01/22/2023

ADAMA HOSPITAL MEDICAL COLLEGE

DEPARTMENT OF
EMERGENCY MEDICINE&CRITICAL CARE

APPROACH TO A PATIENT WITH

ALTERED MENTAL STATUS &SELAM
PRESENTER: COMAH/KIROS

MODULATOR- DR. SHIMELIS K (MD, EMERGENCY MEDCINE &

CRITICAL CARE SPECIALIST).
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OUTLINES

• Definition of terms
• Introduction to mental status
• Approach to patient with delirium
• Approach to a patient with coma
• summary
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OBJECTIVES
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DEFINITION OF TERMS

• Consciousness :Refers to the ability to arouse

 Respond spontaneously and appropriately to external and internal stimuli.
 It is dependent upon the integrity & interaction b/n the cerebral cortices & ascending
reticular activating system.
 Arousal is determined in the brainstem ascending RAS
Awareness is determined in the cortex
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CONT…

• Alertness: The patient is awake and fully aware of normal external and internal stimuli.
• Lethargy: The patient is not fully alert, tends to drift to sleep when not stimulated, When
aroused has appropriate response
• Obtundation- Refers to mild to moderate reduction in alertness accompanied by
decreased interest in the environment.
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CONT…

• Stupor - Deep sleep, patient can be aroused only by vigorous and repetitive stimulation.
 Returns to deep sleep when not continually stimulated.
• Coma (Unconscious):- Coma is defined as "unarousable unresponsiveness"
 unresponsive to all external stimuli
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INTRODUCTION

• Mental status is an acute clinical state of emotional and intellectual functioning of an

individual.
• 2% of all ED visits
• 10% of hospitalized patients
• 50% of elderly hospitalized patients
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CONT…

• Altered mental status is disorder of arousal, content of consciousness or combination.

• Arousal- wakefulness and alertness
• Content of consciousness- self awareness, language, reasoning, social relation ship,
emotion
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DELIRIUM(ACUTE ENCEPHALOPATHY)

• Delirium is acute stage of fluctuating attention and change in cognition.

• More common in older adults.(1:10 in ED, 1:4 hospitalized older adults)
• Dementia is a chronic disorder of deteriorating cognition with or without behavioral
disturbance.
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CAUSES OF DELIRIUM

• Primary intracranial disease

• Systemic diseases secondarily affecting the CNS
• Exogenous toxins (including prescribed pharmacotherapies)
• Drug withdrawal and pain
• Major trauma or surgery
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CLINICAL FEATURES

• Acute onset and intermittent symptoms

• Disordered attention and acute fluctuating course
• Disrupted Sleep-wake cycles
• Tremor, asterixis, tachycardia, sweating,
• hypertension, or emotional outbursts
• Hallucinations
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DIAGNOSIS

• Clinical and mini mental status exam

• Lab(CBC, U/A, Serum e’t, OFT, head CT,
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MANAGEMENT

• Nonpharmacologic approaches to delirium are the standard of care.

Environmental manipulations(adequate lighting, psychosocial support)

 Re-orientation activities, and mobilization (to enhance the patient’s ability to
interpret the surroundings)
Antipsychotics(In circumstances of risk of harm to self or others)
• Treat the underlying causes
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CASE STUDY

• A 70 years old female patient known type II diabetic patient for the past 5years on
Glibenclamide 5mg po daily and known hypertensive patient for the last 2months on
Amilodipine 5mg po daily.
currently she presented with LOC of 3 days duration. Associated with she has hx of 1-2
episodes of non projectile vomiting of ingested matter of 4 days duration.
she has hx of 4 attacks of lowering blood sugar level for the past 2months.
Has hx of abdominal surgery 2months back.
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CONT…

• Other wise she has no hx of :

ABM
Drug discontinuation
Head trauma
Fever, chills and rigors
Cough or contact with tb pt
Palpitation, orthopenia or known cardiac history
Yellowish discoloration of the eye
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PHYSICAL EXAM

GA- ASL
V/S- BP-
HEENT-
LGS-
RS- coarse crepitation all over the chest
CVS-
GUS-
MSS- grade II bilateral pitting edema
IS-
NS- GCS-10/15
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INVESTIGATION

• RBS- 34mg/dl
• Serum e’t- Na 116.5mg/dl
• RFT- crt 5.2
- urea 150
• Cxr- multiple opacities on both lung fields
• Brain CT scan- normal
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COMA

• Coma is a state of reduced alertness and responsiveness from which the patient cannot be aroused.
• The Glasgow Coma Scale is a widely used clinical scoring system for alterations in consciousness
 GCS 01/22/2023

Component score
Motor 6 Follows command
5 Localizes pain
4 Withdraws to pain
3 flexion
2 extension
1 No response

Verbal 5 Oriented
4 Confused speech
3 Inappropriate words
2 Incomprehensible
1 No response

Eye opening 4 Spontaneous opening

3 To verbal
2 To pain
1 No response
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PSEUDOCOMA OR PSYCHOGENIC COMA

• Pupillary responses, extraocular movements, muscle tone, and reflexes are intact on
careful examination.
• Resistance to manual eye opening
• Patient always looking away from the examiner, or
• If nystagmus is demonstrated with caloric vestibular testing, this is strong evidence for
nonphysiologic or feigned unresponsiveness
 CAUSES OF COMA 01/22/2023

• Hypoxia
• Hypoglycemia
• Sepsis
• Hypertensive encephalopathy
• Wernicke's encephalopathy
• Drug Overdose
• CNS infections (meningitis, encephalitis)
• CNS trauma
• Intracranial hemorrhage (eg, subarachnoid, subdural)
• Epilepsy (eg, nonconvulsive)
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CONT…

• Urinary tract infections

• Pneumonia
• Electrolyte abnormalities
• Medication adverse effects and interactions
• Medication withdrawal syndromes
• Endocrine disease (eg, thyroid)
• CNS mass lesions
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DDX

• Psychosis
• Bipolar
• Dementia
• Schizophrenia
• depression
• Stroke
• Aphasic pt
• Pt with visual abnormality
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APPROACH TO A PT WITH AMS & COMA

• ABCDs of life
• Brief hx is taken, initial GCS is established (if <8 may need intubation)
• Take V/S
Treat hypotension with volume expanders or vasopressors
hypertension with repeated doses of IV labetalol 5-20mg bolus
• Check ABG
• Iv access & send blood for lab investigation
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“TONG” OR COMA COCKTAIL OR “DONT”

• Thiamine 100mg IV for alcoholic patients and malnourished

• O2 intranasal

• 50ml of 50% dextrose IV bolus

 If low blood sugar or
 Pt has hx of diabetes or is on insulin or on oral hypoglycemic drug
 we are unable to measure.
• If Iv access is challenging, give glucagon 1mg IM.
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CONT…

• Naloxone 0.4-2mg IV, If pt has signs of opoid intoxicity,

 Depressed GCS
 Depressed RR
 Pin point pupils
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HX AND P/E

• Duration of the unconsciousness

• Associated symptoms
• Hx of medical or psychiatric disorders
• Medication history
• Recent infection, fever
• Head trauma
• Toxin ingestion
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CONT..

• Hx of Alcohol or drug use

• Hx of recurrent headache
• ABM
• Similar symptoms in other family members
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P/E

• GA-
• V/S- BP, PR, RR, To, SPaO2
• HEENT-
• RS-
• CVS-
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CONT…

• GI-
• GUS-
• MSK-
• IS-
• NS-
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INVESTIGATON

• RBS
• CBC
• U/A
• Serum electrolyte
• BF
• RFT
• TFT
• LFT
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CONT…

• LP
• Cardiac markers
• Toxicologic screen
• CXR
• Brain CT
• Brain MRI
• Brain Biopsy
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MANAGEMENT

• Treat underlying cause

• Coma care
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SPECIAL CONSIDERATIONS IN COMA

• If trauma is suspected, maintain stabilization of the cervical spine.

• If protection of the airway is in doubt or the coma state is likely prolonged, intubate the
patient.
• For children, consider ingestions, infections, and child abuse in the appropriate clinical
setting.
• In ICP, consider head elevation, mannitol 0.5-1g/kg iv infusion, hyperventilation.
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SUMMARY
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REFERENCES

• TINTINALLI’S Emergency Medicine, 9th edition

• HARRISON`S principles of internal medicine 20th edition
• UPTODATE 21.6
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