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

2. Fever --> positive = find source

3. Obvious cause --> positive = pursue

4. Non-obvious -->

Give thiamine & narcan

CBC

Chem 10

UA

ECG

UTox

CXR

Head CT

LFTs

PT

Consider:

CSF

ABG

TSH

EEG

ASA/Tylenol levels

Ammonia

HIV

DDx Confusion

I. Hypoxia/diffuse ischemia

    A. Respiratory failure

    B. CHF

    C. MI

    D. Severe anemia

    E. Shock

II. Systemic

    A. Hypoglycemia

    B. Electrolyte/fluid disturbance

    C. Endocrine dz

         1. Thyroid

         2. Adrenal

    D. Hepatic failure (ammonia)

    E. Wernicke's

    F. Infection/sepsis

         1. Urine

         2. PNA

         3. Other

III. CNS Disease

    A. Infection

    B. Trauma

    C. CVA/TIA

    D. SAH

    E. Seizure

         1. Postictal

         2. Nonconvulsive

         3. Complex partial

IV. Hypertensive encephalopathy

V. Increased ICP

VI. Toxins/withdrawal

    A. Sedatives

    B. ETOH

    C. Anticholinergics

    D. Other

VII. Neoplasm

DDx Coma and...

DIFFUSE CNS DYSFUNCTION

I. Diffuse Neuronal Deprivation

    A. Hypoglycemia

    B. Hypoxia (with nl Cerebral Blood Flow (CBF))

         1. Respiratory failure

              a. CHF

              b. PNA

              c. Obstructive

         2. Severe anemia

    C. Decreased CBF

         1. Shock

              a. AMI

              b. Hypovolemia

         2. Post arrest

    D. Cellular Toxin

         1. CO

         2. Cyanide

         3. Hydrogen sulfide

    E. Thiamine deficiency (Wernicke-Korsakoff)

II. Endogenous CNS Toxins

    A. Hyperammonemia (hepatic coma)

    B. Uremia (renal failure)

    C. CO2 Narcosis

    D. Hyperglycemia

III. Exogenous CNS Toxins

    A. Alcohols

         1. ETOH

         2. Isopropyl

    B. Acids

         1. Methanol

         2. Ethylene glycol

         3. Salicylate

    C. Sedatives

    D. Narcotics

    E. Anticonvulsants

    F. Psychotropics

    G. Isoniazid

    H. Heavy metals

IV. Endocrine disorders

    A. Myxedema coma

    B. Thyrotoxicosis

    C. Addison's

    D. Cushing's

    E. Pheochromocytoma

V. Ionic abnormalities

    A. Hypo/hyper-natremia

    B. Hypo/hyper-calcemia

    C. Hypo/hyper-magnesemia

    D. Hypophosphatemia

    E. Acidosis/alkalosis

VI. Temperature abnormalities

    A. Hypothermia

    B. Heat stroke

    C. NMS

    D. Malignant hyperthermia

VII. Intracranial HTN

    A. Hypertensive encephalopathy

    B. Pseudotumor cerebri

VIII. CNS inflammation/infection

    A. Meningitis

    B. Encephalitis

    C. Cerebral vasculitis

    D. SAH

    E. Carcinoid meningitis

    F. Traumatic axonal shear

IX. Primay neuronal/glial

    A. CJD

X. Seizure/postical

FOCAL CNS LESION

I. Supratentorial

    A. Hemorrhage

         1. Intracerebral

         2. Epidural

         3. Subdural

         4. Pituitary apoplexy

    B. Infarction

         1. Thrombotic arterial

         2. Embolic arterial

         3. Venous

    C. Tumors

    D. Abscess

II. Infratentorial

    A. Compressive

         1. Cerebellar hemorrhage

         2. Post fossa sub/extra-dural

         3. Cerebellar infarct

         4. Cerebellar tumor

         5. Cerebellar abscess

         6. Basilar aneurysm

    B. Destructive

         1. Pontine hemorrhage

         2. Brainstem infarct

         3. Basilar migraine

         4. Brainstem demyelination

Source

2/27/06 DONALDSON (adapted from Rosen)