Altered mental status emergency management

1. Approach to Altered Mental
Status

2. Objectives
• Recognize the importance of historical factors in diagnosing causes of
AMS
• Identify dementia, delirium and psychosis as the three most common
classifications of AMS
• Articulate a differential diagnosis of AMS based on H&P findings
• Construct an approach to the diagnostic workup and management of
a patient with AMS
• Describe initial management of many causes of AMS
• Discuss the disposition of a patient with AMS

3. Introduction
Its 3am on the 3rd of November 2020 , a patient was brought in from
Miri Home for The Age with a chief complaint of altered mental state.
He is 67 years old, bed bound and communicating minimally. His OPD
card shows a history of dementia , alcoholism and generalised anxiety
disorder.

4. Primary Survey
• A : Open and protected, secretions, Oxygen saturation ( hypoxia is a
potentially reversible cause)
• B: Inadequate ventilation can lead to hypercapnia.
• C: Distal Pulses, BP, cardiac rhythm ( hypoperfusion reduces O2 and
Glucose supply to the brain)
• D: GCS, pupils, spontaneous movement ( hemiparesis, paraparesis)
• E : trauma, drug patches, dialysis access, petechiae, infectious
sources

5. Initial Action
• Assessment of the ABC's
• Cardiac monitoring and pulse oximetry
• Supplemental oxygen if hyperemic
• Bedside glucose testing
• Intravenous access
• Evaluation for signs of trauma and consider c-spine stabilization
• Consider naloxone administration if narcotic overdose is suspected

7. A Alcohol
E
Epilepsy, Electrolytes,
and Encephalopathy
I Insulin
O Opiates and Oxygen
U Uremia
T Trauma and Temperature
I Infection
P Poisons and Psychogenic
S
Shock, Stroke, Subarachnoid
Hemorrhage and Space-
Occupying Lesion

8. DELIRIUM DEMENTIA PSYCHOSIS
ONSET Rapid Slow Variable
COURSE Fluctuating Progressive Variable
VITALS Often Abnormal Normal
Variable
(Usually normal)
PHYSICAL EXAM Often Abnormal Normal (usually) Normal (usually)
HALLUCINATIONS
Visual (External
stimuli)
Rare
Auditory (Internal
Stimuli)
UNDERLYING
CAUSE
Organic (myriad)
Organic
(degenerative)
Functional
PROGNOSIS
Poor (if cause not
treated)
Progressive Variable

9. History
• Can you tell me what you see different about your grandmother?
• Can you describe how she is different
• When did this change start?
• What do you think might have cause it?
• History of preexisting illnesses & medications

10. Physical Examination
• Neurologic status : GCS, alertness, content of thought and speech,
orientation, weakness or pronator drift, cranial nerves, reflexes ,
tremors, nuchal rigidity
• CVS : arrhythmia , murmur ? Endocarditis , peripheral circulation,
carotid bruit
• Respiratory : pneumonia ( sepsis ), pulmonary edema ( hypoxia)
• Abdomen : hepatic encephalopathy , tenderness
• Genitourinary : Urine output ( uraemia ) , infection
• Rectal : Malaena

11. Physical Examination
• Skin , extremity : petechiae , dialysis graft, needle track, transdermal
drug patch , jaundice, pressure sores , abcess , cellulitis
• MSK : signs of trauma ( racoon eyes , Battle’s sign)

12. Diagnostic Tests
• EKG / cardiac monitoring
• CBC, electrolytes, Ca, Mg, cardiac enzymes, DXT ( if not done)
• Urine dipstick
• ABG
• Drug screen
• Imaging – CXR , CTB
• lumbar puncture
• liver, thyroid

13. Treatment
• Dextrose for hypoglycemia
• Naloxone for opioid toxicity
• Supportive care and sedation for agitated withdrawal states
• Intravenous fluids for dehydration, hypovolemia, hypotension or hyperosmolar states
such as HHNS or hypernatremia
• Empiric antibiotics for suspected infections ( meningitis, urosepsis, pneumonia, etc.)
• Rewarming or cooling for temperature extremes
• Antidotes for specific toxins
• Controlled reduction of blood for hypertensive encephalopathy
• Correction of electrolyte imbalances
• Glucocorticoids for metastatic CNS lesions with vasogenic edema
• Consider thiamine for suspected Wernicke's encephalopathy

14. Disposition
Majority of patients will require hospitalisation, however patients with
alterations that are easily reversible can be observed and safgely discharged
home eg:
• Seizure-Patients with known seizure disorders found to have low
anticonvulsant levels may be discharged if medications can be loaded and
appropriate safe follow-up can be assured.
• Hypoglycemia- Diabetic patients found to be transiently hypoglycemic and
improve with dextrose may be discharged if a clear reason can be found,
they are not on long acting agents, and appropriate supervision and safe
follow-up can be assured.
• Narcotic overdose-When properly treated and observed in the emergency
department, these patient may be safely discharged home.

16. References
• Altered Mental Status. (n.d.). Retrieved from https://www.saem.org/cdem/education/online-education/m4-curriculum/group-m4-
approach-to/approach-to-altered-mental-status.
• Evaluation of abnormal behavior in the emergency department. (n.d.). Retrieved January 1, 2020, from
https://www.uptodate.com/contents/evaluation-of-abnormal-behavior-in-the-emergency-department?search=Altered mental
status&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2.
• Sanello, A., Gausche-Hill, M., Mulkerin, W., Sporer, K., Brown, J., Koenig, K., … Gilbert, G. (2018). Altered Mental Status: Current Evidence-
based Recommendations for Prehospital Care. Western Journal of Emergency Medicine, 19(3), 527–541.
doi:10.5811/westjem.2018.1.36559
• Xiao, H. Y., Wang, Y. X., Xu, T. D., Zhu, H. D., Guo, S. B., Wang, Z., & Yu, X. Z. (2012). Evaluation and treatment of altered mental status
patients in the emergency department: Life in the fast lane. World journal of emergency medicine, 3(4), 270–277.
doi:10.5847/wjem.j.1920-8642.2012.04.006