Altered Level of Consiousness

8/12/2019 Altered Level of Consiousness

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We will cover

Terminology & definitionsTerminology & definitions

Developing a thorough differentialDeveloping a thorough differential

Identifying the delirious patientIdentifying the delirious patient

A variety of challenging casesA variety of challenging cases

Focused H&P highlightsFocused H&P highlights

Key lab and imaging studiesKey lab and imaging studiesAvoiding errorsAvoiding errors


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Scope / Spectrum2002 data from a University2002 data from a University

HospitalHospital

ALOC pts - 5% of the ED volume

64% got admitted

28% neuologic 21% toxicologic14% trauma 14% psychiatric

10% infectious 5% endocrine / metabolic

3% pulmonary 3% oncologic


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Altered Mental StatusApproach

Functional (psychogenic)

Organic

Toxic / metabolic (diffuse disease), infectious

Structural (focal disease)

Dementia

{Delirium


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Bottom Line

Psychiatric / functionalPsychiatric / functional

Pt gets labeled /Pt gets labeled / treatable but not reversibletreatable but not reversible

DeliriumDelirium

80% reversible and up to 15% mortality80% reversible and up to 15% mortality

DementiaDementia

20% reversible20% reversible


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Delirium

Organic Disease

Acute onset with a wildly fluctuating course.

Difficulty focusing, easily distracted.

Disorganized thinking, rambling, hard tofollow.

Altered level of consciousness.

Visual hallucinations are common.

Abnormal vital signs.


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Dementia

Organic Disease

Insidious, gradual onset.

Normal alertness and attentiveness.

Disorientation is the baseline.

No hallucinations.

Vital signs - normal.


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Acute Psychosis

Functional Disease

Abrupt onset with a stable course.

Normal level of consciousness.

Auditory hallucinations.

Orientation usually normal.

Vital signs may be elevated.


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Lets Review

Wildly fluctuatingWildly fluctuating

coursecourse AuditoryAuditory

hallucinationshallucinations

DisorientedDisoriented

Normal LOCNormal LOC

Abnormal Vital SignsAbnormal Vital Signs

Delirium

Psychosis

Delirium

Psychosis

Both


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Levels of ConsciousnessNomenclature - terminology

Traditional Descriptive (AVPU)

Alert Awake and Aware

Lethargy Responds to verbal stim

Stupor Responds to painful stim

Coma Unresponsive


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The Naked Man

History

32 year old male was found running nude in a field

near a school. He was well known to the police and

the medical community as an alcohol and speed

abuser. While being booked by the police he fell off a

bench, hit his head and became unconscious. No

other acute history was available.


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ALOC - Naked Man

Physical

BP 70/p HR 200 RR 16 T 41.6 C (106.9 F)

Comatose - unresponsive to painful stimuli

HEENT - small contusion on his forehead. Pupils

were 4 mm and sluggishly reactive to light. He had a

decreased gag reflex, and equivocal plantar reflexes

bilaterally. The rest of his exam was WNL.


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ALOC - Naked ManFollow up

Despite aggressive resuscitative efforts the patient

expired several hours later. All ED studies were

unhelpful in making a diagnosis.

The differential was broad (toxins, hypothalamic

dysfunction, such as tumors, bleeds, CNS infections).

A thorough head-to-toe exam would have

keyed-in the examiner to the diagnosis.

*


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ALOC - Naked ManPostmortem diagnosis:

Thyrotoxicosis


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DDX - Altered Consciousness

AEIOU TIPS

A. Alcohols T. Trauma, Tox, temp, Thyroid

E. Endocrine, lytes I. Infections

I. Insulin (diabetes) P. Psychiatric

O. Oxygen, Opiates S. SAH, Seizures

U. Uremia

, ASA


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Star t from the head and work down


Central nervous system

Bleeds (traum a and nontraum a)

Infarcts

Infections

Seizures

Conversion reaction / psych


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Mouth: Toxins / Meds

Alcohols OpiatesAnticholinergics Phenothiazines

Anticonvulsants Salicylates

Barbiturates Sedative HypnoticsCarbon Monoxide SSRIs

Cyanide Sympathomimetics

Hallucinogens Tricyclic antidepressantsHeavy Metals


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Cocaine delirium and sudden death.Gamma hydroxybutyrate (GHB) = (GBH)

Grievous bodily harm.

An anesthetic with euphoric and sexual

enhancement properties.

Short acting benzodiazepines - Rohypnol

(Roofies, Ruffies, Love Drug)

Special Case Toxins


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Neck and Chest

Neck

Thyroid & parathyroid disease

Chest

Hypoxia

Hypercarbia

Emboli


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Abdom en

Liver

Hepat ic encephalopathy

Wern ickes syndrom e

Pancreatic disease Adrenal insufficiency

Renal disease: electrolyte and metabolic

disorders


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Heat StrokeHeat Stroke think of while getting rectal tempthink of while getting rectal temp

HypothermiaHypothermia rectal temprectal temp

SepsisSepsis

VasculitisVasculitis may consider as part of renalmay consider as part of renalcausescauses

HyperviscosityHyperviscosityALOC as it affects the CNSALOC as it affects the CNS


Skin Other??


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To Tube or not to Tube

History

14 year old girl found down near a bus stop near her

school.

No one came with the girl to the hospital, so initially,

there was no other history available.


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ALOC - Tube?

Physical exam

Gurgling respirations.

BP - 98/ 74 HR - 110 RR - 10 Pulse ox 89% RA.

HEENT - PERRL 3 mm sluggish - disconjugate gaze

++AOB.

Neck, chest, abdomen, extremities - all WNL.


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ALOC - Tube?

Physical exam - continued

Neurologic

Comatose - responds appropriately to deep

painful stimuli

Poor gag reflex, moves all 4 extremities equally to

painful stimuli

DTRs 1-2+ equal

Plantar reflexes equivocal


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ALOC - Tube?Medical decison making

(for coding purposes only)

Possibly all secondary to alcohol ingestion in a young

girl, but airway control was needed. The glucose was

119 mg / dl. No response to 2 mg of narcan.

Prior to CT she would need RSI.......however

*


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ALOC - Tube?

Outcome

She woke up after 3 doses of 0.2 mg (total of 0.6mg)

of flumazenil to the point of spontaneously talking

(although she was dysarthric). Her blood alcohol was

190mg / dl.


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FLUMAZENIL

Benzodiazepine competitive antagonist

Dose 0.2 - 2.5 mg

Duration 40-60 min

Controversial in:

Mixed ingestions

Chronic benzodiazepine users

Patients with seizure disorders


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Altered Mental Status

History Sources

PatientPatient Pill bottlesPill bottles

MedicsMedics Hospital & PsychHospital & Psychrecordsrecords

RelativesRelatives FriendsFriends

Medic alert tagMedic alert tag Personal physicianPersonal physician

WalletWallet PocketsPockets


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Physical exam

Respiratory rate and pattern

Heart rate and rhythm

Blood pressure

Rectal temperature

-Vital Signs


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Physical Exam - General

Head - signs of trauma

Breath odor - alcohol, fruity, almond, garlic, onion, +Neck - thyroid, scar, meningismus


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Physical Exam - General

Chest - breath sounds, murmurs, rhythm

Abdomen - organomegaly, ascites, peritonitis

Skin - jaundice, petechiae, moisture, temperature,

color, needle tracks, spider angiomatas


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Spontaneous movementsSpontaneous movements Purposeful movementsPurposeful movements

Response to painful stimuliResponse to painful stimuli

ToneTone

Altered Level of Consciousness

Motor Exam


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Neurologic Exam

Eyes

Ears

M en tal Status Exam

Keys


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Altered level of consciousness

The eye exam

Pupils

Funduscopic exam

Eye movements

Eyelids


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Caloric Testing

Cold Water < 30 0 C

Normal - deviation away with nystagmus

Cerebral dysfunction - tonic deviation to

one side

Brainstem dysfunction - no response


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Mini-mental status exam

Confusion assessment method (CAM)


C f i A t M th d


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Confusion Assessment Method

To diagnose delir ium:

1) Acute onset with fluctuating course

2) Inattention - difficulty focusing

and

1) Disorganized thinking

or

2) Altered level of consciousness


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Diagnosis in < ten minutes

Bedside studies

History and physical

Glucometer / dextrostick - dextrose

Pulse oximetry

ABGs - Hypoxia / Hypercarbia / acidosis

. Istat


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Rapid diagnostic studiesBedside studies - interventions

Urinalysis

Infection, hyperglycemia, dehydration

Breathalyzer

Electrocardiogram / rhythm strip

Narcan, thiamine

Flumazenil, physostigmine


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Physostigmine

Reversible inhibitor of acetylcholinesterase

Used to RX, or DX severe anticholinergic syndrome

Useful in GHB ingestion?

DO NOTuse in tricyclic overdoses

Dose - 0.5 mg slow IVP up to a total of 2 mg

Keep atropine nearby


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Additional studies to consider

Lytes, BUN, Cr, osmolality, calcium

Complete blood count

Carboxyhemoglobin

Lumbar puncture


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Directed drug screen

Thyroid function tests

Head CT scan

Peritoneal tap

...and more studies to consider

Osmolar Man


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Osmolar Man

History

An 18 year old male calls 911 for a severe headache.

Upon arrival he refuses to let the medics in his home

and they leave. Thirty minutes later his mother calls

911 and the medics arrive to find a comatose male.

His mother explains that he is diabetic and frequently

forgets to take his insulin. The medics transport and

administer 25 gms of dextrose en route.


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ALOC - Osmolar Man

Physical

BP 170/ 70 HR 92 RR 14

Comatose male who appears otherwise healthy. Skin

is moist, pupils are PERRL at 6 mm, neurologic exam

is non-focal except for bilateral upgoing toes. The

general exam is otherwise normal.


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ALOC - Osmolar man

Blood glucose on his pre-hospital dextrose

blood was 19 mg/dl. A second bolus of

dextrose did not change his mental status.

Early labs

Do we ever really need a second amp of glucose?


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ALOC - Osmolar Man

Follow-up

Repeat exam noted an unmeasurable amount of

anisocoria unnoticed before. CT scan found a large

subdural with midline shift; the patient was taken to

the OR and did well.

*

AT i i C


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A 28 year old man was brought unconscious to the

emergency department. Fifteen minutes earlier, withslurred speech, he had instructed a taxi driver to take

him to the hospital. He passed out before arriving atthe hospital.

A Taxi ing Case

History


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ALOC - Taxi manPhysical

BP 130/ 90 HR 100 RR 40

Most of the physical exam was within normal limits.

On neurologic exam: Pupils were PERRL at 3 mm,

DTRs were 3+ and equal, plantar reflexes were both

extensor and he had intermittent bilateral

decerebrate posturing.

*

ALOC T i


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ALOC - Taxi man

Follow up

Hypoglycemia commonly presents with focal

neurologic findings that can mimic structural lesions.

It is obviously important not to skip the basics. This

patients blood glucose was 20 mg/ dl and he awoke

after receiving 25 grams of dextrose.

Mid Term Review


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Mid Term Review

Odor of breathOdor of breath

arsenicarsenic

Absent pupilAbsent pupil

response to lightresponse to light

Average inc. in BSAverage inc. in BSafter 1 amp D50after 1 amp D50

Flumazenil is avoidedFlumazenil is avoided

in which patients?in which patients?

GarlicGarlic

Structural defect

130 mg/dl

Mixed ingestions


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ALOC - SUMMARYTake back to the ER points

Assume the patient is delirious

DDX - start from the head and work your

way down

Think like a detective

The eyes, ears, and mental status are keys

Dont be afraid of flumazenil or physostigmine


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Common Errors

Failure to consider the basics (glucose, oxygen,

thiamine)

Treatment delay during the evaluation

Failure to re-examine at frequent intervals

Incomplete differential ddx


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Not So Funny Man?


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Not So - Funny Man?

History

911 called for a pt. exhibiting bizarre behavior. No

similar past history. Friends stated he had been

acting funny, agitated, and not sleeping for several

days. No hx of drug use but the family had

suspicions. No other significant past or present

history.

Not So - Funny Man?


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Not So - Funny Man?

Physical exam

Hyper-alert and agitated. Talking very fast but not

making much sense.

BP 160/110 HR 124 RR 18 T 101 F

HEENT - PERRL 5 mm Mucous membranes - moist

No distinctive breath odor

Skin - warm and dry

Rest of the exam was WNL


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Not So - Funny Man?Confusion assessment exam

++ Acute onset with a fluctuating course.

++Inattentive - could not focus on the questions.

+Disorganized thinking - speech / subject was hard

to follow.

+- ALOC - hyperalert.


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Not So - Funny Man?

ED differential and course

Tox, CNS infection, thyroid disease.

Blood glucose was 97 mg/dl.

Tox was positive for amphetamine.

To tap or not to tap?

Sleeping Beauty


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Sleeping Beauty

History

A 20 year old woman is found unconscious in her

room two hours after a fight with her parents. She

was well prior to the incident. She has a history of

emotional problems and occasional migraine

headaches. Medications include Tylenol and

Vicodin for her headaches

ALOC - Sleeping Beauty


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Physical

BP 108/ 64 HR 68 RR 12

The general PE was within normal limits. When left

alone she appeared to be sleeping. Pupils were

PERRL at 3mm. There was no response to painful

stimuli but there was some resistance to passive

elevation of her eyelids. Cold calorics elicited tonic

deviation of the eyes with no nystagmus.

ALOC-Sleeping Beauty


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ALOC Sleeping Beauty

Follow up

The history and physical suggested light coma or

simulated coma. However, caloric testing indicated

organic cerebral dysfunction. The patient remained

stable and gradually awakened over 48 hours. She

admitted to ingesting a handful of phenobarbital.

Pathophysiology of Coma


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Pathophysiology of Coma

Structural causes

Bilateral cortical disease.

Suppression of the Reticular Activating System.

Supratentorial lesions

Infratentorial lesions

Intrinsic brainstem lesions

Brainstem torque

Altered Level of Consiousness

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