Approach to altered mental status

Question 1

What cause does delirium always have?

Answer 1

Organic

Question 2

Define delirium

Answer 2

difficulty in focusing, shifting or sustaining attention

Question 3

Describe confusion of delirium

Answer 3

fluctuating

Question 4

4 causes of delirium

Answer 4

1. Primary intracranial dz
2. Systemic dz
3. Exogenous toxins
4. Drug withdrawal

Question 5

Delirium characteristics:

Answer 5

Slide 13-note that visual hallucinations are associated

Question 6

What must be present to diagnose delirium?

Answer 6

Findings in history and PE

Question 7

6 Elements of MSE

Answer 7

Appearance, behavior, and attitude
Disorders of thought
Disorders of perception
Mood and affect
Insight and judgment
Sensorium and intelligence

Question 8

MMSE elements

Answer 8

Orientation
Registration
Attention and calculation
Recall
Language

Question 9

What does MMSE not detect?

Answer 9

Mild impairment

Question 10

Quick confusion scale

Answer 10

Year
Month
Present memory phrase
Time
Count backward
Reverse month
Repeat memory phrase

Question 11

Advantage of quick confusion scale over MMSE

Answer 11

Quicker-no reading, drawing, writing

Correlates well with MMSE

Question 12

Tx of delirium

Answer 12

Consider sedation
-Haldol
-Lorazepam
(Reduce haldol if given with benzo)

Question 13

Disposition for delirium

Answer 13

• Admit majority

- Must call internal med

Question 14

Define dementia

Answer 14

*Loss of mental capacity

Slow, insidious onset*

Question 15

2 Categories of dementia

Answer 15

Idiopathic

Vascular

Question 16

Characteristics of dementia

Answer 16

Slide 29

Question 17

Memory features of dementia

Answer 17

Recent affected > long term

Question 18

Exaggerated or Asymmetric DTRs, Gait Disturbance, Extremity Weakness =

Answer 18

Vascular dementia

Question 19

What does not determine presence of dementia?

Answer 19

General PE

Remember, delirium is determined by PE and hx

Question 20

What must you remember to consider in dementia?

Answer 20

Co-existing causes of delirium

Question 21

What must be r/o with dementia?

Answer 21

Treatable cause or delirium

Question 22

When might you be able to discharge dementia?

Answer 22

Stable, reliable caregivers, and prompt f/u AFTER life-threats excluded

Question 23

Definition of coma

Answer 23

Pt cannot be aroused

Question 24

GCS

Answer 24

Slide 41

Question 25

What condition CANNOT cause coma?

Answer 25

Stroke (unilateral hemispheric dz) except uncal herniation

Question 26

Toxic metabolic coma findings (4)

Answer 26

- Diffuse CNS function - Lacks focal findings - Symmetrical findings - Pupillary response preserved

Question 27

What is an ominous finding of CNS malfunction?

Answer 27

Abnormal flexion and extension

Question 28

Which type of posturing is worse?

Answer 28

Decerebrate worse than decorticate (know positions of limbs; term not important)

Question 29

Decorticate posture

Answer 29

arms adducted and flexed, wrists and fingers flexed on chest, legs may be internally rotated and stiffly extended, plantar flexion of the feet

Question 30

Decerebrate posture

Answer 30

arms adducted and extended, wrists pronated and fingers flexed, legs may be internally rotated and stiffly extended, plantar flexion of the feet

Question 31

Decerebrate posturing indicates injury where?

Answer 31

Brain stem

Question 32

Decorticate posturing indicates injury where?

Answer 32

Corticospinal tract

Question 33

Supratentorial mass has what finding?

Answer 33

Progressive ipsilateral hemiparesis

Question 34

What does uncal herniation cause?

Answer 34

Medial temporal lobe shift-compresses upper brain stem

Question 35

What leads to abrupt coma?

Answer 35

Posterior fossa & infratentorial lesions: Cerebellar hemorrhage & infarction

Question 36

What is a unique sign of pontine hemorrhage?

Answer 36

Pinpoint pupils

Question 37

What imaging is best for abrupt coma and pinpoint pupils?

Answer 37

MRI-everything else is CT first

Question 38

What are findings of pseudocoma or psychogenic coma?

Answer 38

Pupillary, EOMs, Muscle Tone, Reflexes ALL intact & symmetric Patient will resist manual eye opening “Drop arm” test is positive Avoidance gaze Nystagmus with caloric vestibular testing

Question 39

Abrupt onset of coma is caused by:

Answer 39

trauma, stroke, seizures, cardiac

Question 40

Slow onset of coma caused by:

Answer 40

progressive CNS lesion (tumor, SDH), hyperglycemia

Question 41

PE for diagnosis of coma:

Answer 41

Assess vital signs: oxygen saturation & temperature Look for signs of trauma, toxidrome, etc. Bedside glucose Neurological exam

Question 42

What is the goal of coma diagnosis?

Answer 42

rapid determination of diffuse vs focal cause of CNS dysfunction

Question 43

Study of choice for coma:

Answer 43

CT-bleeding shows white

Question 44

If you think there's a bleed, but CT is negative, you must do:

Answer 44

LP (also when infection suspected)

Question 45

Airway issues when treating coma:

Answer 45

Don’t forget to protect the C-spine! | ICP:RSI and maintenance sedation indicated

Question 46

For status epilepticus, what should you do if not better after 30 min or if subtle?

Answer 46

Urgent EEG and/or neuro consult

Question 47

What should your treatment for coma be aimed at?

Answer 47

Underlying cause-*MUST focus on reversible causes | -Hypoxia, hypoglycemia, hypo-hypertension, hypo-hyperthermia

Question 48

What steps should be performed while taking diagnostic steps?

Answer 48

Brain-saving: Sedate, paralyze and intubate Elevate head of bed 30 degrees Mannitol Hyperventilate-last resort (only in herniation)! Steroids for tumors, septic shock, spinal cord injury

Question 49

Coma cocktail:

Answer 49

D-50% Dextrose (D50) 1 amp IVP after finger stick O-Oxygen at high flow N-Naloxone (Narcan) 0.4 to 2 mg IV initially T-Thiamine 100mg IV: prevents Wernicke’s

Question 50

For suspected seizures when treating coma, give what?

Answer 50

Lorazepam or diazepam

Question 51

If head bleed, who do you refer to?

Answer 51

Neurosurgery

Question 52

If ischemic stroke, who do you refer to?

Answer 52

Neurology