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 ED plays a critical role in the evaluation and management of older patients with altered mental status. The ED 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).

First goal in the management of altered mental status is stabilization of the patient, prevent nervous system damage. The following conditions must be identified and corrected promptly,

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

Airway

• Breathing spontaneous on initial assessment and adequate ventilation present:

:Maintain oxygenation with cannula or mask if oxygen saturation is below 94% titrate to 94%-99%

• Breathing spontaneous on initial assessment without adequate ventilation present:

1. Check airway for obstruction and clear if needed
2. After airway is clear, assist ventilation with an appropriate adjunct and oxygen
3. If adequate ventilation is not maintained, proceed to an advanced airway

• Not breathing on initial assessment:

1. Open airway with head tilt chin lift. If successful, assist ventilation at an adequate rate and depth then reassess
2. If head tilt chin lift is not successful, check airway for obstruction and clear if needed
3. After airway is clear, assist ventilation
4. If adequate ventilation is not maintained, proceed to an advanced airway

• Mechanical ventilation if,

1. Hypoventilation
2. If increased intracranial pressure- to induce hypocapnia.

IV Access

Establish IV access and

• Measure glucose level,

1. If blood glucose level is <60 mg/dl: administer oral glucose 15mg, if there is no risk of aspiration and the patient is able to swallow.
2. 50% Dextrose in adults 12.5 -25 gm IV
3. 10% Dextrose in children

• Thiamine is given with dextrose to avoid precipitation of Wernicke’s encephalopathy and if IV access can not be established, give IM Glucagon
• If patient does not recover, and respiration is depressed, administer IV Naloxone
• If no recovery, consider head trauma, stroke, intoxication, hypoxia, hypothermia
• Determine cardiac rhythm by 12 lead ECG
• If dehydration is suspected, or if blood sugar level is >250mg/dl, give IV fluid bolus once.

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.

History	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