Altered Mental Status

Common Medical Emergencies

 OUTLINE OF LECTURE
• Introduction to consciousness and altered
mental status
• Causes of altered mental status
• Hypoglycemia as cause of altered mental
status
• Approach to examination and management of
altered mental status.
 OBJECTIVES OF LECTURE
• Understand the meaning of altered mental
status condition
• Know the causes of altered mental status
• Able to elicit possibility of hypoglycemia as
cause of altered mental status
• Able to manage patient with altered mental
status.
 CONSCIOUSNESS
• CNS functions
– Voluntary movements
– Interpretation and integration of sensation
– Consciousness
– Cognitive function
• Consciousness
– Awareness of self and environment
 ALTERED MENTAL STATUS
INTRODUCTION
• Altered mental status
– Alteration in higher cerebral functions – memory,
attention or awareness.
– Ability to sustain and focus attention is impaired.
• Potential life threatening condition
• Etiology might be chronic or acute, reversible or
irreversible.
• Many different organ systems might be
implicated
 ALTERED MENTAL STATUS
COMMON CAUSES
• Hypoglycemia
• Poisoning
• Post seizure
• Infection
• Head trauma
 ALTERED MENTAL STATUS
PATIENT APPEARANCE
• Intoxicated appearance, staggering, slurred
speech to complete unresponsiveness
• Uncharacteristic behavior
– Anxious or combative
• Seizures
 ALTERED MENTAL STATUS
HYPOGLYCEMIA
• An abnormally low level of glucose in the
blood.
• Usually occur in people with diabetes mellitus
– Treated with hypoglycaemic drugs or insulin
• Mechanism of hypoglycemia in diabetics
– Too high a dose of medications
– Diabetic person misses a meal or takes strenuous
exercise.
 HYPOGLYCEMIA
CLUES TO HYPOGLYCEMIA
• Past illness of diabetes mellitus
• Medications history
– Insulin pen
– Diabetic medications
• Rapid onset of altered mental status
– Patient on medication but miss a meal
– Patient on medication but unable to tolerate orally –
poor appetite or vomiting or fever
– After an unusual exercise or physical work episode
HYPOGLYCEMIA
 HYPOGLYCEMIA
SYMPTOMS
• Hunger
• Dizziness
• Headache,
• Confusion
– Behaviour is often irrational and aggressive.
– Coma in severe cases.
 HYPOGLYCEMIA
SIGNS
• Elevated heart rate
• Cold, clammy skin
• Sweating
• Dizziness
• Trembling
• Coma may occur in severe cases.
 ALTERED MENTAL STATUS
AMPLE HISTORY
• Allergies if any
• Medications
– Diabetic medications
– Drugs that cause drowsiness – sleeping pills, psychiatric
medications
– Drugs of abuse – morphine, heroin
• Past illness
– Diabetes mellitus
– Epilepsy
• Last meal
 ALTERED MENTAL STATUS
AMPLE HISTORY
• Events related to altered mental status
– Onset when it started
– Any other features – fever, seizures, headache
– History of trauma
 ALTERED MENTAL STATUS
PRIMARY SURVEY
• Establish responsiveness of patient
• Pay attention to airway and breathing
– Patient with poor consciousness level may not be
able to protect airway
– Examine for features of airway obstruction or
breathing difficulties
• Circulation
– Look for features of poor perfusion
 ALTERED MENTAL STATUS
INTERVENTION
• In unresponsive patient
– Open the airway and provide oxygen
• Initiate ventilation using bag-mask method if
inadequate breathing
• If patient has history of diabetes and
hypoglycemia features suspected on history
– Obtain medical direction for oral glucose
administration – protocol guided.
 APPROACH TO PATIENT
MONITORING AND COMMUNICATIONS
• Altered mental status considered as emergency –
vital signs monitoring every 5 minutes
– Mental status
– Airway patency
– Breathing for rate and quality
– Pulse for rate and quality.
• Communicate with base
– Medical direction for medication
– Patient-related information
– Intervention related information
 PRE-HOSPITAL CARE
TRANSPORTATION
• Patient must be transported to medical facility
• Further monitoring required
– Oral hypoglycemic agents have long duration of
action
– Other causes must be ruled out.
 PRE-HOSPITAL CARE
SUMMARY
• Altered mental status – alterations in higher
cerebral functions
• Potential life threatening condition which
many different organ systems might be
implicated
• Hypoglycemia is a reversible cause if treated
early