Post on 26-Mar-2015
Altered Mental Status
Intern Survival SeriesJuly 2011
JeanPierre ELKHOURY, MDAKA 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
What is Consciousness?
Arousal function Alerting and wakefulness Anatomically-reticular activating
system Content functions
Language, reasoning Anatomically-cerebral cortex
DEFINITION
Content of Consciousness
Cerebral cortex Emotions Reasoning Self-awareness Spatial relationships
DEFINITION
Disorder of Arousal functions
Content functions disrupted
Altered Mental Status ?
DEFINITION
7
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
DEFINITION
Pathophysiology
4 general causes
1. Primary intracranial disease
2. Systemic disease affecting CNS
3. Exogenous toxins
4. Drug withdrawal
CAUSES
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
Intern’s Role
Primary survey Establish unresponsiveness A,B,C’s
Resuscitation glucose, thiamine
Secondary assessment Definitive care
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 ?
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
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
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
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
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?
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
ASSESSMENT & MANAGEMENT
The Brief Mental Status ExaminationITEM (number of errors) X (weight) = (Total)
What year is it now?What year is it now? 0 or 10 or 1 x 4 =x 4 =________
What month is it?What month is it? 0 or 10 or 1 x 3 =x 3 =________
Present memory phrase: “Repeat this phrase after Present memory phrase: “Repeat this phrase after me and remember it: me and remember it: John Brown, 42 Market John Brown, 42 Market Street, New York.Street, New York.””
About what time is it?About what time is it? 0 or 10 or 1 x 3 =x 3 =________
(Answer correct if within one hour)(Answer correct if within one hour)
Count backwards from 20 to 1.Count backwards from 20 to 1. 0, 1, or 20, 1, or 2x 2 =x 2 = ________
Say the months in reverseSay the months in reverse0, 1, or 20, 1, or 2 x 2 =x 2 =________
Repeat memory phraseRepeat memory phrase 0,1,2,3,4,or 50,1,2,3,4,or 5 x 2 =x 2 =________
(each underlined portion is worth 1 point)(each underlined portion is worth 1 point)
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.
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
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…
ASSESSMENT & MANAGEMENT
Treatment of underlying cause
Sedation
Restraints if needed
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
TREATEMENT
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
TREATEMENT
Treat the underlying cause
Sedation Haloperidol IV/IM Lorazepam IV
Confinement or restraints if patient is at risk of harming himself or others (Hospital staff…)
TREATEMENT
Sedation and Restraints