Altered mental status resident survival guide: Difference between revisions

Altered mental status Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Do's
Don'ts

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Latest revision as of 01:34, 12 December 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Moises Romo, M.D.

Synonyms and Keywords: approach to delirium, approach to encephalopathy, encephalopathy workup, delirium workup

Overview

Altered mental status can result from a variety of factors, including alterations in the chemical environment of the brain, insufficient oxygen or blood flow in the brain, and excessive pressure within the skull. The level of consciousness may decline abruptly or slowly, or it may increase and decrease intermittently. Life threatening causes of altered mental status include malignant hypertension, myocardial infarction, rabies and sepsis. Other common causes of altered mental status include alcohol withdrawal, dehydration, electrolyte disturbance and hypoglycemia.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of altered mental status according to the the American Academy of Neurology guidelines.^[1]^[2]^[3]^[4]

Patient with altered mental status (Amnesia, confusion, loss of alertness, disorientation, disruption of judgement, behavior and perception)

Evaluate ABCDEF
• Airway
• Breathing
• Circulation
• Disability (Glasgow coma scale)
• Exposure (Rapid head to toe revision)
• Fingerstick blood glucose

Check vital signs

Unstable?

Yes

Stabilize

No

Combative?

Yes

Apply physical or chemical restrain

No

Alcoholism and thiamine deficiency suspected?

Yes

Administer thiamine

Improvement

Yes

End

No

Hypoglicemic?

Yes

Administer dextrose

Improvement?

Yes

End

No

Opioid intoxication suspected?

Yes

Administer naloxone

Improvement?

Yes

End

No

Take history

Perform physical examination with full neurologic evaluation

Order CBC, electrolyte panel, liver and kidney function tests (including albumin), urinalysis, urine culture, urine toxicology screen, chest x-ray, EKG

Suspected neurodegenerative disease?

Yes

Perform minimental exam

Positive for neurodegenerative disease?

No

Positive for neurodegenerative disorder, electrolyte imbalance, hepatic encephalopathy, urinary infection, pneumonia, drug intoxication?

Yes

End

No

Perform non-contrasted CT scan of the brain

Positive for stroke or structural causes (hidrocephalus, neoplasms)?

Yes

End

No

Perform lumbar puncture

Yes

End

Positive for neuro infection or subarachnoid hemorrhage?

Yes

End

No

Suspicious for status epilepticus?

Yes

Perform EEG

Positive for status epilepticus?

Yes

End

No

Order the following tests guided by findings of the evaluation:

Serum ammonia, thyroid function tests, morning cortisol, vitamin B12, arterial blood gas analysis, sedimentation rate, autoimmune serologies including antinuclear antibodies, thyroperoxidase

and thyroglobulin antibodies, blood cultures, extended toxicology screen

Positive for sepsis, intoxication, overdose, withdrawal, concusion, Hashimoto encephalopathy, hypothyroidism, uremic encephalopathy, porphyria, B12 deficiency, autoimmune encephalitis, carbon monoxide intoxication?

Yes

End

No

Perform a thorough psychiatric evaluation to rule out psychiatric conditions

Do's

Perform an ABCDEF evaluation as a first step.
If combative, use physical or chemical restraining.
Take a non-contrasted CT scan of the head before contrasted when head trauma is suspected.^[5]
Sodium imbalances should be slowly corrected to avoid a central pontine myelinolysis or a brain herniation.^[6]^[7]

Don'ts

Do not administer glucose before thiamine, when alcoholism and thiamine deficiency is suspected. Administration of glucose before thiamine may lead to Wernicke encephalopathy.^[8]
Do not assume psychiatric causes of altered mental status until the level of extent from other physical or chemical triggers is ruled out.

References

↑ "www.loyolamedicine.org" (PDF).
↑ Walker HK, Hall WD, Hurst JW, Tindall SC. PMID 21250221. Missing or empty |title= (help)
↑ . doi:10.5847/wjem.j.1920-8642.2012.04.006. Missing or empty |title= (help)
↑ Han JH, Wilber ST (February 2013). "Altered mental status in older patients in the emergency department". Clin. Geriatr. Med. 29 (1): 101–36. doi:10.1016/j.cger.2012.09.005. PMC 3614410. PMID 23177603.
↑ Lee B, Newberg A (April 2005). "Neuroimaging in traumatic brain imaging". NeuroRx. 2 (2): 372–83. doi:10.1602/neurorx.2.2.372. PMC 1064998. PMID 15897957.
↑ "Central Pontine Myelinolysis Information Page | National Institute of Neurological Disorders and Stroke".
↑ Gankam Kengne, Fabrice; Decaux, Guy (2018). "Hyponatremia and the Brain". Kidney International Reports. 3 (1): 24–35. doi:10.1016/j.ekir.2017.08.015. ISSN 2468-0249.
↑ Merlin MA, Carluccio A, Raswant N, Dossantos F, Ohman-Strickland P, Lehrfeld DP (November 2012). "Comparison of Prehospital Glucose with or without IV Thiamine". West J Emerg Med. 13 (5): 406–9. doi:10.5811/westjem.2012.1.6760. PMC 3556948. PMID 23359624.

[urlwww.loyolamedicine.org-1] "www.loyolamedicine.org" (PDF).

[pmid21250221-2] Walker HK, Hall WD, Hurst JW, Tindall SC. PMID 21250221. Missing or empty |title= (help)

[3] . doi:10.5847/wjem.j.1920-8642.2012.04.006. Missing or empty |title= (help)

[pmid23177603-4] Han JH, Wilber ST (February 2013). "Altered mental status in older patients in the emergency department". Clin. Geriatr. Med. 29 (1): 101–36. doi:10.1016/j.cger.2012.09.005. PMC 3614410. PMID 23177603.

[pmid15897957-5] Lee B, Newberg A (April 2005). "Neuroimaging in traumatic brain imaging". NeuroRx. 2 (2): 372–83. doi:10.1602/neurorx.2.2.372. PMC 1064998. PMID 15897957.

[urlCentral_Pontine_Myelinolysis_Information_Page_|_National_Institute_of_Neurological_Disorders_and_Stroke-6] "Central Pontine Myelinolysis Information Page | National Institute of Neurological Disorders and Stroke".

[Gankam_KengneDecaux2018-7] Gankam Kengne, Fabrice; Decaux, Guy (2018). "Hyponatremia and the Brain". Kidney International Reports. 3 (1): 24–35. doi:10.1016/j.ekir.2017.08.015. ISSN 2468-0249.

[pmid23359624-8] Merlin MA, Carluccio A, Raswant N, Dossantos F, Ohman-Strickland P, Lehrfeld DP (November 2012). "Comparison of Prehospital Glucose with or without IV Thiamine". West J Emerg Med. 13 (5): 406–9. doi:10.5811/westjem.2012.1.6760. PMC 3556948. PMID 23359624.

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@@ Line 1: / Line 1: @@
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+! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" |{{fontcolor|#2B3B44|Altered mental status Resident Survival Guide Microchapters}}
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Altered mental status resident survival guide#Overview|Overview]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Altered mental status resident survival guide#Causes|Causes]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Altered mental status resident survival guide#Diagnosis|Diagnosis]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Altered mental status resident survival guide#Do's|Do's]]
+|-
+! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Altered mental status resident survival guide#Don'ts|Don'ts]]
+|}
 {{CMG}}; {{AE}}[[User:MoisesRomo|Moises Romo, M.D.]]
+'''''Synonyms and Keywords:''' approach to delirium, approach to encephalopathy, encephalopathy workup, delirium workup''
 ==Overview==
 [[Altered mental status]] can result from a variety of factors, including alterations in the [[chemical environment]] of the [[brain]], insufficient [[oxygen]] or [[blood flow]] in the [[brain]], and excessive pressure within the [[skull]]. The level of [[consciousness]] may decline abruptly or slowly, or it may increase and decrease intermittently.
 Life threatening causes of [[altered mental status]] include [[malignant hypertension]], [[myocardial infarction]], [[rabies]] and [[sepsis]]. Other common causes of [[altered mental status]] include [[Alcohol|alcohol withdrawal]], [[dehydration]], [[electrolyte disturbance]] and [[hypoglycemia]].
-==Causes ==
+==Causes==
 ===Life Threatening Causes===
 Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated
@@ Line 30: / Line 48: @@
 ==Diagnosis==
-Shown below is an algorithm summarizing the diagnosis of [[altered mental status]] according to the the American Academy of Neurology guidelines.<ref name="urlwww.loyolamedicine.org">{{cite web |url=https://www.loyolamedicine.org/sites/default/files/gme/internal-medicine/continuum_2011_altered_mental_status.pdf |title=www.loyolamedicine.org |format= |work= |accessdate=}}</ref><ref name="pmid21250221">{{cite journal |vauthors=Walker HK, Hall WD, Hurst JW, Tindall SC |title= |journal= |volume= |issue= |pages= |date= |pmid=21250221 |doi= |url=}}</ref><ref>{{cite journal|doi=10.5847/wjem.j.1920-8642.2012.04.006}}</ref><ref name="pmid23177603">{{cite journal |vauthors=Han JH, Wilber ST |title=Altered mental status in older patients in the emergency department |journal=Clin. Geriatr. Med. |volume=29 |issue=1 |pages=101–36 |date=February 2013 |pmid=23177603 |pmc=3614410 |doi=10.1016/j.cger.2012.09.005 |url=}}</ref>
+Shown below is an [[algorithm]] summarizing the [[diagnosis]] of [[altered mental status]] according to the the American Academy of Neurology guidelines.<ref name="urlwww.loyolamedicine.org">{{cite web |url=https://www.loyolamedicine.org/sites/default/files/gme/internal-medicine/continuum_2011_altered_mental_status.pdf |title=www.loyolamedicine.org |format= |work= |accessdate=}}</ref><ref name="pmid21250221">{{cite journal |vauthors=Walker HK, Hall WD, Hurst JW, Tindall SC |title= |journal= |volume= |issue= |pages= |date= |pmid=21250221 |doi= |url=}}</ref><ref>{{cite journal|doi=10.5847/wjem.j.1920-8642.2012.04.006}}</ref><ref name="pmid23177603">{{cite journal |vauthors=Han JH, Wilber ST |title=Altered mental status in older patients in the emergency department |journal=Clin. Geriatr. Med. |volume=29 |issue=1 |pages=101–36 |date=February 2013 |pmid=23177603 |pmc=3614410 |doi=10.1016/j.cger.2012.09.005 |url=}}</ref>
+<br />
 {{Family tree/start}}
@@ Line 40: / Line 60: @@
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | D01 |-| D02 |-| D03 | | | |D01= Unstable? |D02= Yes |D03= [[Stabilize]]}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | | | | | | |!| | | }}
-{{Family tree | | | | E01 | | | |E01= No}}
+{{Family tree | | | | E01 | | | | | | |!| |E01= No}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |)|-|-|-|-|-|-|-|'| }}
 {{Family tree | | | | F01 |-| F02 |-| F03 | | | |F01= [[Combative]]? |F02= Yes |F03= Apply [[physical]] or [[chemical restrain]]}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | | | | | | |!| | | }}
-{{Family tree | | | | G01 | | | |G01= No}}
+{{Family tree | | | | E01 | | | | | | |!| |E01= No}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |)|-|-|-|-|-|-|-|'| }}
 {{Family tree | | | | H01 |-| H02 |-| H03 |-| H04 |-| H05 |-| H06| | | |H01= [[Alcoholism]] and [[thiamine deficiency]] suspected? |H02= Yes |H03= Administer [[thiamin]]e |H04= Improvement |H05= Yes |H06= End}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | | | | | | | | | | |!| }}
-{{Family tree | | | | I01 | | | |I01= No}}
+{{Family tree | | | | I01 |-|-|-|-|-|-|-|-|-|-|'| I01= No}}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | J01 |-| J02 |-| J03 |-| J04 |-| J05 |-| J06| | | |J01= [[Hypoglicemic]]? |J02= Yes |J03= Administer [[dextrose]] |J04= Improvement? |J05= Yes |J06= End}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | | | | | | | | | | |!| | }}
-{{Family tree | | | | K01 | | | |K01= No}}
+{{Family tree | | | | K01 |-|-|-|-|-|-|-|-|-|-|'| K01= No}}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | L01 |-| L02 |-| L03 |-| L04 |-| L05 |-| L06| | | |L01= [[Opioid intoxication]] suspected? |L02= Yes |L03= Administer [[naloxone]] |L04= Improvement? |L05= Yes |L06= End}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | | | | | | | | | | |!| | }}
-{{Family tree | | | | M01 | | | |M01= No}}
+{{Family tree | | | | K01 |-|-|-|-|-|-|-|-|-|-|'| K01= No}}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | N01 | | | |N01= Take [[history]]}}
@@ Line 67: / Line 87: @@
 }}
 {{Family tree | | | | |!| | | | | }}
-{{Family tree | | | | Q01 |-| Q02 |-| Q03 | | | |Q01= Suspected [[neurodegenerative disease]]? |Q02= Yes |Q03= Perform [[minimental]] exam}}
+{{Family tree | | | | Q01 |-| Q02 |-| Q03 |-| Q04 | |Q01= Suspected [[neurodegenerative disease]]? |Q02= Yes |Q03= Perform [[minimental]] exam |Q04= Positive for neurodegenerative disease? }}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | | | | | | | | | | |!| | }}
-{{Family tree | | | | R01 | | | |R01= No}}
+{{Family tree | | | | K01 |-|-|-|-|-|-|-|-|-|-|'| K01= No}}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | S01 |-| S02 |-| S03 | | | |S01= Positive for [[neurodegenerative]] disorder, [[electrolyte imbalance]], [[hepatic encephalopathy]],
@@ Line 89: / Line 109: @@
 {{Family tree | | | | V01 |-| V02 |-| V03 | | | |V01= Positive for [[neuro infection]] or [[subarachnoid hemorrhage]]? |V02= Yes |V03= End
 }}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | }}
-{{Family tree | | | | B01 | | | |B01= No}}
+{{Family tree | | | | K01 | | K01= No}}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | V01 |-| V02 |-| V03 |-| V04 |-| V05 |-| V06| | | |V01= Suspicious for [[status epilepticus]]?
   |V02= Yes |V03= Perform EEG |V04= Positive for [[status epilepticus]]?
   |V05= Yes |V06= End}}
-{{Family tree | | | | |!| | | | | }}
+{{Family tree | | | | |!| | | | | | | | | | | |!| | }}
-{{Family tree | | | | B01 | | | |B01= No}}
+{{Family tree | | | | K01 |-|-|-|-|-|-|-|-|-|-|'| K01= No}}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | B01 | | | |B01= Order the following tests guided by findings of the evaluation:
@@ Line 112: / Line 132: @@
 to rule out psychiatric conditions
 }}
-{{Family tree/end}}
+{{Family tree/end}}<br />
 ==Do's==
@@ Line 120: / Line 140: @@
 *Take a [[non-contrasted]] [[CT scan]] of the [[head]] before [[contrasted]] when head trauma is suspected.<ref name="pmid15897957">{{cite journal |vauthors=Lee B, Newberg A |title=Neuroimaging in traumatic brain imaging |journal=NeuroRx |volume=2 |issue=2 |pages=372–83 |date=April 2005 |pmid=15897957 |pmc=1064998 |doi=10.1602/neurorx.2.2.372 |url=}}</ref>
 *[[Sodium]] imbalances should be slowly corrected to avoid a [[central pontine myelinolysis]] or a [[brain herniation]].<ref name="urlCentral Pontine Myelinolysis Information Page | National Institute of Neurological Disorders and Stroke">{{cite web |url=https://www.ninds.nih.gov/Disorders/All-Disorders/Central-Pontine-Myelinolysis-Information-Page#:~:text=Central%20pontine%20myelinolysis%20(CPM)%20is,pulls%20water%20from%20brain%20cells. |title=Central Pontine Myelinolysis Information Page &#124; National Institute of Neurological Disorders and Stroke |format= |work= |accessdate=}}</ref><ref name="Gankam KengneDecaux2018">{{cite journal|last1=Gankam Kengne|first1=Fabrice|last2=Decaux|first2=Guy|title=Hyponatremia and the Brain|journal=Kidney International Reports|volume=3|issue=1|year=2018|pages=24–35|issn=24680249|doi=10.1016/j.ekir.2017.08.015}}</ref>
 ==Don'ts==
@@ Line 128: / Line 147: @@
 ==References==
-{{Reflist|2}} {{WikiDoc Help Menu}} {{WikiDoc Sources}}
+{{Reflist|2}}
+[[Category:Primary care]]
+[[Category:Up-To-Date]]