Altered mental status: Difference between revisions
No edit summary
Line 1: Line 1:
==Overall Causes==
==Background==
# Delirium
*Alteration of arousal or content of consciousness or both
# Dementia
*Delirium vs dementia vs psych
# Psych


==Workup/Treatment==
===Delirium===
# Check glucose/SaO2 --> correct
====Clinical Features====
# Focal neuro def --> R/O CVA/mass/bleed
#Impairment of arousal and content of consciousness
# Fever --> positive = find source
#Generally develops over days
# Obvious cause --> positive = pursue
#Symptoms may be intermittent and vary in severity
# Non-obvious -->
##Give thiamine & narcan
##CBC
##Chem 10
##UA
##ECG
##UTox
##CXR
##Head CT
##LFTs
##PT


Consider:
====Workup====
#CSF
#CBC
#ABG
#Chemistry
#TSH
#LFTs
#EEG
#UA
#ASA/Tylenol levels
#CXR
#Ammonia
#CT/LP
#HIV


==DDx Confusion==
====DDX====
# Hypoxia/diffuse ischemia
#Infection
## Respiratory failure
##PNA, UTI, meningitis/encephalitis, sepsis
## CHF
#Metabolic
## MI
##Hypoglycemia
## Severe anemia
##Electrolyte abnormalities
## Shock
##Hepatic encephalopathy
# Systemic
#Neuro
## Hypoglycemia
##TIA/CVA
## Electrolyte/fluid disturbance
##Seizure or postictal state
## Endocrine dz
##SAH/ICH/SDH
### Thyroid
##CNS mass lesion
### Adrenal
#Cardiopulmonary
## Hepatic failure (ammonia)
##CHF
## Wernicke's
##MI
## Infection/sepsis
##PE
### Urine
##Hypoxia or CO2 narcosis
### PNA
#Drug-related
### Other
##ETOH ingestion
# CNS Disease
##ETOH or drug withdrawal
## Infection
##Sedative-hypnotics
## Trauma
##Anticholinergics
## CVA/TIA
##Narcotics
## SAH
##Polypharmacy
## Seizure
### Postictal
### Nonconvulsive
### Complex partial
# Hypertensive encephalopathy
# Increased ICP
# Toxins/withdrawal
## Sedatives
## ETOH
## Anticholinergics
## Other
# Neoplasm


==DDx Coma and...==
====Treatment====
===Diffuse CNS Dysfunction===
*Treat underlying cause
# Diffuse Neuronal Deprivation
 
## Hypoglycemia
===Dementia===
## Hypoxia (with nl Cerebral Blood Flow (CBF))
====Clinical Features====
### Respiratory failure
#Loss of mental capacity
#### CHF
#Slow and steady course
#### PNA
#Hallucinations, delusions, repetitive behaviors, and depression are all common
#### Obstructive
 
### Severe anemia
 
## Decreased CBF
====DDX====
### Shock
#Degenerative
#### AMI
##Alzheimer's disease
#### Hypovolemia
##Huntington's disease
### Post arrest
##Parkinson's disease
## Cellular Toxin
#Vascular
### CO
##Multiple infarcts
### Cyanide
##Hypoperfusion (MI, profound hypotension)
### Hydrogen sulfide
##Subdural hematoma
## Thiamine deficiency (Wernicke-Korsakoff)
##SAH
# Endogenous CNS Toxins
#Infectious
## Hyperammonemia (hepatic coma)
##Meningitis (sequelae of bacterial, fungal, or tubercular)
## Uremia (renal failure)
##Neurosyphilis
## CO2 Narcosis
##Viral encephalitis (herpes, HIV), Creutzfeldt-Jakob disease
## Hyperglycemia
#Inflammatory
# Exogenous CNS Toxins
##SLE
## Alcohols
##Demyelinating disease
### ETOH
#Neoplastic
### Isopropyl
##Primary tumors / metastatic disease
## Acids
##Carcinomatous meningitis
### Methanol
##Paraneoplastic syndromes
### Ethylene glycol
#Traumatic
### Salicylate
##Traumatic brain injury
## Sedatives
##Subdural hematoma
## Narcotics
#Toxic
## Anticonvulsants
##ETOH
## Psychotropics
##Meds (anticholinergics, polypharmacy)
## Isoniazid
#Metabolic
## Heavy metals
##B12 or folate deficiency
# Endocrine disorders
##Thyroid disease
## Myxedema coma
##Uremia
## Thyrotoxicosis
#Psychiatric
## Addison's
##Depression (pseudodementia)
## Cushing's
#Hydrocephalic
## Pheochromocytoma
##Normal-pressure hydrocephalus (communicating hydrocephalus)
# Ionic abnormalities
##Noncommunicating hydrocephalus
## Hypo/hyper-natremia
## Hypo/hyper-calcemia
## Hypo/hyper-magnesemia
## Hypophosphatemia
## Acidosis/alkalosis
# Temperature abnormalities
## Hypothermia
## Heat stroke
## NMS
## Malignant hyperthermia
# Intracranial HTN
## Hypertensive encephalopathy
## Pseudotumor cerebri
# CNS inflammation/infection
## Meningitis
## Encephalitis
## Cerebral vasculitis
## SAH
## Carcinoid meningitis
## Traumatic axonal shear
# Primay neuronal/glial
## CJD
# Seizure/postical


===Focal CNS Lesion===
# Supratentorial
## Hemorrhage
### Intracerebral
### Epidural
### Subdural
### Pituitary apoplexy
## Infarction
### Thrombotic arterial
### Embolic arterial
### Venous
## Tumors
## Abscess
# Infratentorial
## Compressive
### Cerebellar hemorrhage
### Post fossa sub/extra-dural
### Cerebellar infarct
### Cerebellar tumor
### Cerebellar abscess
### Basilar aneurysm
## Destructive
### Pontine hemorrhage
### Brainstem infarct
### Basilar migraine
### Brainstem demyelination


==See Also==
==See Also==
[[Toxidromes]]
*[[Toxidromes]]


==Source ==
==Source ==
2/27/06 DONALDSON (adapted from Rosen)
Tintinalli


[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 22:23, 3 October 2011

Background

  • Alteration of arousal or content of consciousness or both
  • Delirium vs dementia vs psych

Delirium

Clinical Features

  1. Impairment of arousal and content of consciousness
  2. Generally develops over days
  3. Symptoms may be intermittent and vary in severity

Workup

  1. CBC
  2. Chemistry
  3. LFTs
  4. UA
  5. CXR
  6. CT/LP

DDX

  1. Infection
    1. PNA, UTI, meningitis/encephalitis, sepsis
  2. Metabolic
    1. Hypoglycemia
    2. Electrolyte abnormalities
    3. Hepatic encephalopathy
  3. Neuro
    1. TIA/CVA
    2. Seizure or postictal state
    3. SAH/ICH/SDH
    4. CNS mass lesion
  4. Cardiopulmonary
    1. CHF
    2. MI
    3. PE
    4. Hypoxia or CO2 narcosis
  5. Drug-related
    1. ETOH ingestion
    2. ETOH or drug withdrawal
    3. Sedative-hypnotics
    4. Anticholinergics
    5. Narcotics
    6. Polypharmacy

Treatment

  • Treat underlying cause

Dementia

Clinical Features

  1. Loss of mental capacity
  2. Slow and steady course
  3. Hallucinations, delusions, repetitive behaviors, and depression are all common


DDX

  1. Degenerative
    1. Alzheimer's disease
    2. Huntington's disease
    3. Parkinson's disease
  2. Vascular
    1. Multiple infarcts
    2. Hypoperfusion (MI, profound hypotension)
    3. Subdural hematoma
    4. SAH
  3. Infectious
    1. Meningitis (sequelae of bacterial, fungal, or tubercular)
    2. Neurosyphilis
    3. Viral encephalitis (herpes, HIV), Creutzfeldt-Jakob disease
  4. Inflammatory
    1. SLE
    2. Demyelinating disease
  5. Neoplastic
    1. Primary tumors / metastatic disease
    2. Carcinomatous meningitis
    3. Paraneoplastic syndromes
  6. Traumatic
    1. Traumatic brain injury
    2. Subdural hematoma
  7. Toxic
    1. ETOH
    2. Meds (anticholinergics, polypharmacy)
  8. Metabolic
    1. B12 or folate deficiency
    2. Thyroid disease
    3. Uremia
  9. Psychiatric
    1. Depression (pseudodementia)
  10. Hydrocephalic
    1. Normal-pressure hydrocephalus (communicating hydrocephalus)
    2. Noncommunicating hydrocephalus


See Also

Source

Tintinalli

Retrieved from "https://www.wikem.org/w/index.php?title=Altered_mental_status&oldid=6054"