Approach to Altered Approach to Altered LOCLOC

Gabriel PiperGabriel Piper

March 31March 31stst, 2011, 2011

ObjectivesObjectives

►BackgroundBackground►AssessmentAssessment►Approach to the diagnosisApproach to the diagnosis►Managing the undifferentiated altered Managing the undifferentiated altered

LOC patientLOC patient►Cases! Cases!

What is not included?What is not included?

►An exhaustive review of the work-up An exhaustive review of the work-up or management of specific causes of or management of specific causes of altered LOC (these are covered altered LOC (these are covered elsewhere)elsewhere)

Definitions – Altered LOCDefinitions – Altered LOC► HypervigilenceHypervigilence - - abnormally increased arousal, responsiveness to abnormally increased arousal, responsiveness to

stimuli, and scanning of the environment for threats. stimuli, and scanning of the environment for threats.

► ObtundationObtundation - awake but not alert. Psychomotor retardation is - awake but not alert. Psychomotor retardation is presentpresent

► Drowsiness or lethargyDrowsiness or lethargy - simulates light sleep. The patient is - simulates light sleep. The patient is arousable by touch or noise and can maintain alertness for a arousable by touch or noise and can maintain alertness for a period of time.period of time.

► StuporStupor - can be aroused only by vigorous stimuli. Efforts to avoid - can be aroused only by vigorous stimuli. Efforts to avoid stimulation are displayed. Little or no spontaneous activity, and stimulation are displayed. Little or no spontaneous activity, and shows little motor or verbal activity once aroused.shows little motor or verbal activity once aroused.

► ComaComa - the patient is not arousable at all to verbal or physical - the patient is not arousable at all to verbal or physical stimuli, and no attempt is made to avoid painful or noxious stimuli.stimuli, and no attempt is made to avoid painful or noxious stimuli.

DSM IV TR criteria for DSM IV TR criteria for deliriumdelirium

► 1.      Disturbance of consciousness with reduced 1.      Disturbance of consciousness with reduced ability to focus, sustain, or shift ability to focus, sustain, or shift attentionattention2.      Evidence from the Hx, PE, Labs that the 2.      Evidence from the Hx, PE, Labs that the disturbance is caused by a general medical disturbance is caused by a general medical condition, medication or other substance exposure, condition, medication or other substance exposure, substance withdrawal or multiple etiologiessubstance withdrawal or multiple etiologies3.      A 3.      A change in cognitionchange in cognition (memory deficit, (memory deficit, disorientation, language disturbance) or the disorientation, language disturbance) or the development of a development of a perceptual disturbanceperceptual disturbance that is not that is not accounted for better by a pre-existing, established, accounted for better by a pre-existing, established, or evolving dementiaor evolving dementia4.      The disturbance 4.      The disturbance develops over hours to daysdevelops over hours to days the tends to the tends to fluctuatefluctuate during the course of the day during the course of the day

PathophysiologyPathophysiology

Recognizing Altered LOCRecognizing Altered LOC

The evaluation of a patient’s mental The evaluation of a patient’s mental statusstatus

involves an assessment of two factors: involves an assessment of two factors:

1) level of consciousness1) level of consciousness

2) content of consciousness or cognitive 2) content of consciousness or cognitive function function

Assessing Level of Assessing Level of consciousnessconsciousness

►Several scales have been created to Several scales have been created to assess LOCassess LOC

►GCS, AVPU, ACDU, SMSGCS, AVPU, ACDU, SMS►GCS most common in CalgaryGCS most common in Calgary

Glascow Coma ScoreGlascow Coma Score

Simplified Motor ScoreSimplified Motor Score

► SMS is as good as GCS for predicting SMS is as good as GCS for predicting important clinical outcomes (important clinical outcomes (emergency emergency intubation, clinically significant brain injury, intubation, clinically significant brain injury, neurosurgical intervention, and mortality) neurosurgical intervention, and mortality) and and has been found to have higher inter-rater has been found to have higher inter-rater reliabilityreliability

► 3 point scale: 3 point scale:

obeys commands=2obeys commands=2

localizes pain=1localizes pain=1

withdrawals to pain or worse=0withdrawals to pain or worse=0

Assessing DeliriumAssessing Delirium

►ED docs arenED docs aren’t very good at ’t very good at diagnosing deliriumdiagnosing delirium

Study by Lewis of 385 emergency Study by Lewis of 385 emergency patients aged >65patients aged >65

physician had noted altered mental physician had noted altered mental status in only 17% of patients with status in only 17% of patients with deliriumdelirium

Confusion Assessment Confusion Assessment Method Method

1) acute onset and fluctuating course1) acute onset and fluctuating course2) inattention 2) inattention 3) disorganized thinking3) disorganized thinking4) altered level of consciousness. 4) altered level of consciousness.

A diagnosis of delirium according to the A diagnosis of delirium according to the CAM requires the presence of featuresCAM requires the presence of features1, 2, and either 3 or 4 1, 2, and either 3 or 4

Beware the hypoalert patientBeware the hypoalert patient

Hypoactive delirium makes up 50% of delirious patients vs 25% for hyperactive (25% are mixed)

Now that you have made the Now that you have made the diagnosis – what next?diagnosis – what next?

Differential diagnosisDifferential diagnosisI: Infection - Sepsis, encephalitis, meningitis, syphilis, central nervous system I: Infection - Sepsis, encephalitis, meningitis, syphilis, central nervous system

(CNS) abscess, malaria(CNS) abscess, malaria

W: Withdrawal - Alcohol, barbiturates, sedative-hypnoticsW: Withdrawal - Alcohol, barbiturates, sedative-hypnoticsA: Acute Metabolic and endocrine - Acidosis, electrolyte disturbance, hepatic or A: Acute Metabolic and endocrine - Acidosis, electrolyte disturbance, hepatic or

renal failure, magnesium, calcium, porphyria; endocrinopathies: diabetes, renal failure, magnesium, calcium, porphyria; endocrinopathies: diabetes, adrenal, thyroidadrenal, thyroid

T: Trauma – head trauma, burns, abuseT: Trauma – head trauma, burns, abuseC: CNS dz – Hemorrhage (EDH, SDH, SAH, intracerebral), stroke, vasculitis(TTP), C: CNS dz – Hemorrhage (EDH, SDH, SAH, intracerebral), stroke, vasculitis(TTP),

seizures, tumor (benign, malignant primary vs metastatic)seizures, tumor (benign, malignant primary vs metastatic)H: Hypoxia/Hypercarbia – chronic lung dz (ie COPD), acute (Pneumonia, CO, H: Hypoxia/Hypercarbia – chronic lung dz (ie COPD), acute (Pneumonia, CO,

Methemoglobinemia), global hypoperfusionMethemoglobinemia), global hypoperfusion

D: Deficiencies- Vitamin B12, hypovitaminosis, niacin, thiamineD: Deficiencies- Vitamin B12, hypovitaminosis, niacin, thiamineE: Environmental: Hypothermia, hyperthermia;E: Environmental: Hypothermia, hyperthermia;A: Acute Vascular - Hypertensive emergency, subarachnoid hemorrhage, sagittal A: Acute Vascular - Hypertensive emergency, subarachnoid hemorrhage, sagittal

vein thrombosisvein thrombosisT: Toxins/Drugs - Medications, street drugs, alcohol, pesticides, industrial poisons T: Toxins/Drugs - Medications, street drugs, alcohol, pesticides, industrial poisons

(e.g., carbon monoxide, cyanide, solvents), serotonin syndrome, NMS(e.g., carbon monoxide, cyanide, solvents), serotonin syndrome, NMSH: Heavy Metals - Lead, mercury, IronH: Heavy Metals - Lead, mercury, Iron

Other mnemonicsOther mnemonics

►DIM TOPSDIM TOPS Drugs/withdrawalDrugs/withdrawal InfectionInfection MetabolicMetabolic TraumaTrauma Other (endocrine, environmental)Other (endocrine, environmental) PsychPsych Structural, seizureStructural, seizure

► AEIOU TIPSAEIOU TIPS

► Find one that works for you!Find one that works for you!

However…..However…..

Let’s create an approach we can use in the ED

AirwayAirway

►““GCS <8 then intubate”GCS <8 then intubate”► Important to take entire clinical picture Important to take entire clinical picture

into contextinto context► In the abscence of other indications, In the abscence of other indications,

defer intubation until hypoglycemia defer intubation until hypoglycemia and opioid toxicity have been excluded and opioid toxicity have been excluded

►maintain C-spine collar if history maintain C-spine collar if history unknown unknown

BreathingBreathing

►Hypoxia: Hypoxia: pneumonia, CHF, PE, COPD pneumonia, CHF, PE, COPD ► Respiratory depression: opioids, brainstem Respiratory depression: opioids, brainstem

injuryinjury►Hyperpnia:Hyperpnia:

Profound Met AcidosisProfound Met Acidosis       Methanol/EG       Methanol/EG       DKA/AKA/SKA       DKA/AKA/SKA       Sepsis - Pulmonary source       Sepsis - Pulmonary source

Respiratory StimulationRespiratory Stimulation       Salicylates        Salicylates

CirculationCirculation

► Tachy and Altered…too broadTachy and Altered…too broad► Brady and AlteredBrady and Altered

BBBB LiLi OrganophosphatesOrganophosphates Uremic encephalopathy Uremic encephalopathy HyperkalemiaHyperkalemia Ischemia Ischemia shockshock

Circulation contCirculation cont

►Hypotension: Hypotension: volume/blood lossvolume/blood loss SepsisSepsis cardiogenic shockcardiogenic shock Addisonian crisisAddisonian crisis

►Hypertension: Hypertension: hypertensive encephalopathyhypertensive encephalopathy hyperadrenergic crises hyperadrenergic crises

Hot and AlteredHot and Altered

►Meningitis/Encephalitis/AbscessMeningitis/Encephalitis/Abscess► Thyroid stormThyroid storm►HyperthermiaHyperthermia► CVA/CNS bleedsCVA/CNS bleeds► ToxTox

Sympathomimetics/AnticholinergicsSympathomimetics/Anticholinergics WithdrawalWithdrawal NMS/SS/MHNMS/SS/MH CholinergicsCholinergics ASAASA

Cold and AlteredCold and Altered

►EnvironmentalEnvironmental► InfectionInfection►ThyroidThyroid►Wernicke’s (hypothalamic dysfunction) Wernicke’s (hypothalamic dysfunction)

GlucoseGlucose

►Consider it the 5Consider it the 5thth vital sign vital sign► If hypoglycemic, treat with 1-2 amps of If hypoglycemic, treat with 1-2 amps of

D50D50

Coma cocktail - DONTComa cocktail - DONT

►DextroseDextrose►OxygenOxygen►NaloxoneNaloxone►ThiamineThiamine

►Flumazanil?Flumazanil?

Raised ICP?Raised ICP?

►deep coma deep coma ►unilateral dilated pupil (unexplained by unilateral dilated pupil (unexplained by

drug effect or eye disease) drug effect or eye disease) ►abnormal posturing abnormal posturing ►abnormal breathing patterns abnormal breathing patterns

+/- hypertension and bradycardia +/- hypertension and bradycardia

Treat FeverTreat Fever

►AcetominophenAcetominophen►CoolingCooling►BenzodiazepinesBenzodiazepines

Consider early antibioticsConsider early antibioticsfor sepsis/menigitisfor sepsis/menigitis

►Early Abx shown to be important in Early Abx shown to be important in severe infectionssevere infections

►Draw blood cultures prior to starting Draw blood cultures prior to starting AbxAbx

►Give Abx before sending to CT if high Give Abx before sending to CT if high suspicion of infectionsuspicion of infection

Agitated deliriumAgitated delirium

►Clear association exists between illicit Clear association exists between illicit drug use and the syndrome but not drug use and the syndrome but not universal.universal.

►Non-drug related causes are almost Non-drug related causes are almost always psychotic (schizophrenia, bipolar)always psychotic (schizophrenia, bipolar)

►Treat if:Treat if: Presence of excited deliriumPresence of excited delirium Continued maximal struggle despite Continued maximal struggle despite

attempts at maximal restraintattempts at maximal restraint

Agitated delirium and SCDAgitated delirium and SCD

Mechanism of deathMechanism of death No definite etiology usually found at autopsyNo definite etiology usually found at autopsy Catecholamine excess leading to stress Catecholamine excess leading to stress

cardiomyopathy Vs cardiomyopathy Vs Profound metabolic Profound metabolic acidosis likely leading to cardiac arrest?acidosis likely leading to cardiac arrest?

Hyperthermia often contributoryHyperthermia often contributory Convulsions often contributoryConvulsions often contributory Hyperkalemia often contributoryHyperkalemia often contributory Restraint asphyxia unlikely explanation Restraint asphyxia unlikely explanation

Drug therapy for agitated Drug therapy for agitated patientspatients

Drug induced: benzodiazepinesDrug induced: benzodiazepinesDrug withdrawal: benzodiazepinesDrug withdrawal: benzodiazepinesPsychiatric: antipsychoticPsychiatric: antipsychoticDementia: antipsychoticDementia: antipsychoticUnknown: benzodiazepines Unknown: benzodiazepines

► Lorazepam 1-2 mg IV Lorazepam 1-2 mg IV ►Midazolam 2.5-5 mg IMMidazolam 2.5-5 mg IM► halperidol 0.5-1.0 mg IV => double the dose halperidol 0.5-1.0 mg IV => double the dose

every 20-30 minutes prnevery 20-30 minutes prn

Now that you have treated Now that you have treated life threatening emergencies life threatening emergencies and have calmed the patient and have calmed the patient

down…..down…..Time to figure out what is Time to figure out what is

going ongoing on

HistoryHistory

►CollateralCollateral►BaselineBaseline►Change in mental statusChange in mental status►PMHxPMHx►Medications/toxinsMedications/toxins►Social historySocial history►ROSROS

CollateralCollateral

►EMS: onset, location, evidence of EMS: onset, location, evidence of trauma,  information about home trauma,  information about home environment, medications in homeenvironment, medications in home

►Family/friends: focal signs prior to Family/friends: focal signs prior to LOC, prodromal symptoms (fevers, HA, LOC, prodromal symptoms (fevers, HA, etc), ingestions, access to medicationsetc), ingestions, access to medications

►Other: Old charts, net care, medic Other: Old charts, net care, medic alert bracelet alert bracelet

BaselineBaseline

►mental and behavioural status; normally fully mental and behavioural status; normally fully oriented, cognitively intact, attentive and oriented, cognitively intact, attentive and capable of normal social functioning. capable of normal social functioning.

► if the patient has an abnormal baseline if the patient has an abnormal baseline mental status => try and semi-quantitate the mental status => try and semi-quantitate the degree and time course of any mental status degree and time course of any mental status changes (when he last drove a car, balanced changes (when he last drove a car, balanced a checkbook, fed himself, dressed himself, a checkbook, fed himself, dressed himself, had a coherent conversation and so on)had a coherent conversation and so on)

► social functioning, occupational status, social functioning, occupational status, physical statusphysical status

Change in Mental StatusChange in Mental Status► time of onsettime of onset► course and labilitycourse and lability► precipitating events (seizure, head injury)precipitating events (seizure, head injury)► presence of lucid intervalspresence of lucid intervals► changes in sleep-awake cycle; Disturbance in the sleep-wake changes in sleep-awake cycle; Disturbance in the sleep-wake

cycle often occurs early in the course of delirium.cycle often occurs early in the course of delirium.► "sundowning" phenomenon"sundowning" phenomenon► degree of attentiveness and distractability; the ability to degree of attentiveness and distractability; the ability to

sustain a conversation or a tasksustain a conversation or a task► short term memory changesshort term memory changes► perceptual disturbances -illusions, hallucinations, delusionsperceptual disturbances -illusions, hallucinations, delusions► emotional lability and poor capacity to modulate emotional emotional lability and poor capacity to modulate emotional

behaviourbehaviour► psychomotor disturbances - asterixis, myoclonus, motor psychomotor disturbances - asterixis, myoclonus, motor

restlessnessrestlessness

PMHxPMHx

► Chronic illnesses (hepatic or renal failure, Chronic illnesses (hepatic or renal failure, endocrinopathies, COPD, DM, CHF)endocrinopathies, COPD, DM, CHF)

► immunosuppressionimmunosuppression► Previous history of alcoholism or Wernicke's Previous history of alcoholism or Wernicke's

encephalopathyencephalopathy► Physical, emotional, mental disabilities Physical, emotional, mental disabilities ► Recent hospitalisationsRecent hospitalisations► Recent surgeryRecent surgery► Recent cancer treatment (paraneoplastic Recent cancer treatment (paraneoplastic

syndrome) syndrome) ► Recent outpatient therapy or dialysisRecent outpatient therapy or dialysis► Recent depression or suicide ideationRecent depression or suicide ideation

Meds/toxinsMeds/toxins► Overt/occult alcohol or illicit drug abuseOvert/occult alcohol or illicit drug abuse► Any sudden withdrawal from alcohol or sedative drugsAny sudden withdrawal from alcohol or sedative drugs► Any new psychotropic drugs (inluding over-the-counter Any new psychotropic drugs (inluding over-the-counter

medications with anti-cholinergic properties eg. medications with anti-cholinergic properties eg. decongestants and cough preperations)decongestants and cough preperations)

► Any new drugs or drug dose changes; clue to recent Any new drugs or drug dose changes; clue to recent medication changes can be that the patient was recently in medication changes can be that the patient was recently in the office or admitted to the hospital before the onset of the office or admitted to the hospital before the onset of delirium.delirium.

► Any salicylate abuseAny salicylate abuse► Use of nutritional supplements or alternative medicinesUse of nutritional supplements or alternative medicines► Intentional/accidental exposure to pesticides, heavy metals, Intentional/accidental exposure to pesticides, heavy metals,

plant toxinsplant toxins► Intentional/accidental exposure to extreme enviromental Intentional/accidental exposure to extreme enviromental

temperaturestemperatures

Meds to watch forMeds to watch for

► antibioticsantibiotics► anticholinergic drugsanticholinergic drugs► AnticonvulsantsAnticonvulsants► anti-inflammatory agents (corticosteroids)anti-inflammatory agents (corticosteroids)► cardiovascular medications (beta-blockers, cardiovascular medications (beta-blockers,

antidysrhythmics, antihypertensives, cardiac antidysrhythmics, antihypertensives, cardiac glycosides)glycosides)

► SympathomimeticsSympathomimetics► sedative-hypnoticssedative-hypnotics► NarcoticsNarcotics► Psychiatric medications (antidepressants, Psychiatric medications (antidepressants,

antipsychotics, mood stabilizers) antipsychotics, mood stabilizers)

Social HistorySocial History

► ability to dress and groom oneself , ability to ability to dress and groom oneself , ability to feed onself and ability to perform social tasks feed onself and ability to perform social tasks such as shopping and house-keepingsuch as shopping and house-keeping

►Home enviroment and social support systems Home enviroment and social support systems ► nutritional status (thiamine deficiency, Vit B12 nutritional status (thiamine deficiency, Vit B12

and folate deiciency)and folate deiciency)► Any recent life-altering social or emotional Any recent life-altering social or emotional

events events ► any recent scuba diving (? air embolism) or any recent scuba diving (? air embolism) or

foreign travel (malaria)foreign travel (malaria)

Review of SymptomsReview of Symptoms► Recent physical illness Recent physical illness ► recent head injury (subdural hematoma)recent head injury (subdural hematoma)► constitutional symptomsconstitutional symptoms

fever (infectious process)fever (infectious process) weight loss (malignancy)weight loss (malignancy) night sweats (infections, TB)night sweats (infections, TB)

► Specific neurological symptoms suggesting neurological Specific neurological symptoms suggesting neurological diseasedisease gait problems (hydrocephalus, frontal strokes)gait problems (hydrocephalus, frontal strokes) incontinence (hydrocephalus, frontal strokes)incontinence (hydrocephalus, frontal strokes) focal neurological signs (suggestive of a SAH, subdural hematoma, focal neurological signs (suggestive of a SAH, subdural hematoma,

CVA or tumor)CVA or tumor) headacheheadache abrupt changes in language facilityabrupt changes in language facility psychomotor automatisms (complex partial seizures)psychomotor automatisms (complex partial seizures)

► Specific disease symptoms suggestive of acute organ Specific disease symptoms suggestive of acute organ dysfunction (AMI, CHF, pneumonia, UTI, thyrotoxicosis) dysfunction (AMI, CHF, pneumonia, UTI, thyrotoxicosis)

Physical ExamPhysical Exam

►Complete physical exam Complete physical exam ►Look for Look for physical evidence of diseases physical evidence of diseases

that may have precipitated altered that may have precipitated altered LOCLOC

►Mental status exam to diagnose subtle Mental status exam to diagnose subtle delirium and to help differentiate delirium and to help differentiate delirium from dementiadelirium from dementia

NeuroNeuro► Pupils (brainstem lesion, toxidromes)Pupils (brainstem lesion, toxidromes)► nystagmus (Wernicke's encephalopathy, PCP intoxication, nystagmus (Wernicke's encephalopathy, PCP intoxication,

alchohol (s) intoxication)alchohol (s) intoxication)► cranial nerves (CVA, CNS tumor, Wernicke's opthalmoplegia)cranial nerves (CVA, CNS tumor, Wernicke's opthalmoplegia)► muscle strength, tone, clonus, abnormal movements (CVA, muscle strength, tone, clonus, abnormal movements (CVA,

space-occupying lesions, NMS or serotonin syndrome)space-occupying lesions, NMS or serotonin syndrome)► pathologic primitive reflexes (frontal lobe tumor, strokes or pathologic primitive reflexes (frontal lobe tumor, strokes or

subdural)subdural)► gait apraxia (hydrocephalus, chronic subdural)gait apraxia (hydrocephalus, chronic subdural)► peripheral neuropathy (alcoholic, porphyria, paraneoplastic, peripheral neuropathy (alcoholic, porphyria, paraneoplastic,

vitamin B12 deficiency)vitamin B12 deficiency)► circumoral and distal limb paresthesias and tetany circumoral and distal limb paresthesias and tetany

(hypocalcemia)(hypocalcemia)► Reflexes: generalized hyperreflexia can be found in serotonin Reflexes: generalized hyperreflexia can be found in serotonin

syndrome, tetanus, rabies and strychnine poisoning; while syndrome, tetanus, rabies and strychnine poisoning; while delayed "hung up" reflexes are found in myxedema comadelayed "hung up" reflexes are found in myxedema coma

SkinSkin► increased pigmentationincreased pigmentation► Jaundice, spider nevi, caput medusaJaundice, spider nevi, caput medusa► Needle tracksNeedle tracks► cyanosis unresponsive to oxygen (methemoglobinemia)cyanosis unresponsive to oxygen (methemoglobinemia)► feathering burns (lightning injury)feathering burns (lightning injury)► Petechiae and Ecchymosis: Petechiae and Ecchymosis:

Confined to head and neck – seizure or strangulation or emesisConfined to head and neck – seizure or strangulation or emesis Bleeding diathesis – thrombocytopenia, DICBleeding diathesis – thrombocytopenia, DIC VasculitisVasculitis menigococcemiamenigococcemia

► perspiration:  Fevers, Hypoglycemia, pheochromocytomaperspiration:  Fevers, Hypoglycemia, pheochromocytoma- dry, warm, flushed - think tox- dry, warm, flushed - think tox

► Cellulitis/nec fascCellulitis/nec fasc► uremic frost, anasarca (renal failure)uremic frost, anasarca (renal failure)

HEENTHEENT

► Stiff neck, positive Jolt testStiff neck, positive Jolt test► Cherry red lips: COCherry red lips: CO► skull - scalp hematoma, Battle's sign, skull - scalp hematoma, Battle's sign,

hemotympanum, CSF otorrhea, raccoon hemotympanum, CSF otorrhea, raccoon eyes, diffuse subconjunctival hemorrhage, eyes, diffuse subconjunctival hemorrhage, epistaxis, CSF rhinorrhea (traumatic head epistaxis, CSF rhinorrhea (traumatic head injury); palpable shunt (shunt malfunction) injury); palpable shunt (shunt malfunction)

► Tongue bitten on lateral aspect (seizures)Tongue bitten on lateral aspect (seizures)► odor of breath – alcohol, almonds (cyanide), odor of breath – alcohol, almonds (cyanide),

acetone (DKA), ammonia (fetor hepaticus) acetone (DKA), ammonia (fetor hepaticus)

Cardiac/Resp/AbdoCardiac/Resp/Abdo

►cardiac ischemia/AMI (abnormal heart cardiac ischemia/AMI (abnormal heart sounds, murmurs)sounds, murmurs)

►CHF (tachypnea, abnormal heart CHF (tachypnea, abnormal heart sounds, murmurs, rales, sounds, murmurs, rales, hepatomegealy, pedal edema)hepatomegealy, pedal edema)

►pneumonia (tachypnea, rales, pneumonia (tachypnea, rales, bronchial breathing)bronchial breathing)

► Intra-abdominal infections (peritonitis, Intra-abdominal infections (peritonitis, ascites)ascites)

SyndromesSyndromes

► liver failure - jaundice, spider nevi, caput liver failure - jaundice, spider nevi, caput medusae, ascites, hepatomegaly or shrunken medusae, ascites, hepatomegaly or shrunken hard liver, genital atrophy, gynecomastia, fetor hard liver, genital atrophy, gynecomastia, fetor hepaticushepaticus

► Thyrotoxicosis - enlarged thyroid, autonomic Thyrotoxicosis - enlarged thyroid, autonomic hyperactivity, exopthalmos, pretibial hyperactivity, exopthalmos, pretibial myxedemamyxedema

► toxidromes eg. anticholinergic toxicity (red toxidromes eg. anticholinergic toxicity (red flushed skin, mydriasis, tachycardia, flushed skin, mydriasis, tachycardia, hypertension, urinary retention, decreased hypertension, urinary retention, decreased bowel sounds)bowel sounds)

Mental Status exam?Mental Status exam?

►Do I have to do a MMSE?Do I have to do a MMSE?►Exam should include assessment of:Exam should include assessment of:

the patient's ability to focus and sustain the patient's ability to focus and sustain attention attention

the patient's capacity to think in an the patient's capacity to think in an organized manner organized manner

the patient's short-term memory the patient's short-term memory

* A change in baseline in any of these * A change in baseline in any of these should make you think of deliriumshould make you think of delirium

Comatose patientsComatose patients

►Clues to help determine cause of Clues to help determine cause of coma:coma: PupilsPupils Eye MovementsEye Movements BreathingBreathing PosturingPosturing

BloodworkBloodwork

► CBCCBC► Extended Lytes including Ca, MgExtended Lytes including Ca, Mg► OsmolalityOsmolality► Cr, BUNCr, BUN► LFTsLFTs► CKCK► TSH, T3, T4TSH, T3, T4► TnTTnT► Serum drug levels: ASA, APAP, Li, anti-epileptics, Serum drug levels: ASA, APAP, Li, anti-epileptics,

digoxindigoxin► RPR, HIVRPR, HIV► Heavy metal testingHeavy metal testing

Blood gasBlood gas

►pH/pCO2/pO2/HCO3pH/pCO2/pO2/HCO3►LactateLactate►CO level CO level ►MethemoglobinMethemoglobin

UrineUrine

►UrinalysisUrinalysis►Urine pregnancyUrine pregnancy►Urine drugs of Abuse?Urine drugs of Abuse?

Ancillary studiesAncillary studies

►ECGECG►CXRCXR►CT headCT head►LPLP►Blood culturesBlood cultures►EEGEEG

when is it okay to defer the CT when is it okay to defer the CT scan?scan?

►metabolic cause of the coma that is metabolic cause of the coma that is readily reversiblereadily reversible

► if drug intoxication is definitely the if drug intoxication is definitely the known cause of the comaknown cause of the coma

►carefully observe the patient's mental carefully observe the patient's mental status for any unexpected lack of status for any unexpected lack of improvement, or unexplained improvement, or unexplained deterioration, during treatment of a deterioration, during treatment of a particular etiologyparticular etiology

Differential diagnosisDifferential diagnosisI: Infection - Sepsis, encephalitis, meningitis, syphilis, central nervous system

(CNS) abscess, malaria

W: Withdrawal - Alcohol, barbiturates, sedative-hypnoticsA: Acute Metabolic and endocrine - Acidosis, electrolyte disturbance, hepatic or

renal failure, magnesium, calcium, porphyria; endocrinopathies: diabetes, adrenal, thyroid

T: Trauma - Head trauma, burns, abuseC: CNS dz - Hemorrhage, stroke, vasculitis(TTP), seizures, tumorH: Hypoxia/Hypercarbia – chronic lung dz (ie COPD), acute (Pneumonia, CO,

Methemoglobinemia), global hypoperfusion

D: Deficiencies- Vitamin B12, hypovitaminosis, niacin, thiamineE: Environmental: Hypothermia, hyperthermia;A: Acute Vascular - Hypertensive emergency, subarachnoid hemorrhage, sagittal

vein thrombosisT: Toxins/Drugs - Medications, street drugs, alcohol, pesticides, industrial poisons

(e.g., carbon monoxide, cyanide, solvents)H: Heavy Metals - Lead, mercury, Iron

Managing DeliriumManaging Delirium

►minimize sensory overload by limiting minimize sensory overload by limiting the number of care-givers and the number of care-givers and ensuring a quiet enviromentensuring a quiet enviroment

►allow family members to remain in allow family members to remain in constant/frequent attendanceconstant/frequent attendance

►do not leave patients unattended in do not leave patients unattended in the hallway and ensure that the bed the hallway and ensure that the bed side-rails are up side-rails are up

CasesCases

Case 1Case 1

►51 yo M from home51 yo M from home►Found by wife in morning to be Found by wife in morning to be

unresponsive in bed. unresponsive in bed. ►Last seen normal last night.Last seen normal last night.►No known trauma. No known trauma. ►Past few days has felt unwell with Past few days has felt unwell with

fever, chills, increase fatigue.  N/V/D fever, chills, increase fatigue.  N/V/D for past 24 hrsfor past 24 hrs

►Brought in by EMS - LMA placed Brought in by EMS - LMA placed ►O/E: 36.9, 75, 90/50, 8, 100% O2 O/E: 36.9, 75, 90/50, 8, 100% O2 ►PERL 3mm sluggishPERL 3mm sluggish►None-verbal; No eye responseNone-verbal; No eye response

fluctuating motor exam No limb fluctuating motor exam No limb movement-withdrawing from painmovement-withdrawing from pain

►Otherwise normal exam Otherwise normal exam

► PMHx:PMHx: refractory HTNrefractory HTN R frontal R frontal

cavernoma - cavernoma - incidental finding, incidental finding, no symptoms in no symptoms in pastpast

Paroxysmal SVTParoxysmal SVT Depression - Depression -

according to wife, according to wife, untreated, no untreated, no previous SA/ODprevious SA/OD

Chronic HA Chronic HA

Medications:Pantoloc 40 amitriptyleneramipril 5 BIDAvalide 300/25metoprolol 50 BIDZopiclone 7.5 hsditropan xl 5clonazepam 1 hsmelatonin HS

► Hgb 161Hgb 161WBC 17WBC 17Plts 262Plts 262

Na 138, K 5.1, Cl 105, HCO3 24 Na 138, K 5.1, Cl 105, HCO3 24 Cr 113Cr 113BUN 4.5BUN 4.5glucose 7.4glucose 7.4PTT/INR NPTT/INR NCa, Mg, PO4 normalCa, Mg, PO4 normalOsm 294Osm 294Alb 39Alb 39APAP, ASA, EtOH, urine tox NegAPAP, ASA, EtOH, urine tox NegUrine R+M neg Urine R+M neg

►CT head – no change from previousCT head – no change from previous►LP – normalLP – normal►EEG – NormalEEG – Normal

Case 2Case 2

► It is 15 mins after handover and the It is 15 mins after handover and the nurse tells you she is concerned about nurse tells you she is concerned about a 22 year old Female patienta 22 year old Female patient

►handed over as a case of “found down handed over as a case of “found down at a party" with normal CXR, ECG and at a party" with normal CXR, ECG and labs, urine is pending. labs, urine is pending.

►HR = 100 BP = 120/70 RR = 12 T = HR = 100 BP = 120/70 RR = 12 T = 36.036.0

►no response to pain, eyes do not open, no response to pain, eyes do not open, un-intelligible sounds un-intelligible sounds

►you also note a rapid, mild, but you also note a rapid, mild, but prominent twitching of upper and prominent twitching of upper and lower extremities. lower extremities.

Non-convulsive Status Non-convulsive Status epilepticusepilepticus

►ongoing subtle status epilepticus ongoing subtle status epilepticus should be suspected if there any should be suspected if there any ongoing subtle twitching, jerking ongoing subtle twitching, jerking movements, fluttering eyelids - movements, fluttering eyelids - especially if the patient has a history especially if the patient has a history of seizures + evidence of tongue of seizures + evidence of tongue biting, urinary incontinence biting, urinary incontinence

Case 3 Case 3

►32 yo M with presents with 32 yo M with presents with with fever, with fever, altered mental status, and vomiting. altered mental status, and vomiting.

► patient was too altered to provide a history. history patient was too altered to provide a history. history from family membersfrom family members

► 3 days before admission, when he developed fevers 3 days before admission, when he developed fevers and confusion, and began vomiting. He complained and confusion, and began vomiting. He complained of a headache and neck stiffness. of a headache and neck stiffness.

► HIV positive. Has never been on antiretroviral HIV positive. Has never been on antiretroviral therapy. therapy.

► He was not taking any medications before the onset He was not taking any medications before the onset of his illness and had no known drug allergies. His of his illness and had no known drug allergies. His last CD4 count of 146 cells/µL was measured a last CD4 count of 146 cells/µL was measured a month and a half before admission. The patient month and a half before admission. The patient smokes tobacco and reportedly has a history of smokes tobacco and reportedly has a history of significant alcohol intake.significant alcohol intake.

General:General: ill-appearing, thin man; somnolent but ill-appearing, thin man; somnolent but arousesarousesto touch,moaning incomprehensibly, intermittently to touch,moaning incomprehensibly, intermittently opens eyes inopens eyes inresponse to stimuliresponse to stimuliVital signs:Vital signs: 39.0°C; 100/60; 90; 16 O2 sat 98% 39.0°C; 100/60; 90; 16 O2 sat 98%Neurological:Neurological: Glasgow Coma Score (GCS)--11 (motor Glasgow Coma Score (GCS)--11 (motor responsiveness = 5, eye opening = 4, verbal responsiveness = 5, eye opening = 4, verbal performance = 2); moving all extremities performance = 2); moving all extremities spontaneously; pupils equal, round, reactive to light spontaneously; pupils equal, round, reactive to light (PERRL); extraocular movement (EOM) intact except for (PERRL); extraocular movement (EOM) intact except for limitation on lateral gaze with right eye only (consistent limitation on lateral gaze with right eye only (consistent with right 6th cranial nerve palsy)with right 6th cranial nerve palsy)HEENT (head, eyes, ears, nose, throat):HEENT (head, eyes, ears, nose, throat): mild mild scleral icterus; scleral icterus; Neck:Neck: no jugular venous distention; positive neck no jugular venous distention; positive neck stiffness; positive jolt sign; no cervical stiffness; positive jolt sign; no cervical lymphadenopathylymphadenopathyChest:Chest: rhonchi breath sounds bilaterally, no wheezes or rhonchi breath sounds bilaterally, no wheezes or ralesralesCardiovascular: Cardiovascular: normalnormalAbdomen: Abdomen: normalnormal

► White blood count (WBC):White blood count (WBC): 4.5 4.5Hemoglobin:Hemoglobin: 134 134 Platelets:Platelets: 245 245lytes Nlytes NCreatinine:Creatinine: 124.5 µmol/L (reference range: 53-133 124.5 µmol/L (reference range: 53-133 µmol/L)µmol/L)Total bilirubin:Total bilirubin: 29 µmol/L (reference range: 0-17 29 µmol/L (reference range: 0-17 µmol/L)µmol/L)Direct bilirubin:Direct bilirubin: 25.9 µmol/L (reference range: 0- 25.9 µmol/L (reference range: 0-5.1 µmol/L)5.1 µmol/L)Liver enzymes NLiver enzymes NAlbumin: 34 g/L (reference range:Albumin: 34 g/L (reference range: 35-50 g/L) 35-50 g/L)Chest X ray:Chest X ray: bilateral fluffy infiltrates, left side bilateral fluffy infiltrates, left side greater than right side greater than right side

Differential Diagnosis in the Differential Diagnosis in the altered HIV ptaltered HIV pt

► infectiousinfectious Cryptococcus neoformans*Cryptococcus neoformans* toxoplasmosistoxoplasmosis bacterial meningitisbacterial meningitis histoplasmosishistoplasmosis cytomegalovirus (CMV)cytomegalovirus (CMV) progressive multifocal leukoencephalopathyprogressive multifocal leukoencephalopathy herpes simplex virus (HSV)herpes simplex virus (HSV) neurosyphilisneurosyphilis tuberculosistuberculosis

► non-infectiousnon-infectious HIV encephalopathyHIV encephalopathy central nervous system (CNS) lymphoma.*central nervous system (CNS) lymphoma.*

* Cryptococcus and CNS lymphoma are seen with CD4 <100* Cryptococcus and CNS lymphoma are seen with CD4 <100

W/U in the altered HIV ptW/U in the altered HIV pt

► Usual tests Usual tests ► Syphilis serology, serum cryptococcal Syphilis serology, serum cryptococcal

antigenantigen► CT with contrast +/- MRICT with contrast +/- MRI► LP, collect extra fluid for LP, collect extra fluid for Acid-fast stain, Acid-fast stain,

India ink stain, Cryptococcal antigen and India ink stain, Cryptococcal antigen and herpes antigen testing, culture for herpes antigen testing, culture for M M tuberculosistuberculosis (50-80% of known cases of TBM (50-80% of known cases of TBM yield positive results), Polymerase chain yield positive results), Polymerase chain reaction (PCR), Syphilis serology reaction (PCR), Syphilis serology

Case 4Case 4

►88 yo M, brought into ED by family 88 yo M, brought into ED by family because he is less responsive than because he is less responsive than usual usual

►Fell out of bed last nightFell out of bed last night

►36.5, 70, 130/80, 16, 94%36.5, 70, 130/80, 16, 94%►Patient is somnolent and does not Patient is somnolent and does not

answer questions appropriatelyanswer questions appropriately►Exam is unremarkable except for Exam is unremarkable except for

patient is somnolent and does not patient is somnolent and does not answer questions appropriatelyanswer questions appropriately

►According to family he is normally able According to family he is normally able to sustain a conversationto sustain a conversation

Delirium vs. DementiaDelirium vs. Dementia

►both delirium and dementia are both delirium and dementia are characterized by a global impairment characterized by a global impairment in cognitive functioning in cognitive functioning

►meticulous history-taking is sometimes meticulous history-taking is sometimes required to differentiate between required to differentiate between these two entitiesthese two entities

►Beware hypoactive delirium in the Beware hypoactive delirium in the demented patient!demented patient!

DementiaDementia

►DSM IV TRDSM IV TR1. 1. Memory impairmentMemory impairment (impaired ability to learn (impaired ability to learn new info or to recall previously learned info)new info or to recall previously learned info)2. One or more of the following 2. One or more of the following cognitive cognitive disturbancesdisturbances•    aphasia (language disturbance)•    aphasia (language disturbance)•    apraxia (impaired motor activity)•    apraxia (impaired motor activity)•    agnosia (failure to recognize and identify •    agnosia (failure to recognize and identify objects)objects)•    disturbance in executive functioning (ie. •    disturbance in executive functioning (ie. planning, organizing, sequencing, abstractingplanning, organizing, sequencing, abstracting3. The course is 3. The course is gradual and continuing declinegradual and continuing decline

Clinical featureClinical feature DeliriumDelirium DementiaDementia

Nature of onset Nature of onset Abrupt Abrupt Gradual, ill-defined Gradual, ill-defined onsetonset

Rapidity of Rapidity of progression progression

Rapid (hours)Rapid (hours) Slow(months)Slow(months)

Duration Duration Temporary (days)Temporary (days) yearsyears

Variability of Variability of symptoms symptoms

FluctuationsFluctuations stablestable

Lucid intervals Lucid intervals CommonCommon nonenone

Attention Attention short, varies short, varies Unaffected in early Unaffected in early disease, stable disease, stable

Memory changes Memory changes Short-term memory Short-term memory markedly affected markedly affected

Long term memory Long term memory poorpoor

Disturbed sleep-Disturbed sleep-wake cycle wake cycle

CommonCommon rarerare

Clouding of Clouding of consciousness consciousness

Defining featureDefining feature nonenone

Marked Marked psychomotor psychomotor changes changes

CommonCommon absentabsent

autonomic changes autonomic changes Common Common absentabsent

Case 5Case 5

►50 yo M found unconscious in 50 yo M found unconscious in downtown park.  Brought to ED by downtown park.  Brought to ED by EMS.  Patient appears unkempt with a EMS.  Patient appears unkempt with a noted smell of EtOH and urine.  Empty noted smell of EtOH and urine.  Empty wine bottle found at scene. wine bottle found at scene.

►Previous ED visits for EtOH Previous ED visits for EtOH intoxication, falls intoxication, falls

►Vitals - 36.5, 90, 24, 140/90 O2 95% Vitals - 36.5, 90, 24, 140/90 O2 95% glucose 5.1glucose 5.1No eye opening, unintelligble sounds, No eye opening, unintelligble sounds, non-specific withdrawal movementsnon-specific withdrawal movementsPupils non-reactive with a 6mm dilated Pupils non-reactive with a 6mm dilated R pupil. R pupil.

►Exam otherwise normalExam otherwise normal►What do you do now? What is your What do you do now? What is your

Differential diagnosis?Differential diagnosis?

InvestigationsInvestigations

►CT head: large R parietofrontal SDHCT head: large R parietofrontal SDH►EtOH 32 EtOH 32

References:References:

►Rosen’sRosen’s►EM clinics of NA: Volume 28, Issue 3, EM clinics of NA: Volume 28, Issue 3,

Pages 439-718 (August 2010). Pages 439-718 (August 2010). Alterations of Consciousness in the Alterations of Consciousness in the Emergency Department Emergency Department

►Others as noted in presenter’s notesOthers as noted in presenter’s notes