Altered mental status: Difference between revisions

(Created page with "==Overall Causes== 1) Delirium 2) Dementia 3) Psych ==Workup/Treatment== 1. Check glucose/SaO2 --> correct 2. Focal neuro def --> R/O CVA/mass/bleed 2. Fever --> posi...")
 
 
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==Overall Causes==
{{Adult top}} [[altered mental status (peds)]]
==Background==
*Acute alteration in brain function
**May include alteration of arousal or awareness, thought content, memory, or attention
*Both cerebral cortices or brainstem must be affected
*[[Delirium]] vs [[dementia]] vs other organic pathology vs functional (psychiatric)
*Must quickly determine if [[coma]] is from diffuse or focal impairment


==Clinical Features==
*Depends on cause
**Diffuse brain dysfunction - lack of focal findings
**[[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.


1) Delirium
==Differential Diagnosis==
{{AMS DDX}}


2) Dementia
==Evaluation==
{{AMS workup}}


3) Psych
==Management==
*Patients with focal findings may have surgically treatable cause
*Coma cocktail
**[[dextrose|Glucose]], [[thiamine]], [[naloxone]]
*Treat underlying cause


==Disposition==
*Most frequently admission, unless of a chronic and known etiology


==Workup/Treatment==
==See Also==
*[[Toxicology (Main)]]
*[[Glasgow Coma Scale (GCS)]]
*[[Altered mental status (peds)]]
*[[AVPU Scale]]
*[[Brain Death]]


 
==References==
1. Check glucose/SaO2 --> correct
<references/>
 
[[Category:Neurology]]
2. Focal neuro def --> R/O CVA/mass/bleed
[[Category:Symptoms]]
 
2. Fever --> positive = find source
 
3. Obvious cause --> positive = pursue
 
4. Non-obvious -->
 
 
Give thiamine & narcan
 
CBC
 
Chem 10
 
UA
 
ECG
 
UTox
 
CXR
 
Head CT
 
LFTs
 
PT
 
 
Consider:
 
CSF
 
ABG
 
TSH
 
EEG
 
ASA/Tylenol levels
 
Ammonia
 
HIV
 
 
==DDx Confusion==
 
 
I. Hypoxia/diffuse ischemia
 
    A. Respiratory failure
 
    B. CHF
 
    C. MI
 
    D. Severe anemia
 
    E. Shock
 
II. Systemic
 
    A. Hypoglycemia
 
    B. Electrolyte/fluid disturbance
 
    C. Endocrine dz
 
          1. Thyroid
 
          2. Adrenal
 
    D. Hepatic failure (ammonia)
 
    E. Wernicke's
 
    F. Infection/sepsis
 
          1. Urine
 
          2. PNA
 
          3. Other
 
III. CNS Disease
 
    A. Infection
 
    B. Trauma
 
    C. CVA/TIA
 
    D. SAH
 
    E. Seizure
 
          1. Postictal
 
          2. Nonconvulsive
 
          3. Complex partial
 
IV. Hypertensive encephalopathy
 
V. Increased ICP
 
VI. Toxins/withdrawal
 
    A. Sedatives
 
    B. ETOH
 
    C. Anticholinergics
 
    D. Other
 
VII. Neoplasm
 
 
==DDx Coma and...==
 
 
 
DIFFUSE CNS DYSFUNCTION
 
I. Diffuse Neuronal Deprivation
 
    A. Hypoglycemia
 
    B. Hypoxia (with nl Cerebral Blood Flow (CBF))
 
          1. Respiratory failure
 
              a. CHF
 
              b. PNA
 
              c. Obstructive
 
          2. Severe anemia
 
    C. Decreased CBF
 
          1. Shock
 
              a. AMI
 
              b. Hypovolemia
 
          2. Post arrest
 
    D. Cellular Toxin
 
          1. CO
 
          2. Cyanide
 
          3. Hydrogen sulfide
 
    E. Thiamine deficiency (Wernicke-Korsakoff)
 
II. Endogenous CNS Toxins
 
    A. Hyperammonemia (hepatic coma)
 
    B. Uremia (renal failure)
 
    C. CO2 Narcosis
 
    D. Hyperglycemia
 
III. Exogenous CNS Toxins
 
    A. Alcohols
 
          1. ETOH
 
          2. Isopropyl
 
    B. Acids
 
          1. Methanol
 
          2. Ethylene glycol
 
          3. Salicylate
 
    C. Sedatives
 
    D. Narcotics
 
    E. Anticonvulsants
 
    F. Psychotropics
 
    G. Isoniazid
 
    H. Heavy metals
 
IV. Endocrine disorders
 
    A. Myxedema coma
 
    B. Thyrotoxicosis
 
    C. Addison's
 
    D. Cushing's
 
    E. Pheochromocytoma
 
V. Ionic abnormalities
 
    A. Hypo/hyper-natremia
 
    B. Hypo/hyper-calcemia
 
    C. Hypo/hyper-magnesemia
 
    D. Hypophosphatemia
 
    E. Acidosis/alkalosis
 
VI. Temperature abnormalities
 
    A. Hypothermia
 
    B. Heat stroke
 
    C. NMS
 
    D. Malignant hyperthermia
 
VII. Intracranial HTN
 
    A. Hypertensive encephalopathy
 
    B. Pseudotumor cerebri
 
VIII. CNS inflammation/infection
 
    A. Meningitis
 
    B. Encephalitis
 
    C. Cerebral vasculitis
 
    D. SAH
 
    E. Carcinoid meningitis
 
    F. Traumatic axonal shear
 
IX. Primay neuronal/glial
 
    A. CJD
 
X. Seizure/postical
 
 
FOCAL CNS LESION
 
I. Supratentorial
 
    A. Hemorrhage
 
          1. Intracerebral
 
          2. Epidural
 
          3. Subdural
 
          4. Pituitary apoplexy
 
    B. Infarction
 
          1. Thrombotic arterial
 
          2. Embolic arterial
 
          3. Venous
 
    C. Tumors
 
    D. Abscess
 
II. Infratentorial
 
    A. Compressive
 
          1. Cerebellar hemorrhage
 
          2. Post fossa sub/extra-dural
 
          3. Cerebellar infarct
 
          4. Cerebellar tumor
 
          5. Cerebellar abscess
 
          6. Basilar aneurysm
 
    B. Destructive
 
          1. Pontine hemorrhage
 
          2. Brainstem infarct
 
          3. Basilar migraine
 
          4. Brainstem demyelination
 
 
==Source ==
 
 
2/27/06 DONALDSON (adapted from Rosen)
 
 
 
 
[[Category:Neuro]]

Latest revision as of 22:45, 27 March 2024

This page is for adult patients. For pediatric patients, see: altered mental status (peds)

Background

  • Acute alteration in brain function
    • May include alteration of arousal or awareness, thought content, memory, or attention
  • Both cerebral cortices or brainstem must be affected
  • Delirium vs dementia vs other organic pathology vs functional (psychiatric)
  • Must quickly determine if coma is from diffuse or focal impairment

Clinical Features

  • Depends on cause
    • Diffuse brain dysfunction - lack of focal findings
    • 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.

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

Evaluation

AMS Workup

Common Orders

Consider Based on Clinical Situation

Management

  • Patients with focal findings may have surgically treatable cause
  • Coma cocktail
  • Treat underlying cause

Disposition

  • Most frequently admission, unless of a chronic and known etiology

See Also

References

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