Emergency Medicine/Altered mental status

Symptoms

• Decreased conscious state drowsy stupor: non responsiveness to pain or painful procedures
• Delirium - altered perception, hallucination
• Lethargy - decreased activity, loss of eye contact

AEIOU TIPS

A mnemonic to work-through of the possible causes of altered mental state (AMS).

• A — Alcohol/Acidosis
• E — Endocrine

Epilepsy

• Electrolytes
• Encephalopathy

• I — Infection
• O — Opiates, Overdose
• U — Uremia/Underdose
• T — Trauma
• I — Insulin
• P — Poisoning/Psychosis
• S — Stroke/Seizure/syncope

Traumatic , Infection, Neoplastic, Inflammation , M+E ( metabolism and endocrinology) , Pharmacology - doesn't cover seizures ?

• Trauma - head injury, blood loss (shock).
• Infection - meningitis, encephalitis, sepsis, septic shock; pneumonia, urinary tract infection, liver abscess,

occult osteomyelitis.

• Neoplasia - intracranial tumor.
• Inflammation - inflammatory encephalitis, autoimmune encephalitis.
• M+E - electrolytes and endocrinology - sodium (calcium) , uremia, hepatitis ( all of them ? Insulin-related, Cortisol -Related, Thyroid- hyper).
• Pharmacology - opiates, alcohol (and other illicit substances) , other poisons.

What to do ?

Start the usual ...

• ABC - adequate ventilation, adequate oxygen, cervical spine protection if required, airway protection if required
• Oxygen
  • adequate circulation (BP, PR , periphery)
  • IV access
• Cardiac monitor
• Quarrantine or Reverse Isolation (if appropriate)

What happened ( caregiver, witness ) ?
History of Presentation
Past Medical History
Allergies, Medications, Drug/Substance Use 
 
Physical Examination
 Vital signs - Temp, BP,  PR, RR, Oximetry  
 Chest, Abdominal , Head/Eyes, Neurological, 
 Skin = check for ominous changes (purpura, rash, infections...)
 

LABS / TESTS

 ECG
 blood sugar (fingerstick)
 electrolyte panel
 liver function tests
 urinalysis
 EtOH
 ASA
 Tylenol
 toxicology screen
 carbon monoxide level (in appropriate scenario)
 thyroid function tests
 CT Head
 lumbar puncture
 Abdo US

Quick Fixes -

   low glucose level - IV dextrose
   hypoxia - give oxygen
   pinpoint pupils not breathing - IV nalaxone (for opiates on board)
   seizure, stop - IV diazepam (or lorazepam... another benzo)
   cold - warm up
   suspect sepsis - IV antibiotics empiric. ?blood culture x 2 first. If difficult do later.
                  antibiotics before LP is ok (complete the LP within one hour of starting the med)