Here, we have altered
mental status and coma.
There are so many different
times through a pathology
that you’ve have heard the
term altered mental status.
What the heck does that mean?
Well, before we get into any of that,
these are some of the important questions
that you want to
ask your patient,
or ask yourself when you’re going through
level of consciousness versus cognition.
So, please pay attention.
What do you need to be “awake”?
specifically, the reticular
activating system, the RAS.
What do you need for intact cognition?
You need to be awake and
The first question with awake would then
determine your level of consciousness.
You need your cortices and
you need your brainstem.
If it’s cognition, you
These are two important
questions you ask yourself
to see whether or not you’re on the
side of consciousness or cognition.
Here, we’ll take a look at a particular
scale known as a Glasgow coma scale.
Take a look at the points,
eye opening, verbal and motor.
If the patient is able to obey
commands, points here will be 6.
If the patient is oriented,
localizes the pain,
withdrawing to pain
gives you 4.
and decorticate posturing, which we’ll
talk about in great detail next,
To pain, meaning to say, that’s
when the eye would open,
and here we have de-, not corticate,
but decerebrate posturing.
And I’ll walk you through these
in great detail upcoming.
On a scale of 1 to 6, if it’s 1,
Developed mainly for trauma --
Developed mainly for trauma issues,
but a useful quick way to
convey information as well.
So, the above scale, below 8 has profound
predictive value in multiple situations.
Is that clear?
I’ve given you 6 here.
With the different level of
consciousness and cognition,
as you can imagine, if the
patient’s score is a 6,
there’s quite a bit of
cognition intact, isn’t there?
What does that mean?
Functioning, functioning, functioning.
You think cognition, you
think functioning, clear?
If you’re thinking about being
awake or level of consciousness,
this then gives you a low
scale or low point scale.
And this of course is referring
to whether or not you’re awake,
and take a look at
altered mental status.
The key features of
delirium are the following:
Acute onset, fluctuating course,
altered level of consciousness.
Here, we have inattention or
easily being distractible,
and we have underlying
usually, when we think about a
the key features.
The prevalence, 10%
to 15% of older,
what’s known as medical
patients at admission.
An addition of 5% to 30% develop
delirium in the hospital
And we have up to two-thirds of cases
are unrecognized, or perhaps even,
misdiagnosed with delirium.
your sodium, potassium,
we talked about.
Glucose derangement, metabolically,
hypo- or hyper-glycemia.
You have that ammonia which may
then be shunted into the head
resulting in what’s known as
your hepatic encephalopathy.
Uremia, oftentimes associated with what’s
known as your altered mental status.
hypothyroidism or thyrotoxicosis,
or adrenal insufficiency
such as Addison’s disease.
Metabolic causes of
delirium/altered mental status.
Diffuse causes of delirium/altered
mental status include drugs
such as alcohol, narcotics,
or even from withdrawal
or environmental neurotoxins, including
carbon monoxide and organophosphate.
Think of pesticides and such, please.
Remember this is diffuse,
so therefore, hypoxia.
So, if there is a
diminished oxygen delivery
via pulmonary or
then diffusely, we have a problem and
may result in altered mental status.
Other cause of diffuse.
We’ll talk about meningitis,
systemic type of infections
such as, for example, sepsis taking place
secondary to urinary tract infection.
Nutritional deficiency such as B12.
If your patient is an alcoholic, there is
every possibility of Wernicke-Korsakoff,
Other causes, subarachnoid hemorrhage.
We talked about
usually subacute though,
and something called non-convulsive
status epilepticus or post-ictal state.
All causes of diffuse delirium
or altered mental status.
Long list of differentials, a lot
of these we’ve talked about prior.
It’s a nice little place to kind
of like summarize those issues.
Focal/structural causes of delirium.
So not so much diffuse, focal.
Large lesion causing
edema and mass effect.
For example, stroke,
ischemic or hemorrhagic.
Remember with stroke,
we have approximately
85% of your stroke,
which is then being caused
by ischemic events.
Tumors and abscesses may
result in focal destruction.
Smaller focal lesions in certain areas
may initially present as delirium.
we have aphasic syndromes, occipital
lesions or pontine lesions.
So, what’s the clinical approach that you
want to take with altered mental status?
Always review the history.
treatment targeted to
a specific etiology,
and supportive environmental
changes are extremely important.
For example, if your patient was in a
state of carbon monoxide environment,
or let’s say there was an increase
alcohol consumption, so on and so forth.