Altered Mental Status and Coma: Introduction

by Carlo Raj, MD

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    00:01 Here, we have altered mental status and coma.

    00:04 There are so many different times through a pathology that you’ve have heard the term altered mental status.

    00:10 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.

    00:27 What do you need to be “awake”? Bilateral cortices.

    00:33 The brainstem, specifically, the reticular activating system, the RAS.

    00:41 What do you need for intact cognition? You need to be awake and functional networks.

    00:49 The first question with awake would then determine your level of consciousness.

    00:54 You need your cortices and you need your brainstem.

    00:56 If it’s cognition, you need functioning.

    00:59 These are two important questions you ask yourself to see whether or not you’re on the side of consciousness or cognition.

    01:08 Here, we’ll take a look at a particular scale known as a Glasgow coma scale.

    01:14 Take a look at the points, eye opening, verbal and motor.

    01:19 If the patient is able to obey commands, points here will be 6.

    01:23 If the patient is oriented, localizes the pain, 5.

    01:30 Spontaneous, confused, withdrawing to pain gives you 4.

    01:37 To speech, inappropriate verbal, and decorticate posturing, which we’ll talk about in great detail next, is 3.

    01:47 To pain, meaning to say, that’s when the eye would open, verbal absolutely incomprehensible, and here we have de-, not corticate, but decerebrate posturing.

    02:01 And I’ll walk you through these in great detail upcoming.

    02:04 On a scale of 1 to 6, if it’s 1, nothing.

    02:10 Developed mainly for trauma -- Developed mainly for trauma issues, but a useful quick way to convey information as well.

    02:18 So, the above scale, below 8 has profound predictive value in multiple situations.

    02:24 Is that clear? I’ve given you 6 here.

    02:29 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.

    02:41 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.

    02:55 And this of course is referring to whether or not you’re awake, and take a look at number 1, nothing.

    03:03 Delirium, encephalopathy, altered mental status.

    03:06 The key features of delirium are the following: Acute onset, fluctuating course, disorganized thinking, altered level of consciousness.

    03:16 Here, we have inattention or easily being distractible, and we have underlying medical cause, usually, when we think about a delirium; the key features.

    03:28 The prevalence, 10% to 15% of older, what’s known as medical patients at admission.

    03:35 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.

    03:50 Metabolic: Electrolyte abnormalities, your sodium, potassium, magnesium, especially we talked about.

    03:57 Glucose derangement, metabolically, hypo- or hyper-glycemia.

    04:01 Hepatic failure: You have that ammonia which may then be shunted into the head resulting in what’s known as your hepatic encephalopathy.

    04:12 Uremia.

    04:13 Uremia, oftentimes associated with what’s known as your altered mental status.

    04:19 Thyroid dysfunction, hypothyroidism or thyrotoxicosis, or adrenal insufficiency such as Addison’s disease.

    04:27 Metabolic causes of delirium/altered mental status.

    04:32 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.

    04:46 Think of pesticides and such, please.

    04:50 Remember this is diffuse, so therefore, hypoxia.

    04:52 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.

    05:05 Other cause of diffuse.

    05:07 We’ll talk about meningitis, infectious, encephalitis, systemic type of infections such as, for example, sepsis taking place secondary to urinary tract infection.

    05:17 Nutritional deficiency such as B12.

    05:20 If your patient is an alcoholic, there is every possibility of Wernicke-Korsakoff, thiamine deficiency.

    05:27 Other causes, subarachnoid hemorrhage.

    05:29 We talked about carcinomatous meningitis, usually subacute though, and something called non-convulsive status epilepticus or post-ictal state.

    05:42 All causes of diffuse delirium or altered mental status.

    05:46 Long list of differentials, a lot of these we’ve talked about prior.

    05:49 It’s a nice little place to kind of like summarize those issues.

    05:55 Focal/structural causes of delirium.

    05:57 So not so much diffuse, focal.

    05:59 Large lesion causing edema and mass effect.

    06:02 For example, stroke, ischemic or hemorrhagic.

    06:05 Remember with stroke, we have approximately 85% of your stroke, which is then being caused by ischemic events.

    06:14 Tumors and abscesses may result in focal destruction.

    06:19 Smaller focal lesions in certain areas may initially present as delirium.

    06:24 For example, we have aphasic syndromes, occipital lesions or pontine lesions.

    06:31 So, what’s the clinical approach that you want to take with altered mental status? Always review the history.

    06:36 Review meds, lab screen, imaging, EEG, treatment targeted to a specific etiology, and supportive environmental changes are extremely important.

    06:46 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.

    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 function.
    2. Wakefulness and brainstem.
    3. Cerebral cortex.
    4. Brainstem.
    5. Sleep and functionality.
    1. Withdrawal to pain, localizing pain and obeying commands.
    2. Obeying commands, localizing pain and withdrawal to pain.
    3. Localizing pain, withdrawal to pain and obeying commands.
    4. Decorticate posturing.
    5. Decerebrate posturing.
    1. Electrolyte imbalance.
    2. Uremia.
    3. Hepatic encephalopathy.
    4. Adrenal insufficiency.
    5. Hyperthyroidism.
    1. Carbon monoxide poisoning.
    2. Alcohol intoxication.
    3. Organophosphate poisoning.
    4. COPD.
    5. Carbondioxide 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. Drug toxicology.
    5. EEG.

    Author of lecture Altered Mental Status and Coma: Introduction

     Carlo Raj, MD

    Carlo Raj, MD

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