (peds)]]		*[[Altered mental status (peds)]]
	*[[~~AVPU~~ Scale]]		*[[Coma]]
	*[[~~Brain Death~~]]		*[[Delirium]]
			*[[Glasgow Coma Scale]]
			*[[Syncope]]

	==References==		==References==
	<references/>		<references/>

	[[Category:Neurology]]		[[Category:Neurology]]
	[[Category:Symptoms]]		[[Category:Symptoms]]

Ostermayer at 13:01, 15 January 2026

2026-01-15T13:01:03Z

← Older revision		Revision as of 13:01, 15 January 2026
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	{{~~Adult top}} [[~~altered mental status (peds)]]		{{AdultPage\|altered mental status (peds)}}
	==Background==		==Background==
	*Acute alteration in brain function		*Acute alteration in brain function

Rossdonaldson1: /* Video */

2024-03-27T22:45:18Z

Video

← Older revision		Revision as of 22:45, 27 March 2024
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	*[[AVPU Scale]]		*[[AVPU Scale]]
	*[[Brain Death]]		*[[Brain Death]]

	~~==Video==~~
	~~{{#widget:YouTube\|id=Sc0ObjHa3VA}}~~

	==References==		==References==

Rossdonaldson1 at 22:48, 28 November 2019

2019-11-28T22:48:27Z

← Older revision		Revision as of 22:48, 28 November 2019
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	~~''This page is for <u>adult</u> altered mental status. See~~ [[altered mental status (peds)]] ~~for the pediatric page.''~~		{{Adult top}} [[altered mental status (peds)]]
	==Background==		==Background==
	*Acute alteration in brain function		*Acute alteration in brain function

ClaireLewis at 21:58, 1 October 2019

2019-10-01T21:58:08Z

← Older revision		Revision as of 21:58, 1 October 2019
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	<references/>		<references/>
	[[Category:Neurology]]		[[Category:Neurology]]
			[[Category:Symptoms]]

ClaireLewis: /* Management */

2019-10-01T21:57:37Z

Management

← Older revision		Revision as of 21:57, 1 October 2019
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	*Patients with focal findings may have surgically treatable cause		*Patients with focal findings may have surgically treatable cause
	*Coma cocktail		*Coma cocktail
	**[[Glucose]], [[thiamine]], [[naloxone]]		**[[dextrose\|Glucose]], [[thiamine]], [[naloxone]]
	*Treat underlying cause		*Treat underlying cause

ClaireLewis at 21:56, 1 October 2019

2019-10-01T21:56:04Z

← Older revision		Revision as of 21:56, 1 October 2019
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	*Both cerebral cortices or brainstem must be affected		*Both cerebral cortices or brainstem must be affected
	*[[Delirium]] vs [[dementia]] vs other organic pathology vs functional (psychiatric)		*[[Delirium]] vs [[dementia]] vs other organic pathology vs functional (psychiatric)
	*Must quickly determine if coma is from diffuse or focal impairment		*Must quickly determine if [[coma]] is from diffuse or focal impairment

	==Clinical Features==		==Clinical Features==
	*Depends on cause		*Depends on cause
	**Diffuse brain dysfunction - lack of focal findings		**Diffuse brain dysfunction - lack of focal findings
	**Focal brain dysfunction - hemiparesis, loss of motor tone, loss of ocular reflexes		**[[focal neuro deficits\|Focal brain dysfunction]] - hemiparesis, loss of motor tone, loss of ocular reflexes
	*Important to differentiate diffuse brain dysfunction from localized lesion as a patient may appear confused due to visual deficit, dysphasia, etc.		*Important to differentiate diffuse brain dysfunction from localized lesion as a patient may appear confused due to visual deficit, dysphasia, etc.