Download Altered Mental Status - Penn Medicine

Approach to the Patient with…
Altered Mental Status
Sean D. Foster, MD
Department of Emergency Medicine
University of Pennsylvania Perelman
School of Medicine
Department of Emergency Medicine
University of Pennsylvania Health System
Questions/Comments/Suggestions
[email protected]
Department of Emergency Medicine
University of Pennsylvania Health System
Outline
1. Pathophysiology & Definitions (brief)
2. Approach to the “altered patient”
3. Case examples
Department of Emergency Medicine
University of Pennsylvania Health System
Outline
1. Pathophysiology & Definitions (brief)
2. Approach to the “altered patient”
3. Case examples
Department of Emergency Medicine
University of Pennsylvania Health System
Question for the audience:
What is “Altered Mental Status”?
• Symptom or diagnosis?
• Change in Consciousness
Acute (rarely subacute)
What about this?
Department of Emergency Medicine
University of Pennsylvania Health System
Consciousness
1. Alertness or arousal
– “Level”
2. Content of consciousness
– “Confusion”
Department of Emergency Medicine
University of Pennsylvania Health System
1. Level of Consciousness
Terms
• Minimally conscious state:
– Inconsistent but discernable evidence of
consciousness. Able to follow commands.
• Obtundation:
– awake but not alert, with psychomotor retardation
• Stupor:
– awakens with stimuli but little motor or verbal activity
when aroused
Department of Emergency Medicine
University of Pennsylvania Health System
Coma
• Broadly defined as “a state of deep
unconsciousness that lasts for a prolonged or
indefinite period”
• More specifically: complete failure of the arousal
system with no spontaneous eye opening
COMA: brainstem dysfunction and/or
bilateral cortical disease
Department of Emergency Medicine
University of Pennsylvania Health System
2. Content of Consciousness
• Alteration in higher cerebral functions
– Memory, awareness or attention
• Wide range of presentations:
– Mild confusion to delirium
A state of disturbed consciousness with associated:
Motor restlessness
Transient hallucinations
Disorientation
Delusions
Department of Emergency Medicine
University of Pennsylvania Health System
2. Content of Consciousness
• Cause: Widespread cortical dysfunction
1. Substrate deficit
2. Neurotransmitter dysfunction
3. Circulatory dysfunction
• Reserve of CNS function varies by individual
Department of Emergency Medicine
University of Pennsylvania Health System
Common Classifications
DELIRIUM
DEMENTIA
1.Delirium
PSYCHOSIS
ONSET
Rapid
Slow
Variable
COURSE
Fluctuating
Progressive
Variable
VITALS
Often Abnormal
Normal
Variable
(Usually normal)
PHYSICAL EXAM
Often Abnormal
Normal (usually)
Normal (usually)
HALLUCINATIONS
Visual (External
stimuli)
Rare
Auditory (Internal
Stimuli)
UNDERLYING
CAUSE
Organic (myriad)
Organic
(degenerative)
Functional
PROGNOSIS
Poor (if cause not
treated)
Progressive
Variable
2.Dementia
3.Psychosis
Adapted from: CDEM Curriculum “The Approach to Altered Mental Status”
Important points:
1. Focal cortical dysfunction does not usually
cause confusion
2. Subcortical/brainstem dysfunction usually
affects level of consciousness, rather than
content
Department of Emergency Medicine
University of Pennsylvania Health System
Outline
1. Pathophysiology (brief)
2. Approach to the “altered patient”
3. Case examples
Department of Emergency Medicine
University of Pennsylvania Health System
A problem:
Department of Emergency Medicine
University of Pennsylvania Health System
“Worst First”
What are the immediately life threatening and/or
reversible causes of altered mental status?
Department of Emergency Medicine
University of Pennsylvania Health System
Immediate and/or rapidly reversible
life threats
•
•
•
•
•
•
•
•
•
•
Loss of airway
Hypoxia
Respiratory failure
Narcotic overdose
Hypotension/shock
Dysrhythmia
Intracranial catastrophe
Major trauma
Hypo/hyperthermia (Severe)
Hypoglycemia
A
B
C
D
E
Vitals
Glucose
Department of Emergency Medicine
University of Pennsylvania Health System
EM Approach
•
•
•
•
•
•
Airway
Breathing
Circulation
Disability (neurologic)
Exposure
Finger stick glucose
**Should occur as patient is placed on monitor/vitals
obtained/IV access established
***Deal with issues as they are identified
Department of Emergency Medicine
University of Pennsylvania Health System
Airway
• How do you assess?
• What do you look for?
• What interventions can you make?
Department of Emergency Medicine
University of Pennsylvania Health System
Airway: rapid differential
• Loss of protective reflexes
– Many causes…
– Overdose
– Intracranial catastrophe
• Oropharyngeal swelling
– Anaphylaxis
– Angioedema
– Infections
• Ludwig’s angina, PTA
• Stridor
– Infection
• RPA, epiglottitis, tracheitis, croup
– Foreign body aspiration
Breathing
• How do you assess?
–
–
–
–
–
–
Rate
Depth
Pattern
Auscultation (bilateral and equal?)
Pulse oximetry
End Tidal CO2
• What options are there for interventions?
–
–
–
–
–
–
Supplemental O2
Positive pressure support (CPAP, BiPAP)
BVM
Consider narcan if AMS + hypoventilation
Intubation
Decompression
Department of Emergency Medicine
University of Pennsylvania Health System
Breathing: rapid differential
• Hypoxia
– pneumonia, CHF, PE, COPD
• Respiratory depression
– opioids, brainstem injury
– Hypercarbia = “CO2 narcosis”
• Tachypnea
– Profound Met Acidosis
Methanol/EG
DKA/AKA
Sepsis
– Respiratory Stimulation
Salicylates
• Asymmetric exam
– Pneumothorax, hemothorax
– Large effusion
Department of Emergency Medicine
University of Pennsylvania Health System
Circulation
• How do you assess?
–
–
–
–
Distal pulses
Blood Pressure
Cardiac rhythm
Distal perfusion
• What options are there for interventions?
–
–
–
–
–
IV fluids
Blood products
Cardioversion
Cardiac pacing
Inotropes/chronotropes/vasopressors
Department of Emergency Medicine
University of Pennsylvania Health System
Circulation: rapid differential
• Hypotension
– Shock differential (distributive, neurogenic, obstructive,
hypovolemic, cardiogenic)
• Hypertension
– Hypertensive crisis
– Sympathomimetic abuse (cocaine, amphetamines,
designer drugs)
– Elevated ICP (mass lesion, hemorrhage)
– Compensatory reflex (cushing’s, iscemic stroke)
Department of Emergency Medicine
University of Pennsylvania Health System
Circulation (cont’d)
• Tachycardia
– Broad differential…
• Bradycardia
–
–
–
–
–
–
Drug overdose (BB, CCB, digoxin, lithium)
Organophosphate exposure
Uremic encephalopathy
Hyperkalemia
Myocardial ischemia (particularly in elderly)
Neurogenic shock
Department of Emergency Medicine
University of Pennsylvania Health System
Disability (neurologic catastrophe)
• How do you assess?
–
–
–
–
–
GCS or AVPU
Pupillary exam
Look for seizure activity
Evaluate extremity movement
Signs of elevated ICP
• What interventions can you make?
–
–
–
–
Anti-epileptics
Consider c-spine immobilization
Elevate head of bed
Hypertonic agents
Department of Emergency Medicine
University of Pennsylvania Health System
Glascow Coma Score
Department of Emergency Medicine
University of Pennsylvania Health System
AVPU
•
•
•
•
Awake/Alert
Voice
Pain
Unresponsive
Department of Emergency Medicine
University of Pennsylvania Health System
Disability: rapid differential
• Conjugate eye deviation
– Stroke (toward lesion)
– Seizure (away from lesion)
• Hemiparesis
– Stroke
– Post-ictal state
– ICH
• Signs of elevated ICP
– Mass lesions
– Stroke with swelling
– ICH
Exposure
• What does this mean?
– Fully undress patient
– Head to toe rapid exam
• What are you looking for?
– Trauma
– Patches
– Lines, tubes, fistulas
– Rashes, wounds/decubitus ulcers
Department of Emergency Medicine
University of Pennsylvania Health System
Don’t forget the fingerstick!
Hypoglycemia
• Causes?
– Insulin/hypoglycemic drug overdose
• New renal dysfunction
• Accidental ingestion (Children)
– Dietary changes
– Sepsis (alcoholics, babies, elderly)
• Treatment?
– Childen (rule of 50)
– Adult (1-2 amps D50)
– All: Eat something!
Department of Emergency Medicine
University of Pennsylvania Health System
HYPERglycemia
• Can this cause AMS?
– DKA
– HHNK/HHS
– Sepsis
– Medication effect (steroids, CCB overdose)
Now that you have treated life
threatening emergencies and
assessed for immediately reversible
conditions…..
Department of Emergency Medicine
University of Pennsylvania Health System
Still a problem:
Department of Emergency Medicine
University of Pennsylvania Health System
• A (alcohol)
• T (trauma, toxicology,
tumor, temperature)
• E (endocrinopathy,
encephalopathy,
electrolytes)
• I (insulin, infection,
increased intracranial
pressure)
• I (infection, inborn
errors of metabolism)
• P (psychiatric, postictal state)
• O (opiates, oxygen) • S (seizure, stroke,
shock, space• U (uremia)
occupying lesions)
Department of Emergency Medicine
University of Pennsylvania Health System
History, History, History!
Diagnosis usually based on history! – Where can you get it?
Collateral
•
•
•
•
•
EMS
Family/friends
Old charts
Primary physician
Medic alert bracelet
Department of Emergency Medicine
University of Pennsylvania Health System
History
•
•
•
•
•
•
•
Baseline – be specific
How often do they see the patient?
What is the “change” they observed?
Medical history
Medications
Social history
ROS – any recent complaints?
Department of Emergency Medicine
University of Pennsylvania Health System
Physical Exam
• Complete physical exam always indicated
– Look for stigmata of chronic disease
– Signs of trauma
– Evidence of toxidromes
• Undress your patients (always)
• Don’t forget the back exam
Department of Emergency Medicine
University of Pennsylvania Health System
Vital & Physical
Any abnormality should increase your suspicious
for delirium
Department of Emergency Medicine
University of Pennsylvania Health System
By the completion of the H&P, you should
be able to:
• Categorize as delirium, dementia,
psychosis
• Initiate a diagnostic evaluation
Department of Emergency Medicine
University of Pennsylvania Health System
Differential diagnosis
(treatable Causes)
• A (alcohol)
• E (endocrinopathy,
encephalopathy,
electrolytes)
• I (insulin, infection,
increased intracranial
pressure)
• O (opiates, oxygen)
• U (uremia)
• T (trauma, toxicology,
tumor, temperature)
• I (infection, inborn
errors of metabolism)
• P (psychiatric, post-ictal
state)
• S (seizure, stroke, shock,
space-occupying lesions)
Department of Emergency Medicine
University of Pennsylvania Health System
Differential diagnosis
I: Infection - Sepsis, encephalitis, meningitis, syphilis, central nervous system (CNS) abscess,
malaria
W: Withdrawal - Alcohol, barbiturates, sedative-hypnotics
A: Acute Metabolic and endocrine - Acidosis, electrolyte disturbance, hepatic or renal failure,
magnesium, calcium, porphyria; endocrinopathies: diabetes, adrenal, thyroid
T: Trauma – head trauma, burns, abuse
C: CNS dz – Hemorrhage (EDH, SDH, SAH, intracerebral), stroke, vasculitis(TTP), seizures, tumor
(benign, malignant primary vs metastatic)
H: Hypoxia/Hypercarbia – chronic lung dz (ie COPD), acute (Pneumonia, CO,
Methemoglobinemia), global hypoperfusion
D: Deficiencies- Vitamin B12, hypovitaminosis, niacin, thiamine
E: Environmental: Hypothermia, hyperthermia;
A: Acute Vascular - Hypertensive emergency, subarachnoid hemorrhage, sagittal vein thrombosis
T: Toxins/Drugs - Medications, street drugs, alcohol, pesticides, industrial poisons (e.g., carbon
monoxide, cyanide, solvents), serotonin syndrome, NMS
H: Heavy Metals - Lead, mercury, Iron
Department of Emergency Medicine
University of Pennsylvania Health System
Outline
1. Pathophysiology & Definitions (brief)
2. Approach to the “altered patient”
3. Case examples
Department of Emergency Medicine
University of Pennsylvania Health System
Case
22 yo M presenting with EMS after being found
screaming at passersby in center city. He swung
at a police officer and was tazed by police . He
required restraints with EMS. He is thrashing
violently and screaming “I am god”. He won’t
answer your questions.
What is your next step?
Department of Emergency Medicine
University of Pennsylvania Health System
Important point:
You are responsible for the safety of yourself,
your team and your patient
At times this may require restraining and/or
sedating your patient even before completing
your physical exam
Department of Emergency Medicine
University of Pennsylvania Health System
Drug therapy for agitated patients
Drug induced:
Drug withdrawal:
Psychiatric:
Dementia:
Unknown:
Benzodiazepines
Benzodiazepines
Antipsychotic
Antipsychotic
Benzodiazepines
• Lorazepam 1-2 mg IV
• Midazolam 2.5-10 mg IM
• haloperidol 2-5 mg IV => double the dose every
20-30 minutes prn
Department of Emergency Medicine
University of Pennsylvania Health System
Agitated delirium
• Association with illicit drug use
– not universal.
• Treat if:
– Presence of excited delirium
– Continued maximal struggle despite attempts at
maximal restraint
Department of Emergency Medicine
University of Pennsylvania Health System
Sudden Cardiac Death
Mechanism unknown
– No definite etiology usually found at autopsy
– Catecholamine excess leading to stress
cardiomyopathy vs profound metabolic acidosis
likely leading to cardiac arrest?
– Hyperthermia, seizures, hyperkalemia often
contributory
Department of Emergency Medicine
University of Pennsylvania Health System
Now he is calmer, what next?
BP 180/100 HR 137 SpO2 100% RA T 99.8 RR 16
FSBG 100
Airway: intact
Breathing: lungs clear, good effort
Circulation: normal pulses x 4, tachycardic &
hypertensive
Disability: PERRL (Dilated), MAE. GCS 14 (4-4-6)
Exposure: no rashes. Skin flushed, sweaty. No patches
or wounds.
Department of Emergency Medicine
University of Pennsylvania Health System
Detailed exam
GEN: now drowsy but still awake
HEENT: pupils bilaterally dilated, trace reactive.
Mucous membranes moist
CV: tachycardic, regular
PULM: clear bilaterally
ABD: unremarkable
EXT: no trauma or swelling
SKIN: diaphoretic, otherwise normal
NEURO: GCS 14. CN 2-12 intact. Moving all
extremities equal.
Department of Emergency Medicine
University of Pennsylvania Health System
Differential Dx?
• Toxic ingestion
• Infection
– Encephalitis
– Meningitis
• Psychiatric disease
• Neuroleptic malignant syndrome
• Serotonin syndrome
Department of Emergency Medicine
University of Pennsylvania Health System
What else can you try?
Does that explain his symptoms?
Department of Emergency Medicine
University of Pennsylvania Health System
Four Classic Toxidromes
Heart rate
Oral
Findings
Blood
pressure
Mental status
Eyes
Skin
Anticholinergic
Tachy
None
Variable
Delirium
Mumbling
Seizures
Dilated
Dry, flushed
Warm-hot
Sympathomimetic
Tachy
None
High
Delusional
Paranoia
Agitation
Seizures
Dilated
Diaphoretic
Piloerection
Sedative
Brady
None
Low
lethargic
Coma
nonbreathing
Constricted hypothermic
Or
Dilated
Cholinergic
Variable
salivation Variable
Confusion
Seizure
CNS
depression
Constricted
Diaphoretic
Workup
•
•
•
•
EKG
Basic Metabolic Panel
Total CK
UDS
Department of Emergency Medicine
University of Pennsylvania Health System
Sympathomimetic Toxidrome:
Treatment
• Attempt to calm patient
• Maintain safety of team and patient
• Supportive Care
–
–
–
–
Monitor airway
IVF for insensible losses
Benzodiazepines (IV or IM) for agitation or seizure
EKG
– Avoid Beta blockers
Department of Emergency Medicine
University of Pennsylvania Health System
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Case
A 75 year old female is transferred to the
emergency department from a skilled nursing
facility. She arrived last night after discharge from
the hospital for a hip fracture. Overnight she began
screaming that someone was “trying to kill her”,
and insisted that her husband was looking for her,
though he is known to be deceased. The facility is
stating that her dementia was not adequately
described prior to transfer, and that they cannot
meet her level of care needs. EMS found her to be
awake, pleasant and cooperative.
Department of Emergency Medicine
University of Pennsylvania Health System
BP 146/82 HR 90 RR 16 SpO2 96%%
T100.2 (O) FSBG: 132
• Airway: intact. Phonates easily.
• Breathing: intact. Normal sats. Good bilateral
air mvmt.
• Circulation: intact: normotensive. Equal
pulses. Good distal perfusion.
• Disability: perrl, moves all extremities
spontaneously. Alert. GCS 15
• Exposure: no skin lesions, patches, rashes
Department of Emergency Medicine
University of Pennsylvania Health System
•
•
•
•
•
GEN: thin elderly woman. Nontoxic.
HEENT: atraumatic. PEERL. Sclera anicteric.
NECK: supple, no jvd
LUNGS: clear bilaterally
CV: RRR
ABD: soft, nontender
• EXT: no edema, deformity or tenderness
• SKIN: no rash
• NEURO: slightly drowsy but awake. Oriented to
person and place but not time. CN 2-12 intact.
Normal strength and sensation.
What else would you like to know?
Department of Emergency Medicine
University of Pennsylvania Health System
Approximately 1 hour later, the nurse notifies
you that the patient is becoming increasingly
paranoid and is insisting that she is being held
against her will.
What is the diagnosis?
Department of Emergency Medicine
University of Pennsylvania Health System
Delirium
Department of Emergency Medicine
University of Pennsylvania Health System
Delirium vs Dementia
–
–
–
–
–
Delirium
Fluctuating course of
confusion
Acute onset
Reversible cause
Difficult to distinguish
from acute psychosis
Depressed level and
content of consciousness
–
–
–
–
Dementia
Stable course of
confusion
Insidious onset
Irreversible and slowly
progressive
No impairment of level
of consciousness
Delirium always has an organic cause
Differential diagnosis?
• Drug effect (most common overall)
• Infectious process
– UTI (!!!)
– Pneumonia
– Bacteremia
– Skin and soft tissue infection (bed sores?)
• CNS process
– ICH, Subdural
• Acute MI
Department of Emergency Medicine
University of Pennsylvania Health System
Meds to watch for
•
•
•
•
•
•
•
Narcotics
Benzodiazepines
antibiotics
anticholinergic drugs
antiepileptics
anti-inflammatory agents (corticosteroids)
cardiovascular medications (beta-blockers, antidysrhythmics,
antihypertensives, cardiac glycosides)
• sympathomimetics
• Psychiatric medications (antidepressants, antipsychotics,
mood stabilizers)
Department of Emergency Medicine
University of Pennsylvania Health System
Managing Delirium
• minimize sensory overload
– limit the number of care-givers
– quiet environment
– Try to maintain day/night cycle if possible
• allow family members to remain in
constant/frequent attendance
• do not leave patients unattended
• ensure that the bed side-rails are up
Department of Emergency Medicine
University of Pennsylvania Health System
Drug therapy for agitated patients
Drug induced:
Drug withdrawal:
Psychiatric:
Dementia:
Unknown:
Benzodiazepines
Benzodiazepines
Antipsychotic
Antipsychotic
benzodiazepines
• Lorazepam 1-2 mg IV
• Midazolam 2.5-5 mg IM
• haloperidol 2-5 mg IV => double the dose every
20-30 minutes prn
Department of Emergency Medicine
University of Pennsylvania Health System
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Case
An 80 year old female is brought by EMS from
the nursing home with concern for altered
mental status. She was found “babbling
nonsensically” in her room this morning. When
you address her, she appears to regard you but
doesn’t answer questions appropriately, instead
making nonsensical strings of words.
What is the next step of your evaluation?
Department of Emergency Medicine
University of Pennsylvania Health System
BP 175/100 HR 80 RR 14 SpO2 99%
T 98.2 FSBG 98
• Airway: intact. Phonates. Handling secretions.
• Breathing: intact. Good sats, good bilateral air
movement
• Circulation: intact. Hypertensive but equal pulses
and good distal perfusion.
• Disability: GCS 13 (4-3-6). Gaze preference to the
left. PERRL. Follows commands with R side.
• Exposure: no rashes, skin lesions, patches
Department of Emergency Medicine
University of Pennsylvania Health System
GEN: awake, alert.
HEENT: atraumatic. PERRL. Eyes deviated to the L side.
PULM: clear bilaterally
CV: regular rate and rhythm, no murmurs
ABD: soft, nontender
EXT: no swelling
SKIN: no rash or lesions
NEURO: awake, alert. CN exam reveals mild facial
asymmetry with loss of nasal fold on R. gaze preference
to the L. Strength decreased (3/5) on testing of RUE in all
areas. Mildly decreased (4+/5) in RLE.
What else would you like to test?
Department of Emergency Medicine
University of Pennsylvania Health System
Differential Diagnosis
Is this person experiencing “Altered Mental
Status?”
•
•
•
•
Ischemic Stroke
Hemorrhagic stroke
Complex partial seizure
CNS mass lesion
Department of Emergency Medicine
University of Pennsylvania Health System
What workup would you initiate?
•
•
•
•
•
•
•
•
CT Head
EKG
Basic Metabolic Panel
CBC
Coags
Chest XRAY
Urinalysis
Troponin (?)
Department of Emergency Medicine
University of Pennsylvania Health System
Take home points
• Generally speaking, stroke should not produce
“altered mental status”
• Focal neurologic deficits may mimic altered
mental status
– Aphasias, hemisensory neglect, cortical blindnes
• A detailed neurologic assessment is always
indicated
Department of Emergency Medicine
University of Pennsylvania Health System
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Case
19 yo F brought by friends from her dormitory
stating that she isn’t “acting right”. They report
that she was complaining of fatigue and malaise
yesterday, and this morning of a headache.
Nobody had seen her since breakfast and when
they found her she was confused.
What would you like to do next?
Department of Emergency Medicine
University of Pennsylvania Health System
BP 95/50 HR 120 RR 22 T 102.2 SpO2 99% RA
• Airway: intact
• Breathing: mildy tachypneic, good sats, lungs clear
• Circulation: mildly hypotensive but bounding pulses x
4, well perfused digits.
• Disability: Opens eyes, moans and grabs your hand to
painful stimulus (GCS?). PERRL CN intact, moves all
extremities equally
• Exposure: scattered petechiae and purpura on
extremities. Diaphoretic.
Department of Emergency Medicine
University of Pennsylvania Health System
Differential Dx:
• Sepsis
– Meningitis
– Encephalitis
• Toxic ingestion
• Heat stroke
• NMS/SS
What do you do next?
Department of Emergency Medicine
University of Pennsylvania Health System
GEN: lethargic, responds to painful stimuli by opening
eyes,moaning and grabbing your hand
HEENT: PERRL. Oropharnyx unremarkable aside from dry
mucous membranes
CV: tachycardic, regular
PULM: clear bilaterally
ABD: unremarkable
EXT: no trauma or swelling
SKIN: diaphoretic
NEURO: CN 2-12 intact. Moving all extremities equal.
What other exam information do you want?
Meningitis Treatment
• Various algorithms exist
• Options include:
1. Empiric BS Abx, followed by CT head/LP
2. Immediate LP followed by empiric abx
• Largely depends upon degree of suspicion, risk
factors for elevated ICP/mass lesions
Department of Emergency Medicine
University of Pennsylvania Health System
Meningitis Treatment
**Role of steroids (Dexamethasone) unclear. If giving, give before or
concurrently with abx
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Case
35 yo F found by passersby unresponsive and
apneic. Brought by EMS with active bagging en
route. No ID or collateral information present.
What do you do next?
Department of Emergency Medicine
University of Pennsylvania Health System
BP 118/72 HR 50 T 98.0 (R) RR 0
SpO2 95% BVM (100% O2) FSBG 110
• Airway: no gag, sonorous with bagging
• Breathing: no spontaneous respirations
• Circulation: normotensive, mildly bradycardic.
All extremities appear cyanotic.
What next, doctor?
Show of hands:
1. Intubate now
2. Finish rapid initial assessment, then decide
how to proceed
3. Administer antidote to her overdose
Department of Emergency Medicine
University of Pennsylvania Health System
Keeping going…
• Disability: pupils <1mm bilaterally. GCS 3.
• Exposure:
Now what?
Department of Emergency Medicine
University of Pennsylvania Health System
Naloxone
• Pure opioid antagonist
• Routes: IV, IM, IN, Subcutaneous
• Dose: 0.4-2mg (generally)
– double q2-3 minutes until desired effect
• Onset: <1 minute (IV). 1-2 minutes (Other)
• Half life: ~30-60 min
Department of Emergency Medicine
University of Pennsylvania Health System
Naloxone
• What is the indication for administration?
– Insufficient respiratory drive
• What is the target when administering?
– Sufficient respiratory drive
– NOT normalization of mental status
Department of Emergency Medicine
University of Pennsylvania Health System
Naloxone side effects
• Common:
– Dysphoria, nausea, pain (withdrawal symptoms)
• Uncommon (but real)
– Pulmonary edema
– Seizure
– Dysrhythmias
Biggest problem: it wears off before the opiate agent does
Department of Emergency Medicine
University of Pennsylvania Health System
Coming soon to a heroin user near you!
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Case
60 yo F brought by EMS after witnessed seizure
activity in a restaurant. Per EMS, lasted 3-4
minutes and resolved spontaneously. There was
reported tonic-clonic activity. Per family, she has
a known seizure history. She has been
unresponsive since the event, which was
approximately 20 minutes ago.
Department of Emergency Medicine
University of Pennsylvania Health System
BP 142/72 HR 105T 99.1 (R)
RR 18 SpO2 96% RA
• Airway: snoring respirations; handling secretions
• Breathing: adequate rate. Good air movement
• Circulation: normotensive, good pulses and
distal perfusion
• Disability: eyes open but unresponsive to pain.
Doesn’t follow commands. Nonspecifically
withdraws L arm and leg to pain.
GCS 9 (4-1-4)
• Exposure: no rashes, wounds, patches, lesions
What next, doctor?
Department of Emergency Medicine
University of Pennsylvania Health System
FSBG: 110
Department of Emergency Medicine
University of Pennsylvania Health System
•
•
•
•
•
•
•
•
•
GEN: eyes open but unresponsive to pain
HEENT: Eyes deviated to L. PERRL.
NECK: Ranges easily
LUNGS: Clear
CV: mildy tachy, regular, no murmers
ABD: soft, nondistended
EXT: no edema, no deformity
SKIN: no rash
NEURO: groans to pain. GCS is 4-1-4. doesn’t
participate in exam.
What else would you like to know?
Department of Emergency Medicine
University of Pennsylvania Health System
Differential Dx
• Post-ictal state
• Status epilepticus (complex partial status)
• Stroke
– Hemorrhagic
– Ischemic
• Encephalitis
Department of Emergency Medicine
University of Pennsylvania Health System
Workup
• Head CT
• Electrolytes
• Level her AEDs
• Trial of treatment (first line?)
– Benzodiazepines
• Obtain stat EEG
Department of Emergency Medicine
University of Pennsylvania Health System
Seizures/Status Epilepticus
• Post-ictal state common
– Should rarely last longer than 20-30 minutes
– Should progressively improve
• Persistent neurologic deficits possible (todd’s
paralysis), but should raise suspicion for
alternative diagnosis or ongoing epileptic
activity
• Complex partial status epilepticus (aka
nonconvulsive status) is often missed
Department of Emergency Medicine
University of Pennsylvania Health System
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Case
Police bring a 30 year old male directly from the
scene of a two car MVC. He was the
unrestrained driver and hit a parked car at high
speeds. They state that he smells of alcohol. He
is actively being restrained and is thrashing
violently. He is speaking incoherently and not
following your commands.
Department of Emergency Medicine
University of Pennsylvania Health System
What do you do next?
Department of Emergency Medicine
University of Pennsylvania Health System
BP 75/40 HR 155 RR 24 SpO2 95% RA T96.0 (R)
• Airway: protecting (For now). Phonating.
• Breathing: equal bilateral.
• Circulation: weak distal pulses x 4. poor capillary
refill.
• Disability: PERRL, GCS 12 (4-3-5), moves all
extremities
• Exposure: bruising to scalp. Abrasions to abdomen
and R chest wall.
What next?
Department of Emergency Medicine
University of Pennsylvania Health System
Department of Emergency Medicine
University of Pennsylvania Health System
BP 75/40 HR 155 RR 24 SpO2 95% RA T96.0 (R)
• Airway: protecting (For now). Phonating.
• Breathing: equal bilateral.
• Circulation: weak distal pulses x 4. poor
capillary refill.
• Disability: PERRL, GCS 12 (4-3-5), moves all
extremities
• Exposure: bruising to scalp. Abrasions to
abdomen and R chest wall.
Department of Emergency Medicine
University of Pennsylvania Health System
Important Point
Maintain a high index of suspicion for
hypotension, hypoxia or intracranial
abnormalities as cause of agitation in the
trauma patient.
Department of Emergency Medicine
University of Pennsylvania Health System
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Case
A 20 year old male is brought by his concerned
college roommates for altered mental status.
They state that he is behaving erratically and
seems delusional. They report 2 weeks of
progressively increased agitation and for the last
week he has been heard up all night in his room
talking to himself. He hasn’t bathed himself
either, stating “there’s no time”.
Department of Emergency Medicine
University of Pennsylvania Health System
BP 122/72 HR 92 RR 14 SpO2 100%
T 98.4 FSBG 101
• Airway: intact. Phonating easily
• Breathing: good aeration bilaterally. Normal
rate, normal sat
• Circulation: normotensive, good pulses and
perfusion
• Disability: PERRL. GCS 15. Ambulates easily
• Exposure: No rashes, patches, wounds
Department of Emergency Medicine
University of Pennsylvania Health System
• GEN: slightly disheveled, awake, alert. Talkative and
pacing around the room.
• HEENT: atraumatic. Perrl. Oropharynx normal
• NECK: ranges easily, no tenderness
• LUNGS: clear bilaterally
• CV: regular rate and rhythm, no murmers
• ABD: soft, nontender
• EXT: no swelling
• SKIN: no rash
• NEURO: alert, oriented x 3. CN intact. Normal strength
and sensation.
What else would you like to know?
• Psych:
–
–
–
–
Poorly kempt. Clothes brightly colored, mismatched
slightly agitated with pressured speech.
Thinking is disorganized and tangential.
Demonstrates grandiosity (States “I’m going to call the
president if you don’t release me!”).
– Appears to be responding to internal stimuli but
doesn’t acknowledge hearing voices when asked.
– Denies suicidality (laughs, states he is too important
for that) or homicidality.
Department of Emergency Medicine
University of Pennsylvania Health System
Differential Diagnosis?
• Psychosis (acute psychotic break)
– Schizophrenia
– Bipolar disorder
• Drug induced psychosis
– Bath salts
– Stimulants
Department of Emergency Medicine
University of Pennsylvania Health System
Organic Vs Functional:
Organic
Functional (Psychiatric)
History
History
Acute onset
Onset over weeks to months
Any age
Onset ages 12 to 40 years
Mental status examination
Mental status examination
Fluctuating level of consciousness
Alert
Disoriented
Oriented
Attention disturbances
Agitated, anxious
Poor recent memory
Poor immediate memory
Hallucinations: visual, tactile, auditory
Hallucinations: most commonly auditory
Cognitive changes
Delusions, illusions
Physical examination
Physical examination
Abnormal vital signs
Normal vital signs
Nystagmus
No nystagmus
Focal neurologic signs
Purposeful movement
Signs of trauma
No signs of trauma
Management
•
•
•
•
Assess willingness to obtain care
Assess need for involuntary hold (“302”)
Trial anti-psychotic if needed
No medical testing absolutely necessary
– Psychiatrists may request certain testing as
“screen”
– UDS, CBC, BMP
Department of Emergency Medicine
University of Pennsylvania Health System
Questions?
Department of Emergency Medicine
University of Pennsylvania Health System
Confusion in the ED: Take Home Pearls
• Delirium always has an organic etiology
• History from sources other than the patient may be critical and
life saving
• Obtain a full set of vital signs and thorough exam on all
patients (especially those with AMS)
• ED evaluation of AMS always follows the ABCDE approach
Department of Emergency Medicine
University of Pennsylvania Health System
Questions/Comments/Suggestions
[email protected]
Department of Emergency Medicine
University of Pennsylvania Health System