ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS...
Transcript of ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS...
![Page 1: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/1.jpg)
ALTERED LEVEL OF CONSCIOUSNESS
Barry Simon M.D.Chairman, Department of Emergency MedicineHighland General HospitalAlameda County Medical CenterOakland California
UCSF Topics in Emergency Medicine - 2006
![Page 2: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/2.jpg)
We will cover…
Terminology & definitionsTerminology & definitionsDeveloping a thorough differentialDeveloping a thorough differentialIdentifying the delirious patientIdentifying the delirious patientA variety of challenging casesA variety of challenging casesFocused H&P highlightsFocused H&P highlightsKey lab and imaging studiesKey lab and imaging studiesAvoiding errorsAvoiding errors
![Page 3: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/3.jpg)
Scope / Spectrum2002 data from a University 2002 data from a University
HospitalHospital
ALOC pts - 5% of the ED volume
64% got admitted
28% neuologic 21% toxicologic14% trauma 14% psychiatric10% infectious 5% endocrine / metabolic3% pulmonary 3% oncologic
![Page 4: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/4.jpg)
Altered Mental Status
Approach
Functional (psychogenic)•
Organic•
Toxic / metabolic (diffuse disease), infectious•
Structural (focal disease)•
Dementia•
{Delirium
![Page 5: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/5.jpg)
Bottom Line
Psychiatric / functional Psychiatric / functional Pt gets labeled /Pt gets labeled / treatable but not reversibletreatable but not reversible
Delirium Delirium 80% reversible and up to 15% mortality80% reversible and up to 15% mortality
Dementia Dementia 20% reversible20% reversible
![Page 6: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/6.jpg)
Delirium
Organic DiseaseAcute onset with a wildly fluctuating course.•
Difficulty focusing, easily distracted.•
Disorganized thinking, rambling, hard to
follow.
•
Altered level of consciousness.•
Visual hallucinations are common.•
Abnormal vital signs.•
![Page 7: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/7.jpg)
Dementia
Organic Disease
Insidious, gradual onset.•
Normal alertness and attentiveness.•
Disorientation is the baseline.•
No hallucinations.•
Vital signs - normal.•
![Page 8: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/8.jpg)
Acute Psychosis
Functional Disease
Abrupt onset with a stable course.•
Normal level of consciousness.•
Auditory hallucinations.•
Orientation usually normal.•
Vital signs may be elevated.•
![Page 9: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/9.jpg)
Let’s Review
Wildly fluctuating Wildly fluctuating coursecourseAuditory Auditory hallucinationshallucinationsDisorientedDisoriented
Normal LOCNormal LOC
Abnormal Vital SignsAbnormal Vital Signs
Delirium
Psychosis
Delirium
Psychosis
Both
![Page 10: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/10.jpg)
Levels of Consciousness Nomenclature - terminology
Traditional Descriptive (AVPU)•
Alert Awake and Aware•
Lethargy Responds to verbal stim•
Stupor Responds to painful stim•
Coma Unresponsive •
![Page 11: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/11.jpg)
The Naked Man
History
32 year old male was found running nude in a field
near a school. He was well known to the police and
the medical community as an alcohol and speed
abuser. While being booked by the police he fell off a
bench, hit his head and became unconscious. No
other acute history was available.
•
![Page 12: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/12.jpg)
ALOC - Naked ManPhysical
BP 70/ p HR 200 RR 16 T 41.6 C (106.9 F)•
Comatose - unresponsive to painful stimuli•
HEENT - small contusion on his forehead. Pupils
were 4 mm and sluggishly reactive to light. He had a
decreased gag reflex, and equivocal plantar reflexes
bilaterally. The rest of his exam was WNL.
•
![Page 13: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/13.jpg)
ALOC - Naked ManFollow up
Despite aggressive resuscitative efforts the patient
expired several hours later. All ED studies were
unhelpful in making a diagnosis.
•
The differential was broad (toxins, hypothalamic
dysfunction, such as tumors, bleeds, CNS infections).
•
A thorough head-to-toe exam would have
keyed-in the examiner to the diagnosis.
•
*
![Page 14: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/14.jpg)
ALOC - Naked Man
Postmortem diagnosis:
Thyrotoxicosis•
![Page 15: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/15.jpg)
DDX - Altered ConsciousnessAEIOU TIPS
A. Alcohols T. Trauma, Tox, temp, Thyroid
E. Endocrine, ‘lytes’ I. Infections
I. Insulin (diabetes) P. Psychiatric
O. Oxygen, Opiates S. SAH, Seizures
U. Uremia
, ASA
![Page 16: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/16.jpg)
Start from the head and work down
DDX - Altered Consciousness
Central nervous system•
Bleeds (traum a and nontraum a)•
In farcts•
In fect ions•
Seizures•
Conversion react ion / psych•
![Page 17: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/17.jpg)
DDX - Altered ConsciousnessMouth: Toxins / Meds
Alcohols OpiatesAnticholinergics PhenothiazinesAnticonvulsants SalicylatesBarbiturates Sedative HypnoticsCarbon Monoxide SSRI’sCyanide SympathomimeticsHallucinogens Tricyclic antidepressantsHeavy Metals
![Page 18: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/18.jpg)
Cocaine delirium and sudden death.•
Gamma hydroxybutyrate (GHB) = (GBH) •
Grievous bodily harm.•
An anesthetic with euphoric and sexual
enhancement properties.
Short acting benzodiazepines - Rohypnol •
(Roofies, Ruffies, Love Drug)•
Special Case Toxins
![Page 19: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/19.jpg)
DDX - Altered Consciousness
Neck and ChestNeck•
Thyroid & parathyroid disease•
Chest•
Hypoxia•
Hypercarbia•
Emboli•
![Page 20: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/20.jpg)
DDX - Altered Consciousness
Abdomen Liver•
Hepat ic encephalopathy•
Wern icke’s syndrom e•
• Pancreatic disease• Adrenal insufficiency• Renal disease: electrolyte and metabolic
disorders
![Page 21: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/21.jpg)
Heat Stroke Heat Stroke –– think of while getting rectal tempthink of while getting rectal tempHypothermia Hypothermia –– rectal temprectal tempSepsisSepsisVasculitisVasculitis –– may consider as part of renal may consider as part of renal causescausesHyperviscosityHyperviscosity –– ALOC as it affects the CNSALOC as it affects the CNS
DDX - Altered Consciousness
Skin – Other??
![Page 22: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/22.jpg)
To Tube or not to Tube
History
14 year old girl found down near a bus stop near her
school.
•
No one came with the girl to the hospital, so initially,
there was no other history available.
•
![Page 23: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/23.jpg)
ALOC - Tube?
Physical exam
Gurgling respirations.•
BP - 98/ 74 HR - 110 RR - 10 Pulse ox 89% RA.•
HEENT - PERRL 3 mm sluggish - disconjugate gaze
++AOB.
•
Neck, chest, abdomen, extremities - all WNL.•
![Page 24: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/24.jpg)
ALOC - Tube?Physical exam - continued
Neurologic•
Comatose - responds appropriately to deep
painful stimuli
•
Poor gag reflex, moves all 4 extremities equally to
painful stimuli
•
DTR’s 1-2+ equal•
Plantar reflexes equivocal•
![Page 25: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/25.jpg)
ALOC - Tube?Medical decison making (for coding purposes only)
Possibly all secondary to alcohol ingestion in a young
girl, but airway control was needed. The glucose was
119 mg / dl. No response to 2 mg of narcan.
•
Prior to CT she would need RSI.......however•
*
![Page 26: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/26.jpg)
ALOC - Tube?
Outcome
She woke up after 3 doses of 0.2 mg (total of 0.6mg)
of flumazenil to the point of spontaneously talking
(although she was dysarthric). Her blood alcohol was
190mg / dl.
•
![Page 27: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/27.jpg)
FLUMAZENIL
Benzodiazepine competitive antagonistDose 0.2 - 2.5 mg •
Duration 40-60 min•
Controversial in:•
Mixed ingestions•
Chronic benzodiazepine users•
Patients with seizure disorders•
![Page 28: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/28.jpg)
Altered Mental Status
History SourcesPatientPatient Pill bottlesPill bottles
MedicsMedics Hospital & Psych Hospital & Psych recordsrecords
RelativesRelatives FriendsFriends
Medic alert tagMedic alert tag Personal physicianPersonal physician
WalletWallet PocketsPockets
![Page 29: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/29.jpg)
Altered Mental Status
Physical exam
Respiratory rate and pattern•
Heart rate and rhythm•
Blood pressure•
Rectal temperature•
-Vital Signs
![Page 30: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/30.jpg)
Altered Mental Status
Physical Exam - General
Head - signs of trauma•
Breath odor - alcohol, fruity, almond, garlic, onion, +•
Neck - thyroid, scar, meningismus•
![Page 31: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/31.jpg)
Altered Mental Status
Physical Exam - General
Chest - breath sounds, murmurs, rhythm•
Abdomen - organomegaly, ascites, peritonitis•
Skin - jaundice, petechiae, moisture, temperature,
color, needle tracks, spider angiomatas
•
![Page 32: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/32.jpg)
Altered Mental StatusNeurologic exam
General observations•
Autism s•
Yawning•
Hiccups•
Swallowing•
Respiratory patterns•
Posturing•
![Page 33: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/33.jpg)
Spontaneous movementsSpontaneous movementsPurposeful movementsPurposeful movementsResponse to painful stimuliResponse to painful stimuliToneTone
Altered Level of Consciousness
Motor Exam
![Page 34: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/34.jpg)
Neurologic Exam
Eyes•
Ears•
M en tal Status Exam•
Keys
![Page 35: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/35.jpg)
Altered level of consciousnessThe eye exam
Pupils•
Funduscopic exam•
Eye movements•
Eyelids•
![Page 36: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/36.jpg)
Caloric Testing
Cold Water < 30 0 C
Normal - deviation away with nystagmus
Cerebral dysfunction - tonic deviation to one side
Brainstem dysfunction - no response
![Page 37: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/37.jpg)
• Mini-mental status exam
• Confusion assessment method (CAM)
Altered Mental Status
![Page 38: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/38.jpg)
Confusion Assessment Method
To diagnose delirium:
1) Acute onset with fluctuating course•
2) Inattention - difficulty focusing •
and
1) Disorganized thinking
or
•
2) Altered level of consciousness•
![Page 39: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/39.jpg)
Diagnosis in < ten minutes
Bedside studies
History and physical•
Glucometer / dextrostick - dextrose•
Pulse oximetry •
ABG’s - Hypoxia / Hypercarbia / acidosis •. Istat
![Page 40: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/40.jpg)
Rapid diagnostic studies
Bedside studies - interventions
Urinalysis•
Infection, hyperglycemia, dehydration•
Breathalyzer•
Electrocardiogram / rhythm strip•
Narcan, thiamine•
Flumazenil, physostigmine•
![Page 41: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/41.jpg)
Physostigmine
Reversible inhibitor of acetylcholinesterase•
Used to RX, or DX severe anticholinergic syndrome•
Useful in GHB ingestion?•
DO NOT use in tricyclic overdoses•
Dose - 0.5 mg slow IVP up to a total of 2 mg•
Keep atropine nearby•
![Page 42: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/42.jpg)
Altered Level of Consciousness
Additional studies to consider
‘Lytes, BUN, Cr, osmolality, calcium•
Complete blood count•
Carboxyhemoglobin •
Lumbar puncture•
![Page 43: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/43.jpg)
Altered Level of Consciousness
Directed drug screen •
Thyroid function tests•
Head CT scan •
Peritoneal tap•
...and more studies to consider
![Page 44: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/44.jpg)
Osmolar Man
HistoryAn 18 year old male calls 911 for a severe headache.
Upon arrival he refuses to let the medics in his home
and they leave. Thirty minutes later his mother calls
911 and the medics arrive to find a comatose male.
His mother explains that he is diabetic and frequently
forgets to take his insulin. The medics transport and
administer 25 gms of dextrose en route.
•
![Page 45: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/45.jpg)
ALOC - Osmolar Man
Physical
BP 170/ 70 HR 92 RR 14•
Comatose male who appears otherwise healthy. Skin
is moist, pupils are PERRL at 6 mm, neurologic exam
is non-focal except for bilateral upgoing toes. The
general exam is otherwise normal.
•
![Page 46: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/46.jpg)
ALOC - Osmolar man
Blood glucose on his pre-hospital dextrose
blood was 19 mg/dl. A second bolus of
dextrose did not change his mental status.
•
Early labs
Do we ever really need a second amp of glucose?•
![Page 47: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/47.jpg)
ALOC - Osmolar Man
Follow-up
Repeat exam noted an unmeasurable amount of
anisocoria unnoticed before. CT scan found a large
subdural with midline shift; the patient was taken to
the OR and did well.
•
*
![Page 48: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/48.jpg)
A 28 year old man was brought unconscious to the
emergency department. Fifteen minutes earlier, with
slurred speech, he had instructed a taxi driver to take
him to the hospital. He passed out before arriving at
the hospital.
•
A ‘Taxi ing’ Case
History
![Page 49: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/49.jpg)
ALOC - Taxi manPhysical
BP 130/ 90 HR 100 RR 40•
Most of the physical exam was within normal limits.
On neurologic exam: Pupils were PERRL at 3 mm,
DTR’s were 3+ and equal, plantar reflexes were both
extensor and he had intermittent bilateral
decerebrate posturing.
•
*
![Page 50: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/50.jpg)
ALOC - Taxi man
Follow up
Hypoglycemia commonly presents with focal
neurologic findings that can mimic structural lesions.
It is obviously important not to skip the basics. This
patient’s blood glucose was 20 mg/ dl and he awoke
after receiving 25 grams of dextrose.
•
![Page 51: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/51.jpg)
Mid Term Review
Odor of breath Odor of breath ––arsenicarsenicAbsent pupil Absent pupil response to lightresponse to lightAverage inc. in BS Average inc. in BS after 1 amp D50after 1 amp D50Flumazenil is avoided Flumazenil is avoided in which patients?in which patients?
GarlicGarlic
Structural defect
130 mg/dl
Mixed ingestions
![Page 52: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/52.jpg)
ALOC - SUMMARY
Take back to the ER points
Assume the patient is delirious•
DDX - start from the head and work your
way down
•
Think like a detective•
The eyes, ears, and mental status are keys•
● Don’t be afraid of flumazenil or physostigmine
![Page 53: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/53.jpg)
Common Errors
Failure to consider the basics (glucose, oxygen,
thiamine)
•
Treatment delay during the evaluation•
Failure to re-examine at frequent intervals•
Incomplete differential ddx
![Page 54: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/54.jpg)
![Page 55: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/55.jpg)
Not So - Funny Man?
History
911 called for a pt. exhibiting bizarre behavior. No
similar past history. Friends stated he had been
acting funny, agitated, and not sleeping for several
days. No hx of drug use but the family had
suspicions. No other significant past or present
history.
•
![Page 56: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/56.jpg)
Not So - Funny Man?Physical examHyper-alert and agitated. Talking very fast but not
making much sense.
•
BP 160/ 110 HR 124 RR 18 T 101 F•
HEENT - PERRL 5 mm Mucous membranes - moist •
No distinctive breath odor•
Skin - warm and dry•
Rest of the exam was WNL•
![Page 57: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/57.jpg)
Not So - Funny Man?Confusion assessment exam
++ Acute onset with a fluctuating course.•
++Inattentive - could not focus on the questions.•
+Disorganized thinking - speech / subject was hard
to follow.
•
+- ALOC - hyperalert.•
![Page 58: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/58.jpg)
Not So - Funny Man?
ED differential and course
Tox, CNS infection, thyroid disease.•
Blood glucose was 97 mg/dl. •
Tox was positive for amphetamine.•
To tap or not to tap?•
![Page 59: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/59.jpg)
Sleeping Beauty
History
A 20 year old woman is found unconscious in her
room two hours after a fight with her parents. She
was well prior to the incident. She has a history of
‘emotional’ problems and occasional migraine
headaches. Medications include Tylenol and
Vicodin for her headaches
•
![Page 60: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/60.jpg)
ALOC - Sleeping BeautyPhysical
BP 108/ 64 HR 68 RR 12•
The general PE was within normal limits. When left
alone she appeared to be sleeping. Pupils were
PERRL at 3mm. There was no response to painful
stimuli but there was some resistance to passive
elevation of her eyelids. Cold calorics elicited tonic
deviation of the eyes with no nystagmus.
•
![Page 61: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/61.jpg)
ALOC - Sleeping BeautyFollow up
The history and physical suggested light coma or
simulated coma. However, caloric testing indicated
organic cerebral dysfunction. The patient remained
stable and gradually awakened over 48 hours. She
admitted to ingesting a handful of phenobarbital.
•
![Page 62: ALTERED LEVEL OF CONSCIOUSNESS - Continuing … · 2006-12-07 · ALTERED LEVEL OF CONSCIOUSNESS Barry Simon M.D. Chairman, Department of Emergency Medicine Highland General Hospital](https://reader031.fdocuments.us/reader031/viewer/2022020114/5b89f5e27f8b9aa81a8d873f/html5/thumbnails/62.jpg)
Pathophysiology of Coma
Structural causesBilateral cortical disease.•
Suppression of the Reticular Activating System.•
Supratentorial lesions•
Infratentorial lesions•
Intrinsic brainstem lesions•
Brainstem torque•