Altered mental status medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]

Overview

The emergency department plays a critical role in the evaluation and management of older patients with altered mental status. The emergency department is often the initial point of entry for geriatric hospital admissions, and it is tasked with rapidly identifying those who are critically ill, while efficiently diagnosing the underlying etiology, and promptly initiating life saving therapies. The concepts pertinent to delirium can be generalized to stupor and coma, because there is significant overlap. Although altered mental status is common in presentation, its workup is challenging because the potential causes are vast, and they vary from nonserious to life-threatening. Therefore, a thoughtful, comprehensive approach is essential, which involves clarifying the history and onset of symptoms with the patients and/or caregivers, and localizing specific signs or symptoms to narrow the differential.

Medical Therapy

Evaluating a patient with altered mental status is difficult because obtaining a reliable history is often impossible. Initially, it is imperative to establish basic life support. Once the patient's airway, breathing, and circulation have been secured, a secondary emergency survey should be conducted. This includes securing adequate intravenous access, providing oxygen, and obtaining important vitals (e.g., temperature, respiratory rate, heart rate, BP, oxygen saturation, and blood sugar).

Pre-Hospital Care

Emergency medical services are often first to provide care for the patients with altered mental status. Initial goal of the management by an emergency medical services is stabilization of the patient, and prevent further nervous system damage. The following conditions must be identified and corrected promptly,

• Hypotension
• Hypoglycemia
• Hypoxia
• Hypercapnia, and
• Hyperthermia

Airway

1. Breathing spontaneous on initial assessment and adequate ventilation present,
   • Maintain oxygenation with cannula
   • Mask if oxygen saturation is below 94% titrate to 94%-99%
2. Breathing spontaneous on initial assessment without adequate ventilation present:
   • Check airway for obstruction and clear if needed
   • After airway is clear, assist ventilation with an appropriate adjunct and oxygen
   • If adequate ventilation is not maintained, proceed to an advanced airway
3. Not breathing on initial assessment:
   • Open airway with head tilt chin lift. If successful, assist ventilation at an adequate rate and depth then reassess
   • If head tilt chin lift is not successful, check airway for obstruction and clear if needed
   • After airway is clear, assist ventilation
   • If adequate ventilation is not maintained, proceed to an advanced airway
4. Mechanical ventilation if,
   • Hypoventilation
   • If increased intracranial pressure- to induce hypocapnia.
   • Immobilization of cervical spine is crucial and must not be ignored in suspected cervical fractures, especially during intubation and oculocephalic response evaluation.

IV Access

Establish IV access and

1. Measure glucose level,
   • If blood glucose level is <60 mg/dl: administer oral glucose 15mg, only if there is no risk of aspiration and the patient is able to swallow.
   • 50% Dextrose in adults
   • 10% Dextrose in children
   • Thiamine is given with dextrose to avoid precipitation of Wernicke’s encephalopathy
   • If IV access can not be established, give IM Glucagon
2. If patient does not recover, and respiration is depressed, administer IV Naloxone
3. If no recovery, consider head trauma, stroke, intoxication, hypoxia, hypothermia
4. Determine cardiac rhythm by 12 lead ECG
5. If dehydration is suspected, or if blood sugar level is >250mg/dl, give IV fluid bolus once.

Mental Status	Consider following possibilities			Management
Unarousable/difficult to arouse	Cerebrovascular events Sepsis Infections of nervous system Space occupying lesion of CNS Metabolic disturbance like hypoxia, hypoglycemia, hypercalcemia Electrolyte disturbances Uremia Hepatic encephalopathy Wernicke’s encephalopathy. Intoxication Endocrine disturbances Decreased cerebral perfusion states like anemia, decreased cardiac output			Establish IV access Cardiac monitor Secure airway and maintain oxygen saturation Rapid glucose administration Check for increased intracranial pressure Cold calorics Electrolytes Serum calcium level Renal function tests Thyroid scan Workup for sepsis Complete blood count Head CT EEG EKG Follow ACEP guidelines for intoxication Thiamine Naloxone Immobilie cervical spine
Lethargy and decreased level of consciousness	Check blood sugar level and administer glucose accordingly			Mental status examination Confusion assessment methord exam Oxygen saturation and administration if required Electrolytes Serum calcium level Renal function tests Complete blood count Head CT EEG EKG Thiamine
Hyperalert/agitation	Intoxication Drug withdrawal Alcohol withdrawal Psychiatric causes Hypoglyemia Hypoxia Hyperthyroidism			Blood glucose level assessment and IV dextrose Anticipate disruptive behavior *from patient and treat agitation with restrains or pharmacologically if needed Maintain oxygen saturation Thyroid function tests Minimental status examination CAM Toxicology workup Thiamine
Acute cognitive impairment like disorientation, language difficulties, memory and learning disturbances	Intoxication Psychiatric causes CNS inections Cerebrovascular events Space occupying lesions			Minimental status examination CAM Electrolytes Renal function test Complete blood count Head CT LP if CT not available or nonconclusive Sepsis workup EKG Thiamine

Hospital care

After emergency treatment and stabilization of the patient, a directed differential diagnosis should be considered. Directing the differential may be even more problematic in older patients, who often present with relatively common conditions in uncommon, subtle manners. For example, they may present with infections without fever or leukocytosis, or a perforated viscus without abdominal pain or tenderness. It is therefore important to tailor a thoughtful approach specific to individual patients. The use of a logical and stepwise approach is preferred to one that relies on broad testing, which can predispose to iatrogenesis.

Pupil	Suspect			Management
New asymmetry	Cerebrovascular accident Space occupying lesion			Head CT
Bilaterally pin point	Opiods Cholinergics			Head CT Naloxone Toxicology workup
Bilaterally dilated	Brain death Anticholinergics Sympathetic drugs			Toxicology workup

History and presenting symptoms	Consider following possibilities			Management
Intoxication	Carbon monoxide poisoning			Carboxyhemoglobin level 100% Oxygen Follow ACEP guidelines
	Opioid			Naloxone
Chronic drug use	Withdrawal			Supportive
	Drug overdose			Drug specific antidotes, and Supportive
Chronic alcohol use	Withdrawal Subdural hematoma Wernicke’s encephalopathy Hepatic encephalopathy Infection / Sepsis			Septic workup Ammonia level Complete blood Count Head CT Thiamine Mg Glucose
Trauma	Intracranial hemorrhage			Head CT
Headache	Intracranial hemorrhage Intoxication CNS infections Space occupying lesion			Head CT
Seizure	Intoxication or withdrawal symptoms Hypoglycemia Cerebrovascular event CNS infections			Follow ACEP guidelines to manage patient of seizures
Past history of seizure disorder	Status epilepticus- non convulsive Antiepileptic medication overdose			Antiepileptic drug levels EEG Neurological consult
Immunocompromised or HIV positive	Space occupying lesion in brain			MRI CT with and without contrast Lumbar puncture and CSF fluid analysis for syphilis, fungal infections, mycobacterial infections
Taking anticoagulants	Bleeding in brain			Lab studies of coagulation like PT, PTT, INR Head CT
Significant hypertension	Hypertensive encephalopathy Intoxication Thyroticosis Hypertention related to pregnancy Raised intracranial pressure Intracerebral hemorrhage			Fundoscopy Check for end organ damage Thyroid function tests Workup for toxicology Head CT LP if CT nonconclusive or not available Treat hypertension
Heartbeat<60	*Intoxication ICP Hypothyroidism			Cardiac monitoring Maintain airway Oxygen if necessary Thyroid function tests EKG Manage bradycardia Toxicology workup
Heartbeat >100	Intoxication Sepsis Decreased cardiac output Hypoglyemia Hypoxia Withdrawal syndrome Thyrotoxicosis			Cardiac monitoring Maintain airway Oxygen if necessary EKG Toxicology workup Thyroid function tests Crystalloid challenge Complete blood count
Compromised respiratory function	Intoxication Cerebrovascular accident Increased intracranial pressure			Maintain airway Oxygen if necessary Naloxone Head CT Arterial blood gas Toxicological workup
Fever	CNS infections Neuroleptic malignant syndrome Seratonin syndrome Intoxication Cerebrovascular accident Withdrawal syndrome Thyrotoxicosis			Investigate source of infection Sepsis workup Thyroid function test Complete blood count Antibiotics Control temperature
Hypothermia	Hypoglycemia Intoxication Sepsis Hypothyroidism			Sepsis workup Thyroid function tests Toxicology workup Complete blood count
Neurological deficit	Cerebrovascular accident Space occupying lesion Hypoglycemia Todds paralysis Uremia Wernicke’s encephalopathy Metabolic disorders			Measure and maintain blood glucose levels Head CT Thiamine Platelate count
Asterixis	Hepatic encephalopathy Uremia			Renal function test Liver function tests Arterial blood gases Electrolyte Investigate gastrointestinal bleeding
Icterus	Hepatic encephalopathy			Liver function tests Serum ammonia
Papilloedema	Malignant Hypertension Increased intracranial pressure			Head CT
Breath odor: fruity	Ketoacidosis			Serum Glucose Serum ketone Isopropanol levels Electrolytes Arterial blood gases
Nuchal rigidity	Meningeal irritation secendory to infections Subarachnoid hemorrhage			Head CT Lumbar puncture if not contraindicated Antibiotics and steroids bacterial meningitis is suspected

• Physostigmine for anticholinergictype drug overdose, mostly recommended to treat anticholinergic overdose associated with cardiac arrhythmias.

• Use of benzodiazepine antagonists offers some prospect of improvement after overdose of soporific drugs and has transient benefit in hepatic encephalopathy.