ALTERED LEVEL OF CONSCIOUSNESS

Transcription

1 ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital Alameda County Medical Center Oakland California UCSF Topics in Emergency Medicine

2 We will cover Terminology & definitions Developing a thorough differential Identifying the delirious patient A variety of challenging cases Focused H&P highlights Key lab and imaging studies Avoiding errors

3 Scope / Spectrum 2002 data from a University Hospital ALOC pts - 5% of the ED volume 64% got admitted 28% neuologic 21% toxicologic 14% trauma 14% psychiatric 10% infectious 5% endocrine / metabolic 3% pulmonary 3% oncologic

4 Altered Mental Status Approach Functional (psychogenic) Organic Delirium { Toxic / metabolic (diffuse disease), infectious Structural (focal disease) Dementia

5 Bottom Line Psychiatric / functional Pt gets labeled / treatable but not reversible Delirium 80% reversible and up to 15% mortality Dementia 20% reversible

6 Delirium Organic Disease Acute onset with a wildly fluctuating course. Difficulty focusing, easily distracted. Disorganized thinking, rambling, hard to follow. Altered level of consciousness. Visual hallucinations are common. Abnormal vital signs.

7 Dementia Organic Disease Insidious, gradual onset. Normal alertness and attentiveness. Disorientation is the baseline. No hallucinations. Vital signs - normal.

8 Acute Psychosis Functional Disease Abrupt onset with a stable course. Normal level of consciousness. Auditory hallucinations. Orientation usually normal. Vital signs may be elevated.

9 Let s Review Wildly fluctuating course Auditory hallucinations Disoriented Normal LOC Abnormal Vital Signs Delirium Psychosis Delirium Psychosis Both

10 Levels of Consciousness Nomenclature - terminology Traditional Descriptive (AVPU) Alert Awake and Aware Lethargy Responds to verbal stim Stupor Responds to painful stim Coma Unresponsive

11 The Naked Man History 32 year old male was found running nude in a field near a school. He was well known to the police and the medical community as an alcohol and speed abuser. While being booked by the police he fell off a bench, hit his head and became unconscious. No other acute history was available.

12 ALOC - Naked Man Physical BP 70/ p HR 200 RR 16 T 41.6 C (106.9 F) Comatose - unresponsive to painful stimuli HEENT - small contusion on his forehead. Pupils were 4 mm and sluggishly reactive to light. He had a decreased gag reflex, and equivocal plantar reflexes bilaterally. The rest of his exam was WNL.

13 ALOC - Naked Man Follow up Despite aggressive resuscitative efforts the patient expired several hours later. All ED studies were unhelpful in making a diagnosis. The differential was broad (toxins, hypothalamic dysfunction, such as tumors, bleeds, CNS infections). A thorough head-to-toe exam would have keyed-in the examiner to the diagnosis. *

14 ALOC - Naked Man Postmortem diagnosis: Thyrotoxicosis

15 DDX - Altered Consciousness AEIOU TIPS, ASA A. Alcohols T. Trauma, Tox, temp, Thyroid E. Endocrine, lytes I. Infections I. Insulin (diabetes) P. Psychiatric O. Oxygen, Opiates S. SAH, Seizures U. Uremia

16 DDX - Altered Consciousness Start from the head and work down Central nervous system Bleeds (traum a and nontraum a) Infarcts Infections Seizu res Conversion reaction / psych

17 DDX - Altered Consciousness Mouth: Toxins / Meds Alcohols Anticholinergics Anticonvulsants Barbiturates Carbon Monoxide Cyanide Hallucinogens Heavy Metals Opiates Phenothiazines Salicylates Sedative Hypnotics SSRI s Sympathomimetics Tricyclic antidepressants

18 Special Case Toxins Cocaine delirium and sudden death. Gamma hydroxybutyrate (GHB) = (GBH) Grievous bodily harm. An anestheti c wi th euphori c and sexual enhancement properties. Short acting benzodiazepines - Rohypnol (Roofies, Ruffies, Love Drug)

19 DDX - Altered Consciousness Neck Neck and Chest Thyroid & parathyroid disease Chest Hypoxia Hypercarbia Emboli

20 DDX - Altered Consciousness Abdom en Liver Hepatic encephalopathy Wernicke s syndrom e Pancreatic disease Adrenal insufficiency Renal disease: electrolyte and metabolic disorders

21 DDX - Altered Consciousness Skin Other?? Heat Stroke think of while getting rectal temp Hypothermia rectal temp Sepsis Vasculitis may consider as part of renal causes Hyperviscosity ALOC as it affects the CNS

22 To Tube or not to Tube History 14 year old girl found down near a bus stop near her school. No one came with the girl to the hospital, so initially, there was no other history available.

23 ALOC - Tube? Physical exam Gurgling respirations. BP - 98/ 74 HR RR - 10 Pulse ox 89% RA. HEENT - PERRL 3 m m sluggish - disconjugate gaze ++AOB. Neck, chest, abdomen, extremities - all WNL.

24 ALOC - Tube? Physical exam - continued Neurologic Comatose - responds appropriately to deep painful stimuli Poor gag reflex, moves all 4 extremities equally to painful stimuli DTR s 1-2+ equal Plantar reflexes equivocal

25 ALOC - Tube? Medical decison making (for coding purposes only) Possibly all secondary to alcohol ingestion in a young girl, but airway control was needed. The glucose was 119 mg / dl. No response to 2 mg of narcan. Prior to CT she would need RSI...however *

26 ALOC - Tube? Outcome She woke up after 3 doses of 0.2 mg (total of 0.6mg) of flumazenil to the point of spontaneously talking (although she was dysarthric). Her blood alcohol was 190mg / dl.

27 FLUMAZENIL Benzodiazepine competitive antagonist Dose mg Duration min Controversial in: Mixed ingestions Chronic benzodiazepine users Patients with seizure disorders

28 Altered Mental Status Patient History Sources Pill bottles Medics Relatives Medic alert tag Wallet Hospital & Psych records Friends Personal physician Pockets

29 Altered Mental Status Physical exam -Vital Signs Respiratory rate and pattern Heart rate and rhythm Blood pressure Rectal temperature

30 Altered Mental Status Physical Exam - General Head - signs of trauma Breath odor - alcohol, fruity, almond, garlic, onion, + Neck - thyroid, scar, meningismus

31 Altered Mental Status Physical Exam - General Chest - breath sounds, murmurs, rhythm Abdomen - organomegaly, ascites, peritonitis Skin - jaundice, petechiae, moisture, temperature, color, needle tracks, spider angiomatas

32 Altered Mental Status Neurologic exam General observations Autism s Yaw n i n g Hiccups Swallowing Respirator y patterns Posturin g

33 Altered Level of Consciousness Motor Exam Spontaneous movements Purposeful movements Response to painful stimuli Tone

34 Neurologic Exam Keys Eyes Ears M ental Status Exam

35 Pupils Altered level of consciousness The eye exam Funduscopic exam Eye movements Eyelids

36 Caloric Testing Cold Water < 30 0 C Normal - deviation away with nystagmus Cerebral dysfunction - tonic deviation to one side Brainstem dysfunction - no response

37 Altered Mental Status Mini-mental status exam Confusion assessment method (CAM)

38 Confusion Assessment Method To diagnose delirium: 1) Acute onset with fluctuating course 2) Inattention - difficulty focusing and 1) Disorganized thinking or 2) Altered level of consciousness

39 Diagnosis in < ten minutes Bedside studies History and physical Glucom eter / dextrostick - dextrose Pulse oximetry ABG s - Hypoxia / Hypercarbia / acidosis. Istat

40 Rapid diagnostic studies Bedside studies - interventions Urinalysis Infection, hyperglycemia, dehydration Breathalyzer Electrocardiogram / rhythm strip Narcan, thiamine Flumazenil, physostigmine

41 Physostigmine Reversible inhibitor of acetylcholinesterase Used to RX, or DX severe anticholinergic syndrome Useful in GHB ingestion? DO NOT use in tricyclic overdoses Dose mg slow IVP up to a total of 2 mg Keep atropine nearby

42 Altered Level of Consciousness Additional studies to consider Lytes, BUN, Cr, osmolality, calcium Complete blood count Carboxyhemoglobin Lumbar puncture

43 Altered Level of Consciousness...and more studies to consider Directed drug screen Thyroid function tests Head CT scan Peritoneal tap

44 Osmolar Man History An 18 year old male calls 911 for a severe headache. Upon arrival he refuses to let the medics in his home and they leave. Thirty minutes later his mother calls 911 and the medics arrive to find a comatose male. His mother explains that he is diabetic and frequently forgets to take his insulin. The medics transport and administer 25 gms of dextrose en route.

45 ALOC - Osmolar Man Physical BP 170/ 70 HR 92 RR 14 Comatose male who appears otherwise healthy. Skin is moist, pupils are PERRL at 6 mm, neurologic exam is non-focal except for bilateral upgoing toes. The general exam is otherwise normal.

46 ALOC - Osmolar man Early labs Blood glucose on his pre-hospital dextrose blood was 19 mg/ dl. A second bolus of dextrose did not change his mental status. Do we ever really need a second amp of glucose?

47 ALOC - Osmolar Man Follow-up Repeat exam noted an unmeasurable amount of anisocoria unnoticed before. CT scan found a large subdural with midline shift; the patient was taken to the OR and did well. *

48 A Taxi ing Case History A 28 year old man was brought unconscious to the emergency department. Fifteen minutes earlier, with slurred speech, he had instructed a taxi driver to take him to the hospital. He passed out before arriving at the hospital.

49 ALOC - Taxi man Physical BP 130/ 90 HR 100 RR 40 Most of the physical exam was within normal limits. On neurologic exam: Pupils were PERRL at 3 mm, DTR s were 3+ and equal, plantar reflexes were both extensor and he had intermittent bilateral decerebrate posturing. *

50 ALOC - Taxi man Follow up Hypoglycemia commonly presents with focal neurologic findings that can mimic structural lesions. It is obviously important not to skip the basics. This patient s blood glucose was 20 mg/ dl and he awoke after receiving 25 grams of dextrose.

51 Mid Term Review Odor of breath arsenic Absent pupil response to light Average inc. in BS after 1 amp D50 Flumazenil is avoided in which patients? Garlic Structural defect 130 mg/dl Mixed ingestions

52 ALOC - SUMMARY Take back to the ER points Assume the patient is delirious DDX - start from the head and work your way down Think like a detective The eyes, ears, and mental status are keys Don t be afraid of flumazenil or physostigmine

53 Common Errors Failure to consider the basics (glucose, oxygen, thiamine) Treatment delay during the evaluation Failure to re-examine at frequent intervals Incomplete differential ddx

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55 Not So - Funny Man? History 911 called for a pt. exhibiting bizarre behavior. No similar past history. Friends stated he had been acting funny, agitated, and not sleeping for several days. No hx of drug use but the family had suspicions. No other significant past or present history.

56 Not So - Funny Man? Physical exam Hyper-alert and agitated. Talking very fast but not making much sense. BP 160/ 110 HR 124 RR 18 T 101 F HEENT - PERRL 5 mm Mucous membranes - moist No distinctive breath odor Skin - warm and dry Rest of the exam was WNL

57 Not So - Funny Man? Confusion assessment exam ++ Acute onset with a fluctuating course. ++Inattentive - could not focus on the questions. +Disorganized thinking - speech / subject was hard to follow. +- ALOC - hyperalert.

58 Not So - Funny Man? ED differential and course Tox, CNS infection, thyroid disease. Blood glucose was 97 mg/ dl. Tox was positive for amphetamine. To tap or not to tap?

59 Sleeping Beauty History A 20 year old woman is found unconscious in her room two hours after a fight with her parents. She was well prior to the incident. She has a history of emotional problems and occasional migraine headaches. Medications include Tylenol and Vicodin for her headaches

60 ALOC - Sleeping Beauty Physical BP 108/ 64 HR 68 RR 12 The general PE was within normal limits. When left alone she appeared to be sleeping. Pupils were PERRL at 3mm. There was no response to painful stimuli but there was some resistance to passive elevation of her eyelids. Cold calorics elicited tonic deviation of the eyes with no nystagmus.

61 ALOC - Sleeping Beauty Follow up The history and physical suggested light coma or simulated coma. However, caloric testing indicated organic cerebral dysfunction. The patient remained stable and gradually awakened over 48 hours. She admitted to ingesting a handful of phenobarbital.

62 Pathophysiology of Coma Structural causes Bilateral cortical disease. Suppression of the Reticular Activating System. Supratentorial lesions Infratentorial lesions Intrinsic brainstem lesions Brainstem torque