Adult Emergencies: Acute Mental Status Change
Instructor Version
Objectives:
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
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Recognized acute mental status changes in a simulated patient
Gathered from patient and family pertinent history
Performed appropriate physical exam, include a quick MMSE
Listed a reasonable differential diagnosis
Ordered appropriate labs and rads to begin emergent work up of a patient with acute MS
changes.
Different Types of Altered Mental Status:
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


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Confusion: Unable to maintain coherent thought process
Delirium: Waxing, waning confusional state w/additional signs
Drowsiness: Decreased level of consciousness, rapid arousal to verbal, noxious stimuli
Stupor: Impaired arousal, some purposeful movements
Coma: Sleep-like state, unresponsive, no purposeful movements
Etiologies:
Primary Neurologic
Stroke
Seizure
Infection
Epidural or subdural hematoma
Concussion, TBI
Hydrocephalus
Complicated migraine
Venous thrombosis
CNS vasculitis
Cholesterol or fat emboli
Systemic
Cardiac: CHF, HTN encephalopathy
Pulm: PaO2, PaCO2
GI: Liver failure, Wilson’s
Renal: Uremia, hypo/hypernatremia
Endocrine: glc, DKA, HHNS, Ca,
Hypo/hyperthyroidism, Addisonian crisis
ID: PNA, UTI, sepsis
Hypo/Hyperthermia
Medications (opiates, sedatives)
Alcohol, Toxins
Initial Evaluation:
Hx: Previous or recent illnesses, including underlying dementia, psychiatric d/o, head trauma,
alcohol and/or drug use
PE: Evaluate for trauma, stigmata of liver dz, embolic phenomena, signs of drug use, nuchal
rigidity, subarachnoid hemorrhage
NEURO EXAM:
Observe for spontaneous movements, response to stimuli, mini-mental exam
Cranial nerves: eye position at rest, response to visual threat, corneal reflex, facial grimace
Pupil size and reactivity: pinpoint, midposition & fixed, fixed & dilated,
Intact oculocehpalic: Doll’s eyes or oculovestibular (calorics)
Signs of ICP
Motor Response: posturing vs. purposeful movements
DTRs
Treatment:
Control airway, monitor VSs, IV access
C-spine precautions, increase HOB if ICP or herniation suspected, hyperventilation,
dexamethasone, neurosurgical consult
Give thiamine (before dextrose in case of Wernicke’s), dextrose, naloxone, flumazenil
Diagnostic Studies:
Head CT, MRI
CXR, C-spine
CBC, ESR, electrolytes, BUN, Cr, ABG, LFTs, coags, tox screen, TSH, VDRL, B12, folate,
UA, UDS
Lumbar puncture
EKG, EEG
Glasgow Coma Score
Eye Opening
Best Verbal Response
Spontaneous
To Voice
To Painful stimuli
None
Oriented
Confused
Inappropriate words
Unintelligible words
None
Causes of Metabolic Acidosis
M: Methanol
U: Uremia
D: DKA
P: Paraldehyde
I: Infeciton
L: Lactic Acidosis
E: Ethylene gylcol
S: Salicylates
AEIOUM&MTIPS
A: Alcohol
E: Epilespy (esp post-ictal)
I: Insulin
O: Overdose, oxygenation (lack of)
U: Uremia, underdose
M: Myocardial
&: Anesthesia
M: Metabolic
T: Trauma, fracture
I: Infection
P: Psych, poisoning
S: Stroke, shock
Best Motor Response
Follows commands
Localizes pain
Withdraws from pain
Flexor response
Extensor response
None
Points
6
5
4
3
2
1
Adult Emergencies: Altered Mental Status
Objectives:





Recognized acute mental status changes in a simulated patient
Gathered from patient and family pertinent history
Performed appropriate physical exam, include a quick MMSE
Listed a reasonable differential diagnosis
Ordered appropriate labs and rads to begin emergent work up of a patient with acute MS
changes.
Different Types of Altered Mental Status:





Confusion:
Delirium:
Drowsiness:
Stupor:
Coma:
Etiologies:
Primary Neurologic
Stroke
Systemic
Cardiac:
Seizure
Pulm:
Infection
GI:
Epidural or subdural hematoma
Renal:
Concussion, TBI
Endocrine:
Hydrocephalus
Complicated migraine
Venous thrombosis
CNS vasculitis
Cholesterol or fat emboli
ID:
Hypo/Hyperthermia
Medications (opiates, sedatives)
Alcohol, Toxins
Initial Evaluation:
Hx: Previous or recent illnesses, including underlying dementia, psychiatric d/o, head trauma,
alcohol and/or drug use
PE: Evaluate for trauma, stigmata of liver dz, embolic phenomena, signs of drug use, nuchal
rigidity, subarachnoid hemorrhage
NEURO EXAM:
Observe for spontaneous movements, response to stimuli, mini-mental exam
Cranial nerves: eye position at rest, response to visual threat, corneal reflex, facial grimace
Pupil size and reactivity: pinpoint, midposition & fixed, fixed & dilated,
Intact oculocehpalic (‘doll’s eyes’) or oculovestibular (calorics)
Signs of ICP
Motor Response: posturing vs. purposeful movements
DTRs
Treatment:
Control airway, monitor VS, IV access
C-spine precautions, increase HOB if ICP, herniation suspected, hyperventilation,
dexamethasone, neurosurgical consult
Give thiamine (before dextrose in case of Wernicke’s), dextrose, naloxone, flumazenil
Diagnostic Studies:
Head CT, MRI
CXR, C-spine
CBC, ESR, electrolytes, BUN, Cr, ABG, LFTs, coags, tox screen, TSH, VDRL, B12, folate,
UA, UDS
Lumbar puncture
EKG, EEG
Glasgow Coma Score
Eye Opening
Best Verbal Response
Spontaneous
To Voice
To Painful stimuli
None
Oriented
Confused
Inappropriate words
Unintelligible words
None
Causes of Metabolic Acidosis
M: Methanol
U: Uremia
D: DKA
P: Paraldehyde
I: Infection
L: Lactic Acidosis
E: Ethylene gylcol
S: Salicylates
AEIOU M&M TIPS
A: Alcohol
E: Epilespy
I: Insulin
O: Overdose, oxygenation
U: Uremia, underdose
M: MI
&: Anesthesia
M: Metabolic
T: Trauma
I: Infection
P: Psych, poisoning
S: Stroke, shock
Best Motor Response
Follows commands
Localizes pain
Withdraws from pain
Flexor response
Extensor response
None
Points
6
5
4
3
2
1