Emergency Medicine Altered Mental Status Case File

https://medical-phd.blogspot.com/2021/05/emergency-medicine-altered-mental.html

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD,
Adam J. Rosh, MD, MS

Case 32
A 76-year-old nursing home patient is transferred to the emergency department (ED) for reported
altered mental status. The patient is confused and unable to provide any relevant information about
his condition. According to EMS, the patient has been in the nursing home since he fractured his
tibia 4 weeks prior. The patient has a past medical history of hypertension, diabetes, and chronic
obstructive pulmonary disease (COPD).

His vital signs are BP 150/90 mm Hg, HR 110 beats per minute, RR 20 breaths per minute, T
36.7°C, and oxygen saturation of 92% on 4-L nasal cannula. On physical examination, the patient
appears sleepy but is arousable. He has a difficult time following directions and appears confused.
His pupils are 4 mm, equal and reactive. His mucous membranes appear dry. He is tachycardic and
his lung sounds are clear and equal bilaterally. His abdomen is soft and nontender. There is a cast
on his left lower extremity. The capillary refill on his toes is less then 2 seconds, he has strong
femoral pulses. His skin reveals poor turgor and there is tenting. His motor and sensory
examinations are normal.

Laboratory results reveal a WBC 12 cells/mm  and hemoglobin 10 mg/dL. His sodium is 110
3

mEq/L, potassium 4.1 mEq/L, BUN 52 mg/dL, creatinine 1.0 mg/dL, magnesium 1.7 mEq/L, and
glucose 125 mg/dL. His urine drug screen is positive for opiates and benzodiazepines. His
urinalysis is negative for infection.

⯈ What is the most likely diagnosis?

⯈ What is the best management?

ANSWER TO CASE 32:

Altered Mental Status

Summary: This is a 76-year-old man from a nursing home with a history of hypertension, diabetes,
and COPD. He presents to the ED with altered mental status (AMS). He has limited mobility due to
a cast on his left lower leg secondary to a tibia fracture. His examination reveals dehydration and
lab tests are consistent with significant hyponatremia and prerenal azotemia.

 Most likely diagnosis: Electrolyte abnormality (hyponatremia) secondary to deconditioning

and dehydration.
 Next step in management: Intravenous fluid hydration and consider hypertonic saline.

ANALYSIS
Objectives
 1. Recognize the diversity in presentation of patients with altered mental status and understand
the diagnostic approach to the workup.
2. Be able to order the appropriate workup for patients and learn the initial management.

Considerations
This is a 76-year-old man who presents to the ED from a nursing home. The presentation of altered
mental status in a nursing home patient should elicit concerns for underlying infection (eg, sepsis,
meningitis, UTI), electrolyte and metabolic abnormalities (eg, hypo- or hyperglycemia,
hyponatremia), delirium, and hypoxia. In the younger population, it is important to keep in mind
other common causes of altered mental status such as intoxications and withdrawal syndromes.

Once the patient’s airway, breathing, and circulation (ABCs) are addressed, the first step in
management is to obtain a capillary blood glucose to rule out hypoglycemia. The patient appears
dehydrated and an electrolyte panel should immediately be sent to the lab and intravenous fluid
started for resuscitation.

Approach To:
Altered Mental Status

DEFINITIONS

CONFUSION: Reversible disturbance of consciousness, attention, cognition, and perception that

occurs within a short period of time

DELIRIUM: Global disturbance in consciousness and cognition, with an inability to relate to

environment and process sensory input that is not better explained by preexisting or evolving
dementia

DEMENTIA: Progressive, irreversible decline in mental function affecting judgment, memory,

reasoning, comprehension

AGITATION: Excessive restlessness with increased mental and physical activity

COMA: Severe alteration of consciousness where one cannot be aroused

STUPOR: Level of decreased responsiveness where an individual requires aggressive or

unpleasant stimulation

OBTUNDED: Level of diminished arousal or awareness frequently from extraneous causes

(infection, intoxication, metabolic states)

CLINICAL APPROACH
The phrase “altered mental status” generally refers to a change from an individual’s “normal”
mental state. This may reflect a change in behavior, speech, comprehension level, judgment, mood,
or level of consciousness (awareness or arousal state). Changes in mental status should be thought
of in terms of organic, functional or psychiatric, or as a mixed disorder. Organic causes have a
pathological basis primarily with a systemic or metabolic root, however structural lesions must also
be considered. Functional or psychiatric diseases do not have a clearly defined physiologic
foundation.

The reticular activating system (RAS) is physiologically responsible for our level of arousal.
Signals from the RAS run through the pons in the brainstem, through the thalami, then project to
both cerebral hemispheres. Any disruption in this pathway will lead to a decreased level of arousal.
Examples of this may be through chemical depression via endogenous or exogenous agents or via
structural abnormalities such as decreased blood flow resulting in ischemia.

Altered mental status and confusion are estimated to occur in 2% of all ED patients, 10% of
hospitalized patients, and 50% of elderly hospitalized patients.

The evaluation of a patient with altered mental status can be a diagnostic challenge and a complete
history and physical examination (Table 32–1) is imperative to the workup. Because the patient
often cannot provide a reliable history, it is important to obtain information from all available
sources such as family, friends, bystanders, and nursing home staff. The severity of illness must be
quickly assessed and any life-threatening issues must be rapidly addressed (See Table 32-2).

Assessing the patient’s ABCs, and quickly recognizing and managing reversible causes of AMS,
such as hypoglycemia or hypoxia, are critical steps in
Data from Karas S. Behavioral emergencies: differentiating medical from psychiatric disease. Emerg Med Prac.2002;4(3):7-8.

early management. A systematic approach guided by your history and physical and gathering
understanding as to how mentation is altered (see Definition list) should be undertaken. The mini-
mental state examination (MMSE) or Quick Confusion Scale (QCS) can be used and these ask are
4 to 7 questions that can be used in reassessment to monitor change in mental status.

If altered patient is unable to provide a history, then gathering as much information as possible
from EMS, nursing home staff, family or bystanders is critical. EMS may be able to provide clues
by describing the scene from where they transported the patient. Was there an empty pill vial? Did
the patient verbalize any recent complaints? When was the patient last seen normal? What is the
baseline mental status? Was the change in mental status abrupt or gradual? Has the condition
changed since first recognized?
Special consideration must be given to pediatric and geriatric populations. Seizures with prolonged
postictal states, head injuries, and accidental ingestions are common causes for altered mental
status in the pediatric population. In the geriatric population a change in mental status may occur
concomitant with existing dementia. Electrolyte abnormalities and dehydration are common causes
in addition to hypo and hyperglycemia and thyroid hormone abnormalities. The elderly are more
prone to subdural hematomas due to age-related cerebral atrophy; increasing the vulnerability of
the bridging veins to tearing. Polypharmacy and unintentional overdoses also commonly cause an
alteration in mental status.

Many mnemonics are used to aid in the clinical workup for altered mental status. One popular
pneumonic is AEIOU TIPS (see Table 32–3). In elderly patients who are confused and forgetful,
understanding the differences between dementia and delirium is critical (Table 32–4).
Data from Smith J, Seirafi J. Delirium and dementia. In: Rosen P, Barkin R, eds. Emergency Medicine, Concepts and
Clinical Practice. 7th ed. Philadelphia, PA: Mosby; 2009: 1372.

Glasgow Coma Scale

The Glasgow coma scale (Table 32–5) was created as an assessment tool to quantify the degree of
depression in the level of consciousness in patients with head trauma. Its purpose was to track the
progress of patients’ neurologic status. Its use has widened to include patients with undifferentiated
change in mental status. The scoring scale utilizes assessments of eye opening, and motor and
verbal function to provide a rapid indication on any alteration of function. A higher score
corresponds to a higher level of consciousness.

Management
Stabilization of Life Threats Always start by addressing the ABCs and treat any immediate
threats to life. Opening the airway and providing a jaw thrust and
supplemental oxygen are the first steps in treating hypoxic causes of AMS. Subsequently begin
bag-valve-mask ventilation. If the underlying cause of apnea or hypoventilation cannot
immediately be corrected (eg, naloxone for opiate overdose), then the patient will require
endotracheal or nasotracheal intubation and mechanical ventilation.

Assess circulation by feeling for pulses, placing the patient on a cardiac monitor, assess skin
perfusion, and check blood pressure. The only way to fix a hypoperfused brain is to restore
circulation. Begin CPR if the patient is pulseless or a nonperfusing rhythm (v-fib, pulseless v-tach)
is seen on the monitor and prepare for defibrillation or cardioversion. If there is a pulse, but signs of
shock are present (mottled skin, cool extremities), you need to assure adequate volume (IV fluids),
hemoglobin (transfusion), and peripheral vascular resistance (pressors).

As soon as adequate airway, breathing and circulatory support has been established then make a
global assessment of neurologic functioning. Assess the GCS scale. Check for pupil size and
reactivity. Look for any spontaneous movement, especially noting seizure-like activity or lack of
movement on one side suggesting a stroke or below a certain level (spinal cord injury). Any
suspicion of cord injury requires placement of a cervical collar and immobilization. Undress the
patient and onto his or her side to look for any signs of trauma, drug patches or infection sources.