Hi. We’re gonna be talking about the approach to altered mental status
and specifically, we’re gonna be talking about how to approach altered mental status
in the Emergency Department.
We’re gonna start out by talking about some definitions here.
So altered mental status means that a patient is presenting confused.
They have acute alteration in their higher cerebral function
and what that means is that
they are gonna have problems with their memory,
they’re gonna have problems with their attention,
and they’re potentially gonna have problems with their awareness.
So they may not be able to fully cooperate or engage in an exam
or in the history process with you.
It’s important to note that this is an acute change.
So it’s something that’s different than what happened before
and it’s important to distinguish this from dementia.
So dementia is when someone has altered mental status
that progresses over a longer period of time.
Altered mental status is something that happens acutely.
So it’s something that happens days or hours
before the patient comes into the Emergency Department,
not something that happens over weeks to months.
It’s important to note that this is a symptom.
It’s not actually a diagnosis.
So what that means is
this is something that someone’s gonna be coming in complaining of
and our job in the Emergency Department is to look back
and try and figure out what is causing this altered mental status.
Delirium is another definition here
and what delirium means is it means that a patient
has waxing and waning altered mental status.
It’s important to think about delirium in the sense
that sometimes when you see someone who comes in,
they may be acting normal or reasonably normal when you see them.
In these patients, it’s very important to get a history
or some information from a family member,
or from someone who might know them a little bit better
or can tell what’s been going on.
Because even though someone appears to be normal in the Emergency Department,
it might be that they’ve had confusing episodes
or have had concerning symptoms over the last hours to days,
and it’s very important that you try and get that information.
When we’re approaching altered mental status,
there’s a very broad differential.
There’s lots of different things that could be causing it.
Dyspnea or shortness of breath is one of them
and dyspnea generally causes it by hypoxia.
So your oxygen levels get very low
and that can cause altered mental status,
or if you are unable to ventilate appropriately
and you have elevation in your carbon dioxide levels,
that’s another thing that can cause altered mental status.
So it’s very important that you get a history from the patient
or from their medical record to see if they have a history of lung disease.
Head trauma is something else that can make patients be altered
and it can make people be altered in various ways.
So it can make them be altered because they have a concussion.
It can make them be altered because they have bleeding in their brain.
So there is various ways that a blow to a head or a head strike
could make people be altered.
Head trauma can happen if someone was in a car accident,
if someone was hit by a car on a bicycle.
Lots of different mechanisms for head trauma.
Fever is another thing that can cause altered mental status.
It’s very important when we’re thinking about fever
that we think about the most accurate way to measure temperatures.
So oftentimes, temperature is measured orally by putting a thermometer
in someone’s mouth and sometimes,
the temperature is measured with a forehead thermometer
or with a thermometer in the ear.
The most accurate temperature reading you can get though is a rectal temperature.
So if you’re worried that your patient has a fever that’s not being detected
using the other methods of taking a temperature,
you may need to go ahead and go that extra step
and take a rectal temperature for that patient.
Electrolyte abnormalities also included in the differential here.
The most common electrolyte abnormalities
that can cause patients to be altered are a low sodium level,
you can get low sodium levels by a variety of mechanisms,
so by drinking too much free water,
drinking too much water basically from the tap.
Sometimes drinking too much beer can actually cause a low sodium level.
Other electrolytes that can cause altered mental status
would be elevated potassium level
and then also, an elevated sodium level as well can make patients be altered.
And then infectious symptoms is something else that can cause altered mental status.
So patients who have meningitis which is an infection around the brain,
patients who have pneumonia,
patients who have a urinary tract infection,
especially in elderly women if they have a urinary tract infection,
sometimes the only symptom they may present with is actually altered mental status.
So very important to make sure that you’re thinking about infection as a cause here
when patients present with confusion.
Also alterations in glucose levels
such as hypoglycemia
or low blood glucose can be a likely cause
of altered mental status.