Altered Mental Status (AMS): First steps

by Sharon Bord, MD

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    00:01 What are the first things that we wanna do when patients present with confusion to the Emergency Department? The first and primary thing you wanna do is you wanna make sure that you check a blood sugar because hypoglycemia or low blood sugar is a classic thing that can cause altered mental status.

    00:17 We wanna make sure that we think about this every single time, because if we’re not thinking about it, then we won’t think to check it.

    00:23 The other thing you can do is you can administer D50.

    00:27 D50 is a concentrated glucose solution and if you’re not able to check a blood sugar quickly, you can go ahead and give that D50.

    00:34 You also wanna consider giving thiamine prior to giving glucose administration and mainly, you wanna do that in patients who you’re concerned that they may be malnourished.

    00:43 So a patient who is a chronic alcoholic or a patient who doesn’t have regular access to food.

    00:48 Because if you give glucose prior to giving thiamine, you can precipitate Wernicke's encephalopathy and cause further problems for the patient down the line.

    00:57 Naloxone is the other medication you wanna consider giving when patients present with altered mental status.

    01:03 What naloxone does is it reverses opioid intoxication.

    01:07 So you wanna think about giving this to patient in whom you’re concerned that they used opioid medications and that is what led to their altered mental status.

    01:14 Opioid medications can be used via injection drug use.

    01:19 So heroin is the classic thing that we think about.

    01:21 But there’s also a lot of oral opioid medications that are prescribed.

    01:25 Oxycodone, Dilaudid, are two common medications that patients may be prescribed as outpatients.

    01:31 So it’s important that we know not to limit this just to patients who are injecting drugs.

    01:35 Patients who have overdosed on opioids, the classic thing that they’ll present with is pinpoint pupils and/or a respiratory depression.

    01:43 So their respiratory rate will be very low, down to about ten.

    01:47 In Baltimore, where I come from and where I practice Emergency Medicine, opioid overdose is very common.

    01:54 So this is a medication that we frequently give when patients present with altered mental status but definitely, you wanna think about giving this if at all you’re concerned about it.

    02:02 It will rapidly reverse the opioid intoxication and your patient will generally wake up pretty rapidly thereafter.

    02:18 The last thing that you wanna think about doing is applying oxygen to your patient.

    02:22 So if your patient is hypoxic, you definitely wanna go ahead and put them either on nasal cannula oxygen, or a face mask.

    02:29 And if you’re worried that a patient is having ventilation issues, if you’re worried that their carbon dioxide level is very elevated, and that may be based on a history of obstructive lung disease, then you wanna think about starting your patient on BiPAP.

    02:42 And BiPAP stands for Bilevel Positive Airway Pressure and what that does is it helps the patient with both oxygenation as well as ventilation, and it helps them exhale that carbon dioxide.

    02:58 So what is a good clinical pearl here for you to take home? It’s important to remember that hypoglycemia is a common thing that people can present with and it’s rapidly reversible, especially in your patients who are diabetic, who are on insulin, you definitely wanna be thinking about low blood sugar.

    03:15 You always wanna check a finger stick on patients who have altered mental status.

    03:20 I’ve been fooled before and thought that hypoglycemia wasn’t the cause and I’ve admitted someone actually to the medicine floor without checking a blood sugar.

    03:27 And you definitely wanna make sure that you do this before you go ahead and think about other causes of altered mental status.

    03:34 If you’re unable to check a finger stick for whatever reason, your glucose monitor isn’t working, you don’t have a nurse available to get it for you, but you have rapid access to D50, go ahead and administer that medication.

    03:47 If your patient doesn’t have an IV, if they have very challenging IV access, again, if you don’t have anyone available to get that but you do have access to a medication called glucagon, you can go ahead and give that instead.

    04:01 Glucagon is a medication that’s administered intramuscularly but it can take a little bit more time to work and you also wanna think about the use of glucagon in a malnourished patient.

    04:13 Because essentially, what glucagon does is it goes and it acts on the liver and it causes release of the glucose from the liver.

    04:21 So in order for glucagon to work, your patient needs to go have adequate stores of glucose in their liver.

    04:27 Now, if a patient doesn’t have adequate stores of glucose in their liver, glucagon really might not be as effective.

    About the Lecture

    The lecture Altered Mental Status (AMS): First steps by Sharon Bord, MD is from the course Neurologic and Psychiatric Emergencies.

    Included Quiz Questions

    1. Check blood sugar levels
    2. Check for urine drug screen
    3. Admit in the ICU and start normal saline
    4. Check for serum magnesium levels
    5. Perform CT scan to rule out brain tumors
    1. To avoid precipitation of Wernicke’s encephalopathy
    2. To elevate blood glucose levels
    3. For its anti-oxidant effects on cells in the CNS
    4. To correct any underlying electrolyte abnormalities
    5. It is a required coenzyme of glycogen phosphorylase.
    1. Respiratory depression
    2. Dilated pupils
    3. Hyperkalemia
    4. Excessive lacrimation
    5. Tachyarrhythmias
    1. Malnourished patients
    2. Hypothyroidism
    3. Hyperparathyroidism
    4. Hypocalcemia
    5. Hyponatremia

    Author of lecture Altered Mental Status (AMS): First steps

     Sharon Bord, MD

    Sharon Bord, MD

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