Altered Mental Status and Coma: Introduction

by Carlo Raj, MD

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    00:01 Here, we have altered mental status and coma. There are so many different times through a pathology that you’ve 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.

    00:24 So, please pay attention. What do you need to be “awake”? Bilateral cortices. The brainstem, specifically, the reticular activating system, the RAS. What do you need for intact cognition? You need to be awake and functional networks. 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 need functioning. These are two important questions you ask yourself to see whether or not you’re on the side of consciousness or cognition. Now, we will look at a particular scale known as the Glasgow coma scale. This scale is divided in three categories. Eye opening response, verbal response and motor response. If you add the points of each category, you get a score. The maximum score is 15 and the minimum is 3. Let' look at the three different categories in more detail. If the patient is opening their eyes spontaneously,they get 4 points. If they open the eyes to speech, 3 points.

    01:38 If they open the eyes only after you apply a painful stimulus, 2 points. And if they don't open the eyes, 1 point.

    01:45 When you evaluate the verbal response, now the maximum score is 5 when the patient is oriented to time, place and person. If the patient is confused, they get 4 points. If they use inappropriate words, 3 points. If they make incomprehensible sounds, 2 points. And if there is no response, 1 point.

    02:05 In the evaluation of motor response, the maximum score is 6 when the patient obeys commands.

    02:11 When they move to localized pain, they get 5 points. When they exhibit flexion withdrawal from pain, 4 points. For abnormal flexion, 3 points. For abnormal extension, 2 points. And for no response, 1 point.

    02:26 So, as you can understand, if the patient has no eye opening, no verbal or motor response, the score is 3.

    02:33 It can never get below 3. Glasgow coma scale was developed mainly for trauma issues. But it can be used as a tool to evaluate consciousness in other circumstances as well. The score above or below 8 has profound predictive value in multiple situations.

    02:52 Delirium, encephalopathy, altered mental status. The key features of delirium are the following.

    02:58 Acute onset, fluctuating course, disorganized thinking, altered level of consciousness.

    03:06 Here, we have inattention or easily being distractible, and we have underlying medical cause, usually, when we think about a delirium. The key features.

    03:18 The prevalence, 10% to 15% of older, what’s known as medical patients at admission.

    03:25 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.

    03:39 Metabolic. Electrolyte abnormalities, your sodium, potassium, magnesium, especially what we talked about.

    03:47 Glucose derangement, metabolically. Hypo or hyperglycemia. Hepatic failure. You have that ammonia which may then be shunted into the head resulting in what’s known as your hepatic encephalopathy.

    04:02 Uremia. Uremia, often times associated with what’s known as your altered mental status.

    04:08 Thyroid dysfunction, hypothyroidism or thyrotoxicosis, or adrenal insufficiency such as Addison’s disease.

    04:17 Metabolic causes of delirium/altered mental status.

    04:22 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.

    04:36 Think of pesticides and such, please. Remember this is diffuse, so therefore, hypoxia.

    04:42 So, if there is a diminished oxygen delivery via pulmonary or cardiovascular system, then diffusely, we have a problem and may result in altered mental status.

    04:54 Other cause of diffuse. We’ll talk about meningitis, infectious, encephalitis. 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, thiamine deficiency. Other causes, subarachnoid hemorrhage. We talked about carcinomatous meningitis, usually subacute though, and something called non-convulsive status epilepticus or post-ictal state.

    05:31 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.

    05:44 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.

    06:04 Tumors and abscesses may result in focal destruction. Smaller focal lesions in certain areas may initially present as delirium. For example, we have aphasic syndromes, occipital lesions or pontine lesions.

    06:21 So, what’s the clinical approach that you want to take with altered mental status? Always review the history. Review meds, lab screen, imaging, EEG, 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 increased alcohol consumption, so on and so forth.

    About the Lecture

    The lecture Altered Mental Status and Coma: Introduction by Carlo Raj, MD is from the course Altered Mental Status and Coma. It contains the following chapters:

    • Altered Mental Status and Coma
    • Delirium, Encephalopathy, Altered Mental Status

    Included Quiz Questions

    1. Bilateral cortices, reticular activating system, and functional networks
    2. Unilateral cortex, reticular activating system, and functional networks
    3. Bilateral cortices and functional networks
    4. Reticular activating system and functional networks
    5. Bilateral cortices and reticular activating system
    1. Electrolyte imbalance
    2. Uremia
    3. Hepatic encephalopathy
    4. Adrenal insufficiency
    5. Hyperthyroidism
    1. Carbon monoxide poisoning
    2. Methanol poisoning
    3. Organophosphate poisoning
    4. COPD
    5. Carbon dioxide poisoning
    1. Thiamine deficiency
    2. Pneumonia
    3. Urinary tract infection
    4. Viral meningitis
    5. Subarachnoid hemorrhage
    1. Laboratory screen
    2. CT scan brain
    3. MRI brain
    4. Oxygen therapy
    5. EEG

    Author of lecture Altered Mental Status and Coma: Introduction

     Carlo Raj, MD

    Carlo Raj, MD

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