ALTERED MENTAL STATUS

OVERVIEW
• Altered mental status: It Could Be [almost] Anything!
requires a thorough work-up
• What is the differential for altered mental status?
• What is the type of problem that could cause it?
• What is the organ system(s) that could be involved?
 EXAMPLE
• 63 yo female found down next to park bench. Bystander called EMS who are now moving
patient from gurney onto bed.
• You ask for history: There is none
• You ask for ROS: There is none
• You ask for PMH, Meds, Anything!: There is none

WELCOME TO
EMERGENCY
 WHAT COULD BE WRONG WITH HER?
Tramua: Brain laceration/injuryConcussionDepressed skull fractureHead traumaBrain, contusionBrain injury, massiveDiffuse axonal injury/Acute brain trauma
Shaken Baby SyndromeElectromagnetic, Physics, trauma, Radiation CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea waterDrowning/Near- drowningHeat exhaustion/prostrationHeat stroke
Encephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposureElectrocution/lightning strikeHigh altitude cerebral edemaDecompression sickness
High altitude pulmonary edemaIatrogenic, Self Induced DisordersWater intoxicationHypothermic anesthesiaHyponatremia correction, rapidSurgical, Procedure ComplicationAnesthesia, general
Brain surgeryInfectious Disorders (Specific Agent)Pneumonia, bacterialAIDS MeningoencephalitisEncephalitis, herpes simplexEncephalitis, secondary viralEncephalitis, viralMeningitis BacterialMeningitis, aseptic/viral
Meningitis, HemophilusMeningitis, pneumococcalMeningococcal meningitisPneumonia/BronchopneumoniaPneumonia, acute lobarPneumonia, pneumococcalTyphoid feverMeningitis, tuberculosis
Amebic (Naegleria) meningoencephalitisBacterial overwhelming sepsisCandidiasis systemicChickenpox encephalitisEncephalitis, bacterial/cerebritisEncephalitis, Dawsons/inclusion bodyEncephalitis, Eastern equine
Encephalitis, mumpsEncephalitis, Murray valleyEncephalitis, non-viralEncephalitis, St Louis BEncephalitis, Western equineGram negative (e coli) meningitisHistoplasmosis meningitisKunjin viral encephalitis
La Crosse viral encephalitisLegionella meningoencephalitisLeptospiral meningitisLeptospirosis/severe (Weils) typeListeria meningitisLyme meningoencephalitisMalaria, cerebralMeningitis, candidaMeningitis, Coxacki viral
Meningitis, echo viralMeningitis, staphylococcus aureusMononucleosis encephalitisPlague meningitisPost-viral/infectious encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes syndrome
Russian tick-bourne encephalitisToxic shock syndromeTrichinella meningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisLegionaires diseaseListeria monocytogenes/listeriosisMeningitis, fungal
Rocky mountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleeping sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, California
Encephalitis, equine, VenezuelanEncephalitis, Japanese BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acuteFungus brain abscess
Leptospirosis IctohemorrhagicaInfected organ, AbscessesInfectionsAbscess, intracranialBacteremia/SepticemiaBrain abscessEmbolism, septic, cerebralEndocarditis, infectiveMeningoencephalitisPneumonia, aspiration
SepsisSepsis, overwhelmingSeptic shockUrosepsis/septicemiaEncephalomyelitis, acuteEncephalopathy/secondary/toxic/sepsisNecrotizing fasciitis/mixedBrain stem encephalitisEncephalitisMeningitis
PneumoniaGranulomatous, Inflammatory DisordersHemorrhagic pancreatitis, necrotizingPancreatitis/resp distress syndromeNeoplastic DisordersHypercalcemia of malignancyMetastatic brain diseaseBrain stem tumor
Brain tumorFrontal lobe tumorMedulloblastomaMeningeal carcinomatosisParietal lobe tumorPrimary CNS lymphomaTemporal lobe tumorBrain tumor , malignant (astrocytoma)CraniopharyngiomaGlioblastoma multiforme
Insulinoma/Islet cell tumorMeningiomaPontine gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune DisordersEncephalitis, hemorrhagic, acuteEncephalitis, post viralEncephalomyelitis, necrotizing hem. ac.
Encephalomyelitis, post-infectiousStevens-Johnson syndromeTransfusion reaction, hemolyticLupus cerebritisPolyarteritis nodosaBehcet's syndromeHashimotos EncephalitisMetabolic, Storage Disorders
Hypoglycemia, reactive diabeticDiabetic ketoacidosis/comaHyperosmolar hyperglycemic coma, nonketNeonatal hyperbilirubinemiaMetabolic disordersMethemoglobinemia, HereditaryPorphyria, acute intermittent
Glutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical DisordersEncephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHypercalcemia
Hypercapnea HypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontine myelinolysis, centralDeficiency Disorders
Dehydration and feverDehydrationWernicke's encephalopathyMalnutrition/StarvationPellagra/niacin deficiencyMarchiafava-Bignami syndromeCongenital, Developmental Disorders
Nephrogenic diabetes insipidusHereditary, Familial, Genetic DisordersMELAS EncephalopathyVan Bogaert encephalitisUsage, Degenerative, Necrosis, Age Related DisordersAlzheimer's syndrome
Dementia, Lewy-body typeMultiple sclerosisRelational, Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia, factitiousCatatoniaManic deleriumAnatomic, Foreign Body, Structural Disorders
Acute subdural hematoma/hemorrhageBrain compressionEpidural hematomaIntracerebral hematomaIntraventricular brain hemorrhageSubdural hematomaTamponade, cardiacBrain stem herniation/peduncle/tonsils
Fat embolismSuperior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolismCerebral hemorrhageCerebral vein thrombosis/phlebitis
Intracerebral hemorrhageMyocardial infarction, acuteSubarachnoid hemorrhageTransient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosis
Cerebral/Venous sinus thrombophlebitisSuperior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexiaSleep deprivationVegetative, Autonomic, Endocrine Disorders
Cardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shockConvulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotension
Orthostatic hypotensionPost-ictal statusThyrotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignantMalignant hyperthermiaMyxedema coma
Myxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart blockInappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, juvenileNarcolepsy
Pickwick's syndromeReference to Organ SystemShockCerebral edemaDisseminated intravascular coagulopathyHepatic encephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndrome
Brain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremic encephalopathyEncephalopathy
Hyperviscosity syndromePernicious anemiaPontine lesion/disorderThrombotic thrombocytopenic purpuraCombined system disease/pernicious an.Fever Unknown Origin
Reversable Posterior Encephalopathy SyndromePathophysiologicSepsis encephalopathy/elderlyCardiac output reductionCerebral depressed functionsDrugsMedication/drugsBenzodiazepines Administration/Toxicity
Sedative drugs Administration/ToxicityDigitalis toxicity/poisoningHypoglycemia, diabetic/treatmentInsulin overdose/exogenousIntoxication/overdose syndromeSalicylate intoxication/overdoseTricyclic overdose
Barbiturate/sedative abuse/dependentDrug induced Hypoglycemia.Oral hypoglycemic Administration/Toxicity/effectInsulin (Humulin/Novulin) Administration/ToxicityIsoniazid (INH/Nydrazid) Administration/Toxicity
Ergot toxicityIsoniazid hepatitisMilk-alkali syndromePoisoning (Specific Agent)Opiate overdose toxidromeKitchen gas/propane exposureAlcohol/Ethanol ingestion/intakeAlcohol amnestic disorder
Alcohol induced hypoglycemiaAlcohol intoxication, acuteAlcohol seizure (rum fits)Cholinergic crisis toxidromeDelirium tremensInsecticide/organophosphate typeOverdose, drug/alcoholPoisoning
Snakebite (neurotoxic/coral/cobra type)Snakebite (rattlesnake/pit viper type)Alcohol withdrawalHallucinogen abuseLead poisoning in childrenSmoke inhalationHeroin/morphine usage/addiction
Cyanide/Hydrogen cyanide exposure/poisoningVomiting CBW agent (Dm/Da/Dc) Weapon exposureArsine gas (Hydrogen arsenide) poisoningCarbon monoxide poisoning/exposureDiethylene Glycol poisoning
Ethylene glycol [Antifreeze] ingestionInsecticide/pesticide poisoningIntentional poisoningIsopropyl alcohol ingestion/poisoningMustard gas exposure/poisoningNerve gas exposureAluminum toxicity/syndrome
Ammonia exposure/inhalationHydrogen sulfide poisoning/inhalationInsecticide/chlorinated/non-ester's inhLead poisoningLead encephalopathyNitrogen narcotic actionCarbon disulfide inhalant/poisoning
Chlorine gas poisoningMethane gas poisoning/asphyxiaCarbon dioxide gas inhalation/asphyxiaOrgan Poisoning (Intoxication)Neuroleptic malignant syndrome
• From Vertebrobasilar migraine syndrome to Hyponatremia It’s TOO MUCH
• You need a clue:
-EMS report
-Cell phone (call family members)
-Bystander account
-PMH from meds, alert bracelet, wallet, PhysEx (e.g fistula)
-Phys Exam for current physiological state of patient
-Labs
-Imaging
 PHYSIOLOGIC RESERVE DETERMINES HOW
READILY THE PATIENT WILL HAVE AMS!
• Frail Old Patient: A simple Urinary Tract Infection can put this patient in a coma.
• Young Healthy Patient: Likely to be something significant that has gone wrong
• Patient With Obvious Comorbidities: Other causes (than primary medical problem) will
more readily alter this patient (less reserve!)
 YOU MAY GET FRUSTRATED AT THIS PATIENT
AND SAY (DDX):
• M: Metabolic—B12 or thiamine deficiency, serotonin syndrome
• O: Hypoxemia (pulmonary, cardiac, anemia); high CO2
• V: Vascular causes—hypertensive emergency, ischemic/hemorrhagic CVA,
vasculitis, MI
• E: Electrolytes and endocrine
• S: Seizures / status epilepticus, post-ictal
• T: Tumor, trauma, temperature, toxins ( lead, mercury, CO, toxidromes )
• U: Uremia. Renal or hepatic dysfuction with hepatic encephalopathy
• P: Psychiatric, porphyria
• I: Infection (inflammatory-see vasculitis above)
• D: Drugs, including withdrawal (anticholinergics, TCA;s, SSRI’s, BZD’s,
barbiturates, alcohol)
 M: METABOLIC—B12 OR THIAMINE DEFICIENCY,
SEROTONIN SYNDROME
• Glucose metabolism uses up even more thiamine
• Serotonin syndrome=serotonin toxicity and caused by various drugs, medicines and
combinations thereof
-increased heart rate, shivering, sweating, dilated pupils, myoclonus, as well as
overresponsive reflexes
O: HYPOXEMIA (PULMONARY, CARDIAC, ANEMIA);
HIGH CO2
• Purely Hypoxic patient is anxious/agitated
-PE
• Purely Hypercarbic patient is sleepy
-Jet Insufflation in kids or bad COPDer
 V: VASCULAR CAUSES—HYPERTENSIVE
EMERGENCY, ISCHEMIC/HEMORRHAGIC CVA,
VASCULITIS, MI
• All of these cause poor perfusion of the brain either focally or globally through local
effects (CVA) or through loss of forward flow to brain (MI)
 E: ELECTROLYTES AND ENDOCRINE
• Electrolyte shifts can cause swelling in the brain
• High Na or Ca global depression (any electrolyte involved in ion-channel transmission
in the brain can cause a problem)
• Hypoglycemia most common cause of endocrine-related MS depression
S: SEIZURES / STATUS EPILEPTICUS, POST-ICTAL
• Post-ictal state typically resolves in 20-40minutes
• Non-epileptiform seizures can be cause of depressed mental status
-No tonic-clonic activity
-Ultimately diagnosed with EEG
-Eye movement, hx, ’trial of Ativan’ may give clue
T: TUMOR, TRAUMA, TEMPERATURE, TOXINS
(LEAD, MERCURY, CO, TOXIDROMES )
• Tumor causes compression or diffuse edema
• Hypothermia: Global depression of ion-channels
• Toxins: Wide range of responses depending on individual and their reserve
• Look for Toxidromes- A symptom constellation specific to a given toxin (e.g. Slurred
speech, B lateral-gaze nystagmus, cerebellar deficits, altered mood is the toxidrome for
Ethanol)
 U: UREMIA. RENAL OR HEPATIC DYSFUCTION
WITH HEPATIC ENCEPHALOPATHY
• Electrolyte Abnormalities
• Uremia-Urea build-up AND electrolyte abnormalities
• Hepatic Encephalopathy- elevated Ammonia (level should be high but poorly correlated
with actual degree of AMS)
 P: PSYCHIATRIC, PORPHYRIA
• Catatonia: no focal neurological deficits but unresponsive (responds to Ativan!)
• Porphyria: A group of enzyme deficiencies in hematologic biosynthesis pathway that
results in accumulation of Porphyrins (or precursors): Multiple s/sx including various MS
effects
 I: INFECTION (INFLAMMATORY-SEE VASCULITIS
ABOVE)
• Meningitis (A constant concern in all patient, esp at extremes of age)
• Cerebritis
 D: DRUGS, INCLUDING WITHDRAWAL
(ANTICHOLINERGICS, TCA;S, SSRI’S, BZD’S,
BARBITURATES, ALCOHOL)
• Learn and look for Toxidromes (withdrawal states are usually essentially opposite in
symptoms)
 IN SUMMARY: IT ALL BOILS DOWN TO ONE OF
TWO THINGS

• Both cerebral hemispheres are depressed

• The Reticular Activating System is not
functioning.
 APPROACH THE PATIENT COVERING MOST
URGENT BASES FIRST
• ABCs
• Intravenous access, oxygen therapy, cardiac
monitoring with pulse oximetry
• Accu-check / glucose / thiamine
• Cervical spine precautions
• Naloxone
 APPROACH THE PATIENT COVERING MOST
URGENT BASES FIRST
• EKG / cardiac monitoring
• ABG with carboxyhemoglobin
• CBC, electrolytes, Ca, Mg
• Drug screen, EtOH, serum osmolarity
• Urinalysis
• Imaging
• lumbar puncture
• liver, thyroid
 APPROACH THE PATIENT COVERING MOST
URGENT BASES FIRST
• EKG / cardiac monitoring
• ABG with carboxyhemoglobin
• CBC, electrolytes, Ca, Mg
• Drug screen, EtOH, serum osmolarity
• Urinalysis .
• Imaging
• lumbar puncture
• liver, thyroid
 CONCLUSION
• Maintain a wide differential
• Get a Grip on the Diagnosis through systematic ”clue finding”
• Remember: It’s focal in the RAS, or diffuse in the Bilateral Hemispheres
• Re-evaluate patient frequently and do frequent ”hypothesis-testing” in your mind
THANK YOU