Altered mental status

Background

• Alteration of arousal or content of consciousness or both
• Both cerebral cortices or brainstem must be affected
• Delirium vs dementia vs psych
• Must quickly determine if coma is from diffuse or focal impairment
• Peds
  • Most common causes are toxic ingestion, infection, and child-abuse induced trauma

Clinical Features

• Depends on cause
  • Diffuse brain dysfunction - lack of focal findings
  • Focal brain dysfunction - hemiparesis, loss of motor tone, loss of ocular reflexes

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
  • Hypothermia
  • Hyperthermia
• 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
  • Intraparenchymal hemorrhage
• SAH
• Stroke
  • Hemispheric, brainstem
• CNS infections
  • Encephalitis
  • Anti-NMDA receptor encephalitis
  • Meningitis
• Neoplasms
  • Paraneoplastic Limbic encephalitis
  • Malignant Meningitis
  • Pancreatic Insulinoma
• Seizures
  • Nonconvulsive status epilepticus
  • Postictal state
• Dementia
  • Alzheimer's
  • Lewy Body Dementia
  • Frontotemporal Dementia

Psychiatric

• Acute psychosis
• Catatonia
• Excited delirium
• Malingering
• Steroid induced psychosis

Evaluation

AMS Workup

Common Orders

• Point of care glucose
• CBC
• Chemistry
• LFTs
• UA
• CXR
• Utox
• ECG
• Head CT
• CAM score

Consider Based on Clinical Situation

• Blood and urine cultures
• Ammonia level
• Tylenol/Aspirin level
• LP
• Serum Osm
• Coags
• Cortisol
• ABG/VBG
• CO level

Management

• Patients with focal findings may have surgically treatable cause
• Coma cocktail
  • Glucose, thiamine, naloxone
• Treat underlying cause

Disposition

• Most frequently admission, unless of a chronic and known etiology

See Also

• Toxicology (Main)
• Glasgow Coma Scale (GCS)
• Altered Mental Status (AMS) (Peds)
• AVPU Scale
• Brain Death

Video

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