RRT

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RRT Mental Status Change Workshop

• Joseph Silberfarb, PA-C
• Theresa Rohrs, PA-C

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Approach to Mental Status Change

• ABCs
• Identify life-threatening conditions
• Establish a baseline
• Past Medical History
• Review Medications / Mind-altering drugs
• Bedside evaluation
• Differential diagnosis
• Appropriate testing

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• Always airway first
• Blood pressure
• Pulse / rhythm
• Oxygen saturation
• Blood Glucose
• Temperature

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Life Threatening Conditions Responses

• Arrhythmia ACLS
• Hypoxia/apnea/airway protection intubate /
  ventilate oxygenate
• Hypoglycemia D50
• Hypotension IV access

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Level of Consciousness

• Alert - awake
• Drowsy asleep, but easy to arouse
• Lethargic arousable, but not for long
• Stuporous partially or almost completely
  unconscious
• Obtunded very dulled response to stimuli near
  comatose not able to be awakened
• Comatose no response to stimuli

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Mental Status

• Appropriate alert, cooperative
• Anxious - uncertainty, fear, restlessness
• Confused - disturbed orientation
• Agitated - restless with ?activity,
  uncooperative, combative
• Psychotic - loss of contact with reality,
  delusions, hallucinations

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Delerium v. Dementia

• Delerium

• Dementia

• A reversible state of cognitive impairment and
  confusion
• Sudden onset
• Usually toxic or metabolic
• Affects 30 of older hospitalized patients

• An irreversible state of cognitive impairment and
  short term memory loss
• Slow progressive
• Sundowningestablished behavior usually late day
  confusional state, associated with behavioral
  changes

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AEIOU TIPS

• A Alcohol
• E - Electrolyte disturbances
• I Infection
• O Overdose
• U Uremia
• T Trauma
• I Insulin (hypoglycemia)
• P Psychomotor disturbance
• S Space occupying lesion (mass, bleed,
  infarcts, etc.)

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Differential Diagnosis - Extensive

• Neurological

• Respiratory

• Ischemic stroke aphasia
• Hypertensive encephalopathy
• Seizures
• Generalized
• Complex partial
• Post-ictal
• Non-convulsive status epilepticus
• Structural
• Intracranial hemorrhage
• Subdural hematoma
• Hydrocephalus
• Cerebral edema
• Head trauma
• Tumors

• Hypoxemia
• Hypercapnia
• Gastrointestinal
• Hepatic encephalopathy
• Obstipation
• Genitourinary
• Urinary obstruction
• Retention
• Renal failure / uremia

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• Infectious

• Fluid Electrolytes

• SIRS
• Sepsis
• Meningitis
• UTI
• Pneumonia
• Anything that can cause fever
• The higher the fever, the more MS?
• Elderly patients may be hypothermic
• Cardiovascular
• Low perfusion state
• MI w/cardiogenic shock
• Heart failure
• Cardiac tamponade
• Arrhythmias

• Dehydration
• Hyponatremia
• Hypernatremia
• Hypoglycemia
• Uremia
• Thyrotoxicosis
• Wernickes encephalopathy (thiamine deficiency)
• Diabetic states
• Ketosis
• Hyperosmolar hyperglycemia
• Miscellaneous
• Sleep deprivation
• Psychiatric

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Drugs, drugs, drugs

• Initiation of Medications

• Withdrawal

• Benzodiazepines
• SSRIs
• Barbiturates
• Psychotropics
• Alcohol
• Seizures (12-48 hrs)
• Alcoholic hallucinosis
• (12-48 hrs)
• Delerium tremens (48-96 hrs)

• Narcotics
• Benzodiazepines
• Steroids
• Sleepers (Ambien)
• Anticholinergics
• Reglan
• Diphenhydramine
• Oxybutynin

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Physical Exam - Clues

• Dusky appearance
• Jaundice
• Needle tracks
• Smell of alcohol or ketones
• Trauma
• Bitten tongue
• Incontinence
• Tachycardia, flushing, sweating and dilated
  pupils (withdrawal from alcohol or sedatives)
• Peritoneal signs
• Asymmetry or localizing signs

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Case Presentations
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Acute Stroke

• Evaluate
• 1-ABCs
• 2-Onset / LKW
• 3-NIHSS
• 4-Inclusion/Exclusion tPA
• 5-CT Head
• 6-Labs CBC, Coags, BMP, cardiac enzymes

• Treat
• Thrombolytics
• Aspiration Precautions
• VTE Prophylaxis
• Early Antithrombotics if no tPA
• Diagnostics
• Customize to patient
• MRI/MRA, carotid ultrasound, echo, Lipids

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NIH Stroke Scale

• 6 motor legs
• 7 limb ataxia
• 8 sensory
• 9 best language
• 10 dysarthria
• 11 extinction / inattention
• Score 0-42
• Severity of stroke
• Prognosis

1a level of consciousness 1b answers
questions accurately 1c follows commands 2
best gaze 3 - visual fields 4 facial palsy 5
motor arms
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Seizure Initial Assessment

• ABCs
• Neurologic exam
• Oxygenation
• Mechanical ventilation
• Cardiac monitor
• Pulse oximetry
• Frequent vital signs
• Protect against injury

• temperature
• Fingerstick glucose
• Electrolytes
• Toxicology
• CBC
• LFTs
• CA Mg
• ABG

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Seizure Management

• 1 STOP the SEIZURE
• Benzodiazepines
• Diazepam onset 10-20 seconds terminates 50-80
  of seizures may only be effective 20 minutes
• Lorazepam longer onset 2 minutes but duration
  4-6 hours
• 2 PREVENT the next SEIZURE
• Phenytoin 15-20 mg/kg infused 50mg/minute
  cardiac brady-arrhythmias, hypotension risk
  cardiac monitoring required prevents recurrence
• Fosphenytoin pro-drug of phenytoin less local
  irritation at infusion site than phenytoin allows
  faster infusion rate (150mg/min) less
  cardiovascular effects still requires cardiac
  monitoring
• Barbiturates (Phenobarbital / Pentobarbital)
  effective but not first-line slow infusion rate
  and prolonged sedation useful in refractory
  seizures

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Seizures Epilepsy in Elderly

• 25 new seizures occur in gt 65 year old patients
• Seizure is a provoked event not expected to recur
  without a trigger (fever, alcohol withdrawal)
• Epilepsy is recurrent unprovoked seizures
  expected to recur without treatment
• Complex Partial most common may appear as
  episodic confusion, sleepiness, clumsiness,
  prolonged postictal state
• Non-convulsive status epilepticus confusion,
  psychosis, lethary or coma

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Seizure/Epilepsy Etiology

• Seizure Etiology
• Acute Stroke - 50
• (gt hemorrhage, size corticol)
• Metabolic up to 30
• - hypo / hyperglycemia
• - hyponatremia lt 120
• - hypocalcemia 7
• - uremia
• - hepatic encephalopathy
• Drugs 10
• - poly-pharmacy
• - impaired clearance
• - benzos, barbs alcohol withdrawal
• Trauma 5-20

• Epilepsy Etiology
• Stroke 30-50
• Cryptogenic 30-50
• Dementia 15
• Other 5-15
• Tumors, Trauma
• Obstructive Sleep Apnea

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Tramadol or Ultracet
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Right way eyes Wrong way eyes

• Right way

• Wrong way

• Gaze preference TOWARD the side of the lesion
  away from the side of the weakness
• STROKE

• Gaze preference AWAY from the side of the lesion
  look toward the side of the weakness
• SEIZURE

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Delirium Management

• Identify causes
• Treat the underlying illness
• Avoid drugs which increase delirium risk
• Familiar faces offer reassurance
• Sitter for safety
• Cautious trial of antipsychotics for severe
  agitation or psychosis with potential for harm
  (haloperidol 0.5 1 mg PO/IM/IV)
• Benzos can worsen confusion / sedation
• Avoid physical restraints