LITERATURE
Spectrum of arousal
- agitation, combative, hyperactive to drowsy, lethargic, stupor, coma
Issues with cognition
- confusion, amnesia, hallucinations, and detachment
Must carefully distinguish between delirium, dementia, and psychosis
- Delirium – acute, fluctuating decline in attention and cognition
- Dementia –chronic cognitive impairment
- Psychosis –loss of contact with reality defined by delusions, hallucinations, catatonia or thought disorganization
Common Causes of AMS – HE STOPS 4 TIPS on VOWELS (AEIOU)
| Hepatic Encephalopathy | Stroke (brainstem) | Temp | Alcohol |
| Endocrine (thyroid, Addison’s) | Trauma | Infection | Electrolytes (Na/K/Ca/glc) |
| O2 | Porphyria | Intoxication (illicits, antichol) | |
| Psych | Shock | Opiates | |
| Seizure | Uremia |
EVALUATION
Detailed History (usually from surrogate)
- What is specifically different about the patient? When did it start? Do you have any suspicions for the cause? What medications does the patient take? Does he/she handle their medications?
Detailed Physical Exam
- Vital Signs
- Thorough neuro exam in addition to full exam. Even consider pulling out the fundoscope.
Studies
- CBC, CMP, accucheck, abg, thyroid function tests, troponin, UDS, BAL, serum osm, U/A, blood cultures, ammonia
- Depending on history consider –anticonvulsant levels, TCA levels, digoxin, theophylline, acetaminophen, salicylate levels
- CXR, CT head non-contrast
- Consider MRI
- EKG assesses MI
- If clinical suspicion is high for such things as meningitis -> LP
If there is ANY concern for increased ICP (papilledema, seizure, hx of metastatic cancer, focal neuro deficits) – CT HEAD PRIOR TO LP to avoid herniation! Always err on the side of imaging.
GCS (Glasgow Coma Scale)
Initially formulated to assess outcomes in patients with head trauma
Sometimes used as a tool to gauge consciousness and research purposes of brain injury but is not validated for metabolic encephalopathy.
| Eye Opening | Spontaneous | 4 |
| To speech | 3 | |
| To pain | 2 | |
| No response | 1 | |
| Verbal Response | Oriented x 3 | 5 |
| Confused/disoriented | 4 | |
| Inappropriate words | 3 | |
| Incomprehensible sounds | 2 | |
| No response | 1 | |
| Best Motor Response | Obeys commands | 6 |
| Moves to localized pain | 5 | |
| Flexion withdrawal to pain | 4 | |
| Abnormal flexion | 3 | |
| Abnormal extension | 2 | |
| No response | 1 | |
| BEST | 15 | |
| COMATOSE | <8 | |
| UNRESPONSIVE | 3 |