Altered mental status: Difference between revisions
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Revision as of 12:59, 1 June 2015
Background
- Alteration of arousal or content of consciousness or both
- Both cerebral cortices or brainstem must be affected
- Delirium vs dementia vs psych
- Must quickly determine if coma is from diffuse or focal impairment
- Peds
- Most common causes are toxic ingestion, infection, and child-abuse induced trauma
Clinical Features
- Depends on cause
- Diffuse brain dysfunction - lack of focal findings
- Focal brain dysfunction - hemiparesis, loss of motor tone, loss of ocular reflexes
Differential Diagnosis
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Diagnosis
- Stat D-stick
- CBC
- Chemistry
- LFTs
- UA
- CXR
- Utox
- EKG
- Head CT
- ?Blood and urine cultures
- ?Ammonia level
- ?Tylenol/ASA level
- ?LP
- ?Serum Osm
- ?Coags
- ?TFTs
- ?Cortisol
- ?ABG/VBG
Treatment
- Pts w/ focal findings may have surgically treatable cause
- Coma cocktail
- Glucose, thiamine, naloxone
- Underlying cause
See Also
- Toxicology (Main)
- Glasgow Coma Scale (GCS)
- Altered Mental Status (AMS) (Peds)
- AVPU Scale
- Brain Death
Source
Tintinalli