Altered Mental Status

Altered Mental Status

Karl Sporer,MD FACEP, FACP
Clinical Professor
UCSF
High Risk Emergency Medicine

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Patients over 65
25% will have some form of AMS
Unknown Economic Impact

Wilber ST. Altered mental status in older emergency department
patients. Emerg Med Clin North Am. May 2006;24(2):299-316, vi.
Hustey FM et al. The effect of mental status screening on the care
of elderly emergency department patients. Ann Emerg Med. May
2003;41(5):678-684.
Make up 5% of our Emergency

Department patients
2% to 3% present for accidental or
deliberate poisoning.
z 23% of these will have AMS
Kanich W et al. Altered mental status: evaluation and etiology in
the ED. Am J Emerg Med. Nov 2002;20(7):613-617.
Miner JR etal. Serial Bispectral index scores in patients
undergoing observation for sedative overdose in the emergency
department. Am J Emerg Med. Jan 2006;24(1):53-57.

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Scourge of the CT Scanner

Estimated that 1.5 to 2.0% of all
current cancers may be
attributable to the radiation from CT
studies
Principle 1
Is the patient breathing enough?
z
If not, then fix it.
One Caveat
{
Suspected Heroin Overdose
Heroin Toxidrome
z
z
z
AMS,
Pinpoint Pupils
Decreased Respiratory rate
Diagnostic Sensitivity 92%

Specificity 76%
Sporer KA. Acute heroin overdose. Ann Intern Med. Apr 6
Brenner DJ, Hall EJ. Computed tomography--an increasing

source of radiation exposure. N Engl J Med. Nov 29
2007;357(22):2277-2284.

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1999;130(7):584-590.

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Heroin Overdose Toxidrome

Naloxone 0.4 to 2 mg IM, IV or IN
z
Adding a complete naloxone response

to the clinical criteria lowered the
sensitivity to 86%
Partial Naloxone Response
{
2 out of 32 partial responders

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Naloxone Treatment of Heroin

Overdose is associated with a
consistent rate of complications
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z
z
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Seizures (1-2%)
Arrhythmias (<0.5%)
Agitation (10-17%)

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Principal 2
Is the patient perfusing his brain
adequately?
z
If not, then fix it.
Suspected Heroin Overdose

z
Blue- Get Naloxone
Not Blue- Observe
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Principle 3
Does the patient have enough
glucose going to his brain?
z
Measure fingerstick glucose

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Principle 4
Does the patient need a head CT?
z
z
z
Toxidromes
z
Anticholinergic
Mad as a Hatter
{ Blind as a Bat
{ Red as a Beet
{ Full as a Tick
Suspected Intoxication
z
Trauma
Focal neurological exam
Worsening or not improving GCS

{
z
z
z
Ethanol
Sedative
Opiates
Sympathomimetics

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Pupils
z
No Literature on the Utility of Pupil

Exam
Except
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Pinpoint pupils and GCS of 3

Blown pupil and GCS of 3

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Principle 5
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Scrutinize the Vital Signs
Approach to a Suspected Isolated Alcohol

Intoxication
z
Hypothermia
{ Tachycardia
{ Bradycardia
{ Fever
{
ABC, Glucose, Vital Signs, Nonfocal Exam

Must be able to verbalize. Minimum GCS of 12
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Alcohol Intoxication
7.1 Million Alcohol Related ED Visits per
Year
7.9% of ED Visits
No IV, No Blood Alcohol Level, No Laboratory

Work, No Toxicology Screen
Test of Clinical Observation
Aware of Potential for Missed Head Injuries

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Approach to a Suspected Isolated

z
Blood Alcohol Levels

Dont correlate with GCS
Dont rule out head injuries
{ Dont explain any vital sign abnormalities
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Brennan DF et al. Ethanol elimination rates in an ED population. Am J

Emerg Med. May 1995;13(3):276-280.

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Approach to a Suspected Isolated

z
z
z
Glasgow Coma Scale

Serial exams
Reconsider CT for No Improvement in
2-3 hours

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Case Management
Screening, Brief Intervention, and
Referral
Sedative/Opiate Intoxication
z

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Prospective Study of 359 Suspected

Intoxicated Patients
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z
z
Okin RL et al. The effects of clinical case management on hospital service

use among ED frequent users. Am J Emerg Med. Sep 2000;18(5):603-608.
Collaborative AESR. The Impact of Screening, Brief Intervention, and
Referral for Treatment on Emergency Department Patient's Alcohol Use.
Ann Emerg Med. 2007;50:699-710.
If they can talk, observe them
z
z
Suspected Class of Drug Correlated

with Toxicology Screen
Correct in Over 70% of Patients
Benzodiazepines had the lowest correct
rate
Underestimated Drug Use
Bjornaas MA, et al. Clinical vs. laboratory identification of
drugs of abuse in patients admitted for acute poisoning. Clin
Toxicol. 2006;44(2):127-134.

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Undifferentiated Violent, Agitated

Patient
z
z
z
z
4 Point Restraints
Position on Back
IM Sedation
Vital Signs
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Beware of Hyperthermia

Patient
z
z
z
z
z
Physical Restraints
Beware the Hogtie Position
Be Very Concerned with Respiratory
Arrest
Unknown Mechanism
Occurs in SF 4-5 times each year

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Patient
z
z
z
Limited referrals for these patients

Increased HIV transmission rate
Contingency Based Treatment

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No change after Observation

z
z
z
z
ABCs
Glucose
Neuro Exam
Serial GCS
Observation alone adequate if the
patient can talk
Always reconsider when there is no
improvement

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Questions?
Send baseline labs

Reassess Vital Signs
Reconsider CT scan
Consider
Hepatic Encephalopathy
Post itcal
{ Nonconvulsive status epilepticus
{ Unusual OD, baclofen, GHB
{
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Altered Mental Status

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