APPROACH TO

ALTERED MENTAL STATUS AND SEIZURE

PREPARED BY KESHVINI
Learning objectives

 Definition of altered mental status(AMS) and

seizure
 GCS
 Causes of AMS and seizure
 Identify the clinical manifestation of AMS and
seizure
 Definition
AMS
- Condition of being less responsive to and aware of environmental
stimuli

Scope : Range from sleepiness to confusion to coma

 ALERT CONFUSED DROWSINESS

• awareness of self and • disoriented to • drowsy, needs gentle verbal or

surrounding surroundings touch stimulation to initiate
response
 STUPOR COMATOSE

• arousable only • no observable

with repeated and response to any
painful stimuli external stimuli
Consciousness
RAS : responsible for regulating alertness,maintainance of attention and
wakefulness
Anatomy
 Pontine reticular activating system
 Midbrain reticular activating system
 Hypothalamus
 Thalamus
Causes of AMS

• Eg. Stroke
• blockage/disruption of blood flow to the brain
• Only one part of brain affected
STRUCTURAL
• assymmetry is noted in signs and symptoms

• tend to affect both sides of body

METABOLIC • Originates outside
CNS
Metabolic/Systemic disorder
1.Hypoxia
-COAD 6.Endogenous toxins
-carbon monoxide poisoing -hyperammonemia(liver failure)
2.Glucose disorders -uremia(kidney disease)
-hypo/hyperglycemia 7.Exogenous toxins
-HHS -alcohols
3.Decrease cerebral blood flow -acid poisons
-hypovolaemic shock -antidepressant medications
-congestive heart failure -narcotics eg. Morphine,heroin
-pericardial effusion -sedative hypnotics eg.barbiturates
-infection -hallucinogens
4.Electrolyte imbalance 8. Disorders of temperature regulation
5.Endocrine disorders -hypothermia
-myxedema coma,thyrotoxicosis -heat stroke
-addison’s disease,cushing’s disease
 Structural disorders
Trauma
-epidural haematoma
-subdural haematoma
-cerebral concussion/contusion

Stroke
i) Embolism
-cardiac(atrial fibrillation,endocarditis)

ii) Thrombosis
-cerebral venous sinus thrombosis
-pontine haemorrhage
-cerebellar haemorrhage
-ICB

Tumor
-brainstem
-metastatic disease
 Approach

History
Initial
assessment -emphasizing the Clinical Investigations
patient’s examination -blood
Airway, condition before
breathing, onset of -symptoms and -radiography
circulation ,disabi confusion signs -others
lity
History

 Circumstances and rapidity with which neurological symptoms

developed
 Use of medications ,ilicit drugs,or alcohol
 Chronic liver disease,lung,heart,or other medical illness
 Examination
1) Vital signs
2)General look
3)Local examination
–inspection,palpation,auscultation
4)Neurological examination
-cranial nerve functions
-cerebellar functions
-motor and sensory function
GCS

 Scoring from the best response

 Verbal response will not correct in the condition of aphasia,intubation
and facial injury
 Sensory loss may interfere painful stimulus
 Eye opening may interfere by orbital swelling and 3 rd cranial nerve
palsy
 Arm trauma may be impaired from local trauma or cervical cord lesion
 Investigations
Blood
-FBC,RP,electrolyte,LFT, CoAg
-blood glucose
-blood gas
-thyroid function test

Urine
-UFEME
-urine for drugs
-UPT

Radiology
-Xray
-CT
-MRI

Others
-ECG
 Seizure
 Temporary alterations in behaviour caused by abnormal electrical activity in the brain.
 Specific seizure activity is determined by the area in the brain that is involved
Causes
-trauma
-drug/alcohol withdrawal
-eclampsia
-infection
-hypoglycemia
-hypoxia
-electrolyte imbalance
Investigations

Blood
FBC  reveal anaemia and infectious process
Electrolyte
Serum glucose

Pregnancy test rule out eclamptic seizure

Radiology
CT brain
MRI
EEG
Management

1. General measure
-maintain airway
-put patient in left lateral position
-supplemental oxygen
-circulation

2. Specific measure
i) Benzodiazepine
Eg. Diazepam- IV 0.2mg/kg
usual dose 5-10mg repeated 5 to 10 minutes up to 20mg bolus
ii) Phenytoin
Initial loading dose : IV 15-20mg/kg(diluted in 100cc NS)
Daily Maintainance dose : 5mg/kg/d orally or IV 12 h after loading dose
iii) Phenobarbitone
-used when seizure recurs despite a full loading dose of phenytoin
Loading dose : IV 15-20mg/kg
Daily maintainance dose : 5mg/kg/d orally or IV 12-24h after loading dose
iv) Sodium valproate (epilin)
Initial loading dose : IV 15-40mg/kg at a rate of 3mg/kg/min
Maintainance dose : 1mg/kg/hr given 30 min after bolus
v) Levetiracetam (keppra)
IV 500-1500mg/100ml over 15 minutes 12hly
References

 http://emedicine.medscape.com/article/1609
294-overview#a11
 James G.Adams. Emegency
Medicine.saunderselsevier
 Guide to the essentials in Emergency
Department by Shirley Ooi