Altered Mental Status

Transcription

1 Karl Sporer,MD FACEP, FACP Clinical Professor UCSF High Risk Emergency Medicine 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): , 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): Make up 5% of our Emergency Department patients 2% to 3% present for accidental or deliberate poisoning. 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): 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):

2 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 Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. Nov ;357(22): Heroin Toxidrome AMS, Pinpoint Pupils Decreased Respiratory rate Diagnostic Sensitivity 92% Specificity 76% Sporer KA. Acute heroin overdose. Ann Intern Med. Apr ;130(7): Principle 1 Is the patient breathing enough? If not, then fix it. One Caveat Suspected Heroin Overdose Heroin Overdose Toxidrome Naloxone 0.4 to 2 mg IM, IV or IN Adding a complete naloxone response to the clinical criteria lowered the sensitivity to 86% Partial Naloxone Response 2 out of 32 partial responders 2

3 Naloxone Treatment of Heroin Overdose is associated with a consistent rate of complications Principal 2 Is the patient perfusing his brain adequately? Seizures (1-2%) Arrhythmias (<0.5%) Agitation (10-17%) If not, then fix it. Suspected Heroin Overdose Blue- Get Naloxone Not Blue- Observe Principle 3 Does the patient have enough glucose going to his brain? Measure fingerstick glucose 3

4 Principle 4 Does the patient need a head CT? Trauma Focal neurological exam Worsening or not improving GCS Suspected Intoxication Ethanol Sedative Opiates Sympathomimetics Toxidromes Anticholinergic Mad as a Hatter Blind as a Bat Red as a Beet Full as a Tick Pupils No Literature on the Utility of Pupil Exam Except Pinpoint pupils and GCS of 3 Blown pupil and GCS of 3 4

5 Principle 5 Scrutinize the Vital Signs Hypothermia Tachycardia Bradycardia Fever Approach to a Suspected Isolated Alcohol Intoxication ABC, Glucose, Vital Signs, Nonfocal Exam Must be able to verbalize. Minimum GCS of 12 No IV, No Blood Alcohol Level, No Laboratory Work, No Toxicology Screen Test of Clinical Observation Aware of Potential for Missed Head Injuries Alcohol Intoxication 7.1 Million Alcohol Related ED Visits per Year 7.9% of ED Visits Approach to a Suspected Isolated Alcohol Intoxication Blood Alcohol Levels Don t correlate with GCS Don t rule out head injuries Don t explain any vital sign abnormalities Brennan DF et al. Ethanol elimination rates in an ED population. Am J Emerg Med. May 1995;13(3):

6 Approach to a Suspected Isolated Alcohol Intoxication Glasgow Coma Scale Serial exams Reconsider CT for No Improvement in 2-3 hours Sedative/Opiate Intoxication If they can talk, observe them Case Management Screening, Brief Intervention, and Referral 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): Collaborative AESR. The Impact of Screening, Brief Intervention, and Referral for Treatment on Emergency Department Patient's Alcohol Use. Ann Emerg Med. 2007;50: Prospective Study of 359 Suspected Intoxicated Patients 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):

7 Undifferentiated Violent, Agitated Patient 4 Point Restraints Position on Back IM Sedation Vital Signs Beware of Hyperthermia Undifferentiated Violent, Agitated Patient Physical Restraints Beware the Hogtie Position Be Very Concerned with Respiratory Arrest Unknown Mechanism Occurs in SF 4-5 times each year 7

8 Undifferentiated Violent, Agitated Patient Limited referrals for these patients Increased HIV transmission rate Contingency Based Treatment ABC s Glucose Neuro Exam Serial GCS Observation alone adequate if the patient can talk Always reconsider when there is no improvement No change after Observation Send baseline labs Reassess Vital Signs Reconsider CT scan Consider Hepatic Encephalopathy Post itcal Nonconvulsive status epilepticus Unusual OD, baclofen, GHB Questions? 8