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Acute Confusional State, Agitation, Delirium and Coma in the ICU
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Acute Confusional State, Agitation, Delirium and Coma in the ICU

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Common causes of altered mental status in the ICU …

Common causes of altered mental status in the ICU
Edward Omron MD, MPH, FCCP
Pulmonary, Critical Care Medicine
Morgan Hill, CA 95037

Published in: Health & Medicine

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  • 1. Evaluation of Altered Mental Status in the Intensive Care Unit© Edward Omron MD, MPH, FCCP All information contained on the handout is intended for informational and educational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition. Do not use the information on this handout for diagnosing or treating any medical or health condition in the absence of a board certified physician in Critical Care Medicine. 1. Etiology in the absence of focal neurologic findings or abnormal CSF A. Hepatic Encephalopathy (cirrhosis, hepatitis, malignancy, hyperammonemia): NH3, liver enzymes (Rx: Rifaxamin 550 mg po BID, Lactulose 30 mL q6, Ammonul ) B. Infectious disorders: sepsis (all causes) C. Drug Intoxication: alcohol, opiates, benzos, tricyclics, anticholinergics, steroids. Rx: Romazicon, Narcan both lower seizure threshold) D. Drug Withdrawal: alcohol, benzos, barbiturates, cocaine, amphetamines, ssra… E. Wernicke–Korsakoff syndrome (thiamine deficiency): ocular changes, altered mental status, unsteady gait. Rx: Thiamine F. Decreased cerebral perfusion pressure or oxygen delivery (Hypoxic/anoxic encephalopathy, CHF, myocardial infarction, dysrhythmias, shock) G. Endocrinopathy (hyperthyroid, hypothyroid, adrenal excess or deficiency) H. Seizure disorder and post-ictal state: non-convulsive need EEG (ativan, dilantin, keppra, and propofol) I. Patient ventilator asynchrony (Respiratory Therapy and Staff Consultation) J. Airway obstruction: mucous secretions, airway collapse, blood clot. Rx: albuterol +7% saline nebs, bronchoscopy K. Pneumothorax (CXR): chest tube L. Malposition of endotracheal tube: (CXR) M. Hypoglycemia: 1 amp D50, Glucogon N. Hypercapnea: PCO2 > 50 mm Hg, BIPAP, Intubation O. Serotonin Poisoning (Agitation, Hyperreflexive, dilated pupuls, fever): Rx supportive + cyproheptadine. P. Neuroleptic Malignant Syndrome (antipsychotic drugs): muscle rigidity, fever, autonomic instability, increased CK. Rx: Dantrolene and Bromocriptine. Q. Renal Failure (Uremic Encephalopathy) R. Fever (temperature > 100.5 F or 38.1 C) S. Hyponatremia or hypernatremia T. Anticholinergic delirium: fever, pupil dilation, tachycardia, constipation, urinary retention, (atropine, diphenhydramine, glycopyrrolate, benzatropine). Rx physiostigmine U. PAIN (assess pupil diameter and heart rate as rough estimate of pain control) 2. Etiology in the presence of focal neurologic findings and/or abnormal CSF A. Ischemic Infarct B. Neoplasm C. Hemorrhagic Infarct D. Meningitis E. Encephalitis F. Subarachnoid Hemorrhage or Subdural Hematoma G. Cerebral contusion 3. Approach to treatment A. Airway, Breathing and Circulation followed by intubation if necessary (PROTECT THE AIRWAY) B. Oxygen, Glucose, Narcan, Romazicon, Thiamine 100 mg IV or IM Stat C. ABG, VBG, CXR, CMP, NH3, Finger Stick Blood Glucose D. Head CT, EEG, 12 Lead ECG and/or Lumbar Puncture for CSF, MRI if feasible. E. Haldol 1 mg IVP test dose; 5-10 mg IVP q6 PRN not to exceed 40 mgs in 24 hours (monitor QTc, If > 500 msec d/c) F. Zyprexa Zydis 5 mg SL q6 PRN agitation not to exceed 40 mgs in 24 hours (monitor QTc, If > 500 msec d/c) G. Dexmedetomidine 0.2 -0.7 mcg/Kg/hr IV if intubated H. Versed or Ativan 1-5 mg IVP q2-q6 hours PRN I. CAM ICU Assessment with Richmond Agitation Sedation Score if intubated