Altered mental status: Difference between revisions
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== | {{AdultPage|altered mental status (peds)}} | ||
==Background== | |||
*Altered mental status (AMS) is one of the most common and challenging presentations in the ED | |||
*Encompasses a spectrum from mild confusion to deep [[coma]] | |||
*May include alteration of arousal (level of consciousness), awareness, thought content, memory, or attention | |||
*Both cerebral cortices or the brainstem reticular activating system must be affected | |||
*Key distinctions: | |||
**[[Delirium]]: Acute, fluctuating alteration in attention and awareness; typically reversible | |||
**[[Dementia]]: Chronic, progressive cognitive decline; not typically an ED diagnosis | |||
**Psychiatric: Diagnosis of exclusion — always rule out organic causes first | |||
*Must quickly determine if the altered state is from '''diffuse''' (metabolic/toxic) or '''focal''' (structural/vascular) impairment | |||
==Clinical Features== | |||
*History from family/EMS/bystanders is critical: | |||
**Baseline mental status and functional level | |||
**Onset (sudden vs gradual), preceding symptoms, recent medications/substances | |||
**Medical history: diabetes, liver/kidney disease, seizures, psychiatric history, substance use | |||
*Physical exam priorities: | |||
**Vital signs: Fever (infection, toxidrome), hypothermia, hypo/hypertension, tachycardia, hypoxia | |||
**'''Glucose:''' Point-of-care immediately | |||
**Neurologic exam: | |||
***Level of consciousness ([[Glasgow Coma Scale]]) | |||
***Pupil size and reactivity | |||
***Focal deficits (hemiparesis, facial droop, gaze preference) → suggests structural lesion | |||
***Diffuse findings (no lateralizing signs) → suggests metabolic/toxic cause | |||
**Skin: Needle tracks, jaundice, rash (meningococcemia, petechiae), diaphoresis, dryness | |||
**Odor: Alcohol, fruity (DKA), fetor hepaticus | |||
**Meningeal signs: Nuchal rigidity (meningitis, SAH) | |||
==Differential Diagnosis== | |||
{{AMS DDX}} | |||
==Evaluation== | |||
{{AMS workup}} | |||
*Additional workup based on clinical suspicion: | |||
**CT head without contrast — if trauma, focal deficits, no clear metabolic cause, or concern for hemorrhage | |||
**Lumbar puncture — if meningitis/encephalitis suspected (after CT if indicated) | |||
**'''EEG''' — if nonconvulsive status epilepticus suspected (prolonged postictal state, subtle motor activity) | |||
**CT angiography — if acute stroke suspected | |||
**Toxicology screen — urine drug screen; consider serum levels (ethanol, salicylate, acetaminophen, lithium) | |||
**Blood gas (VBG/ABG) — for acid-base disturbances, CO levels | |||
**Ammonia — if hepatic encephalopathy suspected | |||
**Thyroid function — if no other cause identified (myxedema coma, thyroid storm) | |||
**Cortisol — if adrenal crisis suspected | |||
==Management== | |||
*ABCs first: | |||
**Protect airway — intubate if GCS ≤8 or unable to protect airway | |||
**O2, IV access, continuous monitoring | |||
*Immediate interventions: | |||
**[[Dextrose]] (D50 50 mL IV or D10 titrated) if hypoglycemic | |||
**[[Thiamine]] 100 mg IV (give before or with glucose) | |||
**[[Naloxone]] 0.4-2 mg IV if opioid toxicity suspected | |||
*Patients with focal findings may have a surgically treatable cause → emergent imaging | |||
*Treat the underlying cause once identified | |||
*Avoid sedation/restraints if possible until organic cause excluded; use the least restrictive means necessary for safety | |||
== | ==Disposition== | ||
*Admit to ICU: | |||
**GCS ≤12, declining mental status | |||
**Intubated patients | |||
**Hemodynamic instability | |||
**Suspected CNS infection or stroke requiring acute intervention | |||
*Admit to floor: | |||
**AMS with identified cause requiring ongoing treatment/monitoring (e.g., metabolic correction) | |||
**Elderly with new-onset delirium requiring workup | |||
*Discharge: | |||
**Fully resolved AMS with clearly identified and treated benign cause (e.g., hypoglycemia corrected, alcohol intoxication sobered) | |||
**Reliable follow-up arranged | |||
**Safe discharge environment | |||
== Calculators == | |||
{{GCS_Calculator}} | |||
==See Also== | |||
*[[Altered mental status (peds)]] | |||
*[[Coma]] | |||
*[[Delirium]] | |||
*[[Glasgow Coma Scale]] | |||
*[[Syncope]] | |||
==References== | |||
<references/> | |||
[[Category:Neurology]] | |||
[[Category:Symptoms]] | |||
== | |||
[[Category: | |||
Latest revision as of 09:26, 22 March 2026
This page is for adult patients. For pediatric patients, see: altered mental status (peds)
Background
- Altered mental status (AMS) is one of the most common and challenging presentations in the ED
- Encompasses a spectrum from mild confusion to deep coma
- May include alteration of arousal (level of consciousness), awareness, thought content, memory, or attention
- Both cerebral cortices or the brainstem reticular activating system must be affected
- Key distinctions:
- Must quickly determine if the altered state is from diffuse (metabolic/toxic) or focal (structural/vascular) impairment
Clinical Features
- History from family/EMS/bystanders is critical:
- Baseline mental status and functional level
- Onset (sudden vs gradual), preceding symptoms, recent medications/substances
- Medical history: diabetes, liver/kidney disease, seizures, psychiatric history, substance use
- Physical exam priorities:
- Vital signs: Fever (infection, toxidrome), hypothermia, hypo/hypertension, tachycardia, hypoxia
- Glucose: Point-of-care immediately
- Neurologic exam:
- Level of consciousness (Glasgow Coma Scale)
- Pupil size and reactivity
- Focal deficits (hemiparesis, facial droop, gaze preference) → suggests structural lesion
- Diffuse findings (no lateralizing signs) → suggests metabolic/toxic cause
- Skin: Needle tracks, jaundice, rash (meningococcemia, petechiae), diaphoresis, dryness
- Odor: Alcohol, fruity (DKA), fetor hepaticus
- Meningeal signs: Nuchal rigidity (meningitis, SAH)
Differential Diagnosis
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Evaluation
AMS Workup
Common Orders
Consider Based on Clinical Situation
- Blood and urine cultures
- Ammonia level
- Tylenol/Aspirin level
- LP
- Serum Osm
- Coags
- Cortisol
- ABG/VBG
- CO level
- Additional workup based on clinical suspicion:
- CT head without contrast — if trauma, focal deficits, no clear metabolic cause, or concern for hemorrhage
- Lumbar puncture — if meningitis/encephalitis suspected (after CT if indicated)
- EEG — if nonconvulsive status epilepticus suspected (prolonged postictal state, subtle motor activity)
- CT angiography — if acute stroke suspected
- Toxicology screen — urine drug screen; consider serum levels (ethanol, salicylate, acetaminophen, lithium)
- Blood gas (VBG/ABG) — for acid-base disturbances, CO levels
- Ammonia — if hepatic encephalopathy suspected
- Thyroid function — if no other cause identified (myxedema coma, thyroid storm)
- Cortisol — if adrenal crisis suspected
Management
- ABCs first:
- Protect airway — intubate if GCS ≤8 or unable to protect airway
- O2, IV access, continuous monitoring
- Immediate interventions:
- Patients with focal findings may have a surgically treatable cause → emergent imaging
- Treat the underlying cause once identified
- Avoid sedation/restraints if possible until organic cause excluded; use the least restrictive means necessary for safety
Disposition
- Admit to ICU:
- GCS ≤12, declining mental status
- Intubated patients
- Hemodynamic instability
- Suspected CNS infection or stroke requiring acute intervention
- Admit to floor:
- AMS with identified cause requiring ongoing treatment/monitoring (e.g., metabolic correction)
- Elderly with new-onset delirium requiring workup
- Discharge:
- Fully resolved AMS with clearly identified and treated benign cause (e.g., hypoglycemia corrected, alcohol intoxication sobered)
- Reliable follow-up arranged
- Safe discharge environment
Calculators
Glasgow Coma Scale (GCS)
| Component | Response | Points |
|---|---|---|
| Eye Opening (E) | Spontaneous | +4 |
| To verbal command | +3 | |
| To pain | +2 | |
| No eye opening | +1 | |
| Verbal Response (V) | Oriented | +5 |
| Confused | +4 | |
| Inappropriate words | +3 | |
| Incomprehensible sounds | +2 | |
| No verbal response | +1 | |
| Motor Response (M) | Obeys commands | +6 |
| Localizes pain | +5 | |
| Withdrawal from pain | +4 | |
| Flexion to pain (decorticate) | +3 | |
| Extension to pain (decerebrate) | +2 | |
| No motor response | +1 | |
| GCS Score | / 15 | |
| 13–15 | Mild brain injury |
|---|---|
| 9–12 | Moderate brain injury |
| 3–8 | Severe brain injury — consider intubation if unable to protect airway |
| References |
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