Altered mental status

Overall Causes

1. Delirium
2. Dementia
3. Psych

Workup/Treatment

1. Check glucose/SaO2 --> correct
2. Focal neuro def --> R/O CVA/mass/bleed
3. Fever --> positive = find source
4. Obvious cause --> positive = pursue
5. Non-obvious -->

1. Give thiamine & narcan
2. CBC
3. Chem 10
4. UA
5. ECG
6. UTox
7. CXR
8. Head CT
9. LFTs
10. PT

Consider:

1. CSF
2. ABG
3. TSH
4. EEG
5. ASA/Tylenol levels
6. Ammonia
7. HIV

DDx Confusion

1. Hypoxia/diffuse ischemia
   1. Respiratory failure
   2. CHF
   3. MI
   4. Severe anemia
   5. Shock
2. Systemic
   1. Hypoglycemia
   2. Electrolyte/fluid disturbance
   3. Endocrine dz
      1. Thyroid
      2. Adrenal
   4. Hepatic failure (ammonia)
   5. Wernicke's
   6. Infection/sepsis
      1. Urine
      2. PNA
      3. Other
3. CNS Disease
   1. Infection
   2. Trauma
   3. CVA/TIA
   4. SAH
   5. Seizure
      1. Postictal
      2. Nonconvulsive
      3. Complex partial
4. Hypertensive encephalopathy
5. Increased ICP
6. Toxins/withdrawal
   1. Sedatives
   2. ETOH
   3. Anticholinergics
   4. Other
7. Neoplasm

DDx Coma and...

Diffuse CNS Dysfunction

1. Diffuse Neuronal Deprivation
   1. Hypoglycemia
   2. Hypoxia (with nl Cerebral Blood Flow (CBF))
      1. Respiratory failure
         1. CHF
         2. PNA
         3. Obstructive
      2. Severe anemia
   3. Decreased CBF
      1. Shock
         1. AMI
         2. Hypovolemia
      2. Post arrest
   4. Cellular Toxin
      1. CO
      2. Cyanide
      3. Hydrogen sulfide
   5. Thiamine deficiency (Wernicke-Korsakoff)
2. Endogenous CNS Toxins
   1. Hyperammonemia (hepatic coma)
   2. Uremia (renal failure)
   3. CO2 Narcosis
   4. Hyperglycemia
3. Exogenous CNS Toxins
   1. Alcohols
      1. ETOH
      2. Isopropyl
   2. Acids
      1. Methanol
      2. Ethylene glycol
      3. Salicylate
   3. Sedatives
   4. Narcotics
   5. Anticonvulsants
   6. Psychotropics
   7. Isoniazid
   8. Heavy metals
4. Endocrine disorders
   1. Myxedema coma
   2. Thyrotoxicosis
   3. Addison's
   4. Cushing's
   5. Pheochromocytoma
5. Ionic abnormalities
   1. Hypo/hyper-natremia
   2. Hypo/hyper-calcemia
   3. Hypo/hyper-magnesemia
   4. Hypophosphatemia
   5. Acidosis/alkalosis
6. Temperature abnormalities
   1. Hypothermia
   2. Heat stroke
   3. NMS
   4. Malignant hyperthermia
7. Intracranial HTN
   1. Hypertensive encephalopathy
   2. Pseudotumor cerebri
8. CNS inflammation/infection
   1. Meningitis
   2. Encephalitis
   3. Cerebral vasculitis
   4. SAH
   5. Carcinoid meningitis
   6. Traumatic axonal shear
9. Primay neuronal/glial
   1. CJD
10. Seizure/postical

Focal CNS Lesion

1. Supratentorial
   1. Hemorrhage
      1. Intracerebral
      2. Epidural
      3. Subdural
      4. Pituitary apoplexy
   2. Infarction
      1. Thrombotic arterial
      2. Embolic arterial
      3. Venous
   3. Tumors
   4. Abscess
2. Infratentorial
   1. Compressive
      1. Cerebellar hemorrhage
      2. Post fossa sub/extra-dural
      3. Cerebellar infarct
      4. Cerebellar tumor
      5. Cerebellar abscess
      6. Basilar aneurysm
   2. Destructive
      1. Pontine hemorrhage
      2. Brainstem infarct
      3. Basilar migraine
      4. Brainstem demyelination

Source

2/27/06 DONALDSON (adapted from Rosen)