Intern Survival Series July 2011 JeanPierre ELKHOURY, MD AKA JP !! Altered Mental Status Intern Survival Series July 2011 JeanPierre ELKHOURY, MD AKA JP !!

DEFINITION Consciousness is a condition in which an individual is fully responsive to stimuli and demonstrates awareness of the environment An alteration in mental status is the hallmark sign of central nervous system (CNS) injury or illness

DEFINITION What is Consciousness? Arousal function Content functions Alerting and wakefulness Anatomically-reticular activating system Content functions Language, reasoning Anatomically-cerebral cortex 6

Content of Consciousness DEFINITION Content of Consciousness Cerebral cortex Emotions Reasoning Self-awareness Spatial relationships

DEFINITION Altered Mental Status ? Disorder of Arousal functions Content functions disrupted

The nurse will page for Any or all of the following… DEFINITION The nurse will page for Any or all of the following… Seems drowsy or sleepy; not alert Awake and cooperative, but seems confused Awake, but used inappropriate words reported unconscious, but is now awake, with or without impaired memory Awake, but not oriented to self, time, place, or events Unconscious, but responds to verbal or painful stimuli Unresponsive

CAUSES Pathophysiology 4 general causes Primary intracranial disease Systemic disease affecting CNS Exogenous toxins Drug withdrawal

Causes of Altered Mental Status

Mnemonic A Alcohol, Alzheimer's E Endocrine, Environmental I Infection O Opiates, Overdose U Uremia T Tumor, Trauma I Insulin P Poisonings, Psychosis S Stroke Seizures Syncope

ASSESSMENT & MANAGEMENT Intern’s Role Primary survey Establish unresponsiveness A,B,C’s Resuscitation glucose, thiamine Secondary assessment Definitive care 16

ASSESSMENT & MANAGEMENT Gather History… Signs and symptoms Gradual or sudden onset? Associated symptoms? Did they get progressively worse? Medications Inpatient Medications and rule out drugs abuse last doses Last oral intake Alcohol Intoxication in ER Events leading up to Any seizure activity? Any trauma in last two weeks? Any complaints of headache? Was patient acting normal prior to events? Has patient been ill? Any witnesses ? 17

ASSESSMENT & MANAGEMENT Physical Examination Head- any evidence of trauma Pupils Unequal or fixed- increased intracranial pressure (head injury or stroke) Pinpoint- narcotics Sluggish- hypoxia Mouth and oral mucosa- check for cyanosis Chest- trauma, equal rise and fall of chest, lung sounds Abdomen- trauma, check for tenderness with palpation Extremities- pulse, movement, and sensation; edema in lower extremities 19

Neurological Examination ASSESSMENT & MANAGEMENT Neurological Examination Observation, Cranial nerves, Sensory, Motor, Reflexes If assessment findings indicate potential stroke, do a FAST Assessment: Face: Smile, is one side drooping? Arm: Raise arms, does one side drift down? Speech: Repeat a phrase, are your words slurred? Time: Quick treatment if CVA suspected 19

How to do A Mental Status Exam? ASSESSMENT & MANAGEMENT How to do A Mental Status Exam? Appearance, behavior, attitude Thought disorders Perception disorders Mood and affect Insight and judgment Sensorium and intelligence 24

Six Elements of Mental Status Evaluation ASSESSMENT & MANAGEMENT Six Elements of Mental Status Evaluation Appearance, behavior, and attitude Disorders of thought Are the thoughts logical and realistic? Are false beliefs or delusions present? Are suicidal or homicidal thoughts present? Disorders of perception Are hallucinations present? Mood and affect 25

Six Elements of Mental Status Evaluation ASSESSMENT & MANAGEMENT Six Elements of Mental Status Evaluation Insight and judgment Does the patient understand the circumstances surrounding the visit? Sensorium and intelligence Is the level of consciousness normal? Is cognition or intellectual functioning impaired? 25

How to do A Mental Status Exam? ASSESSMENT & MANAGEMENT How to do A Mental Status Exam? Informal testing used most often BUT, informal testing insensitive If a formal screening examination performed, assessments, workup, and dispositions change Formal mental status Mini-mental status exam Brief mental status exam Others 22

The Brief Mental Status Examination ASSESSMENT & MANAGEMENT The Brief Mental Status Examination ITEM (number of errors) X (weight) = (Total) What year is it now? 0 or 1 x 4 = ____ What month is it? 0 or 1 x 3 = ____ Present memory phrase: “Repeat this phrase after me and remember it: John Brown, 42 Market Street, New York.” About what time is it? 0 or 1 x 3 = ____ (Answer correct if within one hour) Count backwards from 20 to 1. 0, 1, or 2 x 2 = ____ Say the months in reverse 0, 1, or 2 x 2 = ____ Repeat memory phrase 0,1,2,3,4,or 5 x 2 = ____ (each underlined portion is worth 1 point) 27

The Brief Mental Status Examination ASSESSMENT & MANAGEMENT The Brief Mental Status Examination Final Score is the sum of the totals For each response, circle the number of errors and multiply the circled number by the weight to determine the score. ______________________________________ Possible score range from 0 to 28. 28

The Brief Mental Status Examination ASSESSMENT & MANAGEMENT The Brief Mental Status Examination The lowest possible score (indicating the least impairment) is 0. The highest possible score is 28. Categories of scores: 0-8 normal 9-19 mildly impaired 20-28 severely impaired

ASSESSMENT & MANAGEMENT Work Up Check Vital Signs (BP, Pulse Ox, RR…) Finger stick blood sugar CBC, CMP, UA, ABG Drug levels – acetaminophen, ASA, etc… UDS Apply monitor and make sure patient has IV Access Be prepared to initiate CPR Head CT without contrast before LP if possible CXR LP

When Is a Spinal Tap Indicated in Delirium? ASSESSMENT & MANAGEMENT When Is a Spinal Tap Indicated in Delirium? The primary indication for an emergent spinal tap is the possibility of CNS infection. CSF should be examined in patients with a fever of unknown origin, especially if an alteration in consciousness is present… 32

TREATEMENT Treatment of underlying cause Sedation Restraints if needed 36

Treat the underlying cause TREATEMENT Treat the underlying cause Infections: pneumonia, UTI, meningitis, sepsis Metabolic: hypoglycemia, electrolytes, hepatic, thyroid disorders, ETOH, or drugs Neurologic: CVA, TIA, seizure, intracranial hemorrhage or mass Cardiopulmonary: CHF, MI, PE, hypoxia Drug related: Narcotics, sedatives, muscle relaxants, antiemetics, digoxin

Treat the underlying cause TREATEMENT Treat the underlying cause If low blood sugar is present: Administer oral glucose if patient is alert and able to swallow (Basic providers) Dextrose 50% IVP or Glucagon IM If narcotic overdose is suspected and airway compromise and/or inadequate respiratory effort is present: Narcan IV or IM Ventilation Support

Sedation and Restraints TREATEMENT Sedation and Restraints Sedation Haloperidol IV/IM Lorazepam IV Confinement or restraints if patient is at risk of harming himself or others (Hospital staff…)