Formative Assessment for Simulation Training (FAST)—Altered Mental Status 1: Young AD with intoxication
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SCENARIO ALGORITHM
SET UP
Sim Man w/ vital signs
Instructor will control Sim Man
Co-instructor will be significant
other
ECG and monitor available
PRE ARRIVAL
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 25 yo male acting odd for
approximately 30 minutes.
Brought to ED by significant other.
 HR 85 BP 138/79 RR 12 Pox 95%
ARRIVAL
 No change
 PMH—Never happened before,
otherwise healthy
 Meds—None currently
 All—None
 SH—Tob x ½ ppd, etoh x1-2/day,
coffee x 4 cpd. Active duty E5.
PRIMARY SURVEY
 ABCs WNL as above
SECONDARY SURVEY
Pt progresses to deeper sedation
with GCS of 8, unable to maintain
airway, resident should consider
intubation or calling for help
Date:
Examiner:
Examinee(s):
Learning Objectives:
1.
2.
3.
4.
5.
Recognized acute mental status changes in a simulated patient
Gathered from patient and family pertinent history
Performed appropriate physical exam to include a quick MMSE and/or GCS if appropriate
Listed a reasonable differential diagnosis
Ordered appropriate labs & rads to begin emergent work up of a patient with acute MS changes
6. Determined appropriate management and disposition for the patient based on the etiology of the MS change
CRITICAL ACTIONS
Place safety net—IV, O2, monitor &
begin ABCs
ID altered mental status & assess
patient as currently stable.
Take thorough history and ID time of
onset
Evaluate MMSE and/or GCS as well
as appropriate secondary physical
exam.
List differential diagnosis for altered
mental status.
Order appropriate labs, rad tests
Interpret findings and determine
management
Determine that intubation is
indicated, discuss RSI or call for
assistance.
Disposition to admission in ICU
LABS & IMAGES
 CXR—WNL
 Labs—BAL 390, UDS positive for
meth
 ECG—NSR
Demonstrate effective
communication including closed loop
feedback
DISPOSITION
Admit, possible ICU if intubated
MS = Milestone
ME = Meets Expectations
NI = Needs Improvement
TOTAL
MS
ME
NI
SUSTAIN
IMPROVE
Formative Assessment for Simulation Training (FAST)—Altered Mental Status 1: Young AD with intoxication
GCS: Glasgow Coma Scale (GCS) in adults:
Best possible score 15 points, range 3-15 points
Eye Opening
Best Verbal
Best Motor
Response
Response
Follows
commands
Oriented
Localizes pain
Spontaneous
Confused
Withdraws from
pain
To Voice
Inappropriate
Flexor response
words
To Painful stimuli
Unintelligible
Extensor
words
response
None
None
None
Points
6
5
4
3
2
1
Reporting GCS scores:
 patient monitoring and information exchange should be based on 3 separate responses on eye-opening, verbal response
and motor response (for example, communicate response as E4, V4, M5) (NICE Grade D)
 if total score recorded or communicated, specify denominator (for example, 13/15) (NICE Grade D)
 describe individual components of GCS in all communications and not just total score (NICE Grade D)
Formative Assessment for Simulation Training (FAST)—Altered Mental Status 1: Young AD with intoxication
Formative Assessment for Simulation Training (FAST)—Altered Mental Status 1: Young AD with intoxication
Mnemonic for differential diagnosis of delirium
AEIOU M&M TIPS
A - Alcohol (including withdrawal)
E - Epilepsy (especially post-ictal)
I - Infection
O - Oxygen (hypoxia) or overdose
U - Uremia
M - Myocardial infarction
& - Anesthesia
M - Metabolic
T - Trauma/fracture
I - Insulin
P - Polypharmacy, psychiatric
S – Stroke, sepsis
Causes of Metabolic Acidosis
M: Methanol
U: Uremia
D: DKA
P: Paraldehyde
I: Infeciton
L: Lactic Acidosis
E: Ethylene gylcol
S: Salicylates
Work up to consider:
Vital signs
Complete blood count with differential, erythrocyte sedimentation rate (ESR)
Blood chemistries (electrolytes, blood urea nitrogen, creatinine, glucose, hepatic function, calcium)
Thyroid studies (TSH, T4)
VDRL (syphilis), HIV
B12, folate
Urinalysis, urine drug screen
Electrocardiogram (ECG)
Chest x-ray
Brain imaging (if focal neurologic deficits or suspicion for intracranial process - computed tomography, magnetic resonance
imaging
Lumbar puncture (if suspicion for meningitis)
Electroencephalogram (EEG)
-often shows diffuse slowing of background activity
-may show seizure activity
-fast if drug withdrawal
Formative Assessment for Simulation Training (FAST)—Altered Mental Status 1: Young AD with intoxication
Formative Assessment for Simulation Training (FAST)—Altered Mental Status 1: Young AD with intoxication
References:
 National Institute of Clinical Excellence (NICE) guideline on head injury (triage, assessment, investigation and early
management of head injury in infants, children and adults) (NICE 2007 Sep:CG56 or at National Guideline Clearinghouse
2010 Jun 21:11468), summary can be found in BMJ 2007 Oct 6;335(7622):719
 Lancet 1974 Jul 13;2(7872):81
 Am Fam Physician 1998 Mar 15;57(6):1358
 J Am Geriatr Soc 2008 May;56(5):823
 DynaMed search database
 UptoDate search database