Emergency Medicine/Altered mental status
- Decreased conscious state drowsy stupor: non responsiveness to pain or painful procedures
- Delirium - altered perception, hallucination
- Lethargy - decreased activity, loss of eye contact
A mnemonic to work-through of the possible causes of altered mental state (AMS).
- A — Alcohol/Acidosis
- E — Endocrine
- I — Infection
- O — Opiates, Overdose
- U — Uremia/Underdose
- T — Trauma
- I — Insulin
- P — Poisoning/Psychosis
- S — Stroke/Seizure/syncope
Traumatic , Infection, Neoplastic, Inflammation , M+E ( metabolism and endocrinology) , Pharmacology - doesn't cover seizures ?
- Trauma - head injury, blood loss (shock).
- Infection - meningitis, encephalitis, sepsis, septic shock; pneumonia, urinary tract infection, liver abscess,
- Neoplasia - intracranial tumor.
- Inflammation - inflammatory encephalitis, autoimmune encephalitis.
- M+E - electrolytes and endocrinology - sodium (calcium) , uremia, hepatitis ( all of them ? Insulin-related, Cortisol -Related, Thyroid- hyper).
- Pharmacology - opiates, alcohol (and other illicit substances) , other poisons.
What to do ?
Start the usual ...
- ABC - adequate ventilation, adequate oxygen, cervical spine protection if required, airway protection if required
- adequate circulation (BP, PR , periphery)
- IV access
- Cardiac monitor
- Quarrantine or Reverse Isolation (if appropriate)
What happened ( caregiver, witness ) ? History of Presentation Past Medical History Allergies, Medications, Drug/Substance Use Physical Examination Vital signs - Temp, BP, PR, RR, Oximetry Chest, Abdominal , Head/Eyes, Neurological, Skin = check for ominous changes (purpura, rash, infections...)
LABS / TESTS
ECG blood sugar (fingerstick) electrolyte panel liver function tests urinalysis EtOH ASA Tylenol toxicology screen carbon monoxide level (in appropriate scenario) thyroid function tests CT Head lumbar puncture Abdo US
Quick Fixes -
low glucose level - IV dextrose hypoxia - give oxygen pinpoint pupils not breathing - IV nalaxone (for opiates on board) seizure, stop - IV diazepam (or lorazepam... another benzo) cold - warm up suspect sepsis - IV antibiotics empiric. ?blood culture x 2 first. If difficult do later. antibiotics before LP is ok (complete the LP within one hour of starting the med)