Altered mental status

Background

  • Alteration of arousal or content of consciousness or both
  • Both cerebral cortices or brainstem must be affected
  • Delirium vs dementia vs psych
  • Must quickly determine if coma is from diffuse or focal impairment
  • Peds
    • Most common causes are toxic ingestion, infection, and child-abuse induced trauma

Clinical Features

  • Depends on cause
    • Diffuse brain dysfunction - lack of focal findings
    • Focal brain dysfunction - hemiparesis, loss of motor tone, loss of ocular reflexes

DDX

  1. Diffuse brain dysfunction
    1. Encephalopathies
      1. Hypoxic encephalopathy
      2. Metabolic encephalopathy
        1. Hypoglycemia
        2. Hyperosmolar state (e.g., hyperglycemia)
        3. Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
        4. Organ system failure
        5. Hepatic Encephalopathy
        6. Uremia/Renal Failure
        7. Endocrine (Addison disease, hypothyroidism)
        8. Hypoxia
        9. CO2 narcosis
      3. Hypertensive Encephalopathy
    2. Toxins
    3. Drug reactions (NMS)
    4. Environmental causes
      1. Hypothermia
      2. Hyperthermia
    5. Deficiency state
      1. Wernicke Encephalopathy
    6. Sepsis
  2. Primary CNS disease or trauma
    1. Direct CNS trauma
      1. Diffuse axonal injury
      2. Subdural/epidural hematoma
    2. Vascular disease
      1. Intraparenchymal hemorrhage
    3. SAH
    4. Infarction
      1. Hemispheric, brainstem
    5. CNS infections
    6. Neoplasms
    7. Seizures
      1. Nonconvulsive status epilepticus
        1. Consider if motor activity of seizure has stopped but pt is not alert w/in 30min
      2. Postictal state

Work-Up

  1. CBC
  2. Chemistry
  3. LFTs
  4. UA
  5. CXR
  6. Utox
  7. Head CT
  8. ?Blood and urine cultures
  9. ?Ammonia level
  10. ?Tylenol/ASA level
  11. ?LP

Treatment

  • Pts w/ focal findings may have surgically treatable cause
  • Coma cocktail
    • Glucose, thiamine, naloxone
  • Underlying cause

See Also

Source

Tintinalli

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