Altered Mental Status

Trauma

• Concussion: If no loss of consciousness, decreased responsiveness, repetitive vomiting, seizure, and/or focal neurologic deficits →

  • Do not obtain MRI

  • Initiate 6-day graded return to play: Regular activities (school) → light aerobic activity → moderate activity → heavy, non-contact → practice with full contact → competition

• Epidural hematoma

  • Adolescent s/p head trauma and a lucid interval presenting with acute onset altered consciousness, headache, vomiting, aphasia, seizures, unilateral weakness

  • Head CT shows lens-shaped collection of epidural blood

  • Consult surgery and do not administer glucocorticoids

  • Mortality 5 to 10 percent

• Glasgow Coma Scale < 8: Intubate

Focal Neurologic Deficit and/or Convulsions

• Seizure

  • Psychogenic non-epileptic seizure

  • Febrile seizure

  • Focal onset seizure

  • Generalized onset seizure

  • Status epilepticus

• Stroke

  • TIA

  • Ischemic stroke

  • Hemorrhagic stroke

• Hemiplegic (complex) migraine

Syncope (Transient Cerebral Hypoperfusion)

Differential Diagnosis

• Neurally mediated (45%): Increased parasympathetic/vagal tone → bradycardia and hypotension

  • Vasovagal: Warm/crowded space, prolonged standing, emotion/fear/pain, nausea, transient diaphoresis

  • Situational: S/p coughing, voiding after a meal

  • Consider seizure (eyes open) and psychogenic syncope (eyes closed)

• Cardiac (20%)

  • Arrhythmia (most common): Elderly patient with h/o atrial fibrillation/flutter and family h/o sudden/unexplained death presents with palpitations, abnormal EKG. Treatment per arrhythmia identified.

  • Structural cardiac abnormality/cardiomyopathy: Elderly, h/o valvular or infiltrative (sarcoidosis, hemochromatosis, amyloidosis) heart disease presents with chest pain at rest, syncope during exercise. Evidence of heart failure on physical exam and PR interval > 200 ms (heart block) on EKG.

  • Hypertrophic cardiomyopathy: Pediatric patient with family h/o sudden cardiac death presents with new onset syncope while exercising in hot weather. Start nadolol and transition to verapamil if initial treatment is ineffective.

• Orthostatic hypotension (10%): Decrease of ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic within 3 minutes of moving from supine to upright position

  • Patient with h/o autonomic dysfunction due to alcoholism, DM, Parkinson disease, multiple sclerosis presents with syncope during postural change. Recent, acute volume loss due to dehydration, hemorrhage. Consumes low-salt diet.

  • Recent changes in medications: Alpha blockers (tamsulosin), beta-blockers (metoprolol), calcium channel blockers (amlodipine), diuretics (furosemide), phosphodiesterase inhibitors (e.g. sildenafil), SSRIs

  • Tachycardia and positive orthostatic vital signs on exam

Evaluation

• Obtain history with focus on precipitating events, h/o cardiac disease, and clinical features (italicized) above

• See section on syncope

Delirium, Encephalopathy, Confusion

• Delirium: Confusion Assessment Method (CAM)

• Meningitis/Encephalitis

  • Bacterial meningitis

  • Viral Meningitis

  • Viral encephalitis

    • Non-arthropod encephalitis

    • Arthropod-borne encephalitis

• Metabolic derangement

  • Temperature

    • Hypothermia

    • Hyperthermia

  • Ventilation: Hypoxia/hypercarbia

  • Hyponatremia

  • Metabolic acidosis (low bicarbonate)

    • Uremia

    • Hyperglycemia (see above)

    • Lactic acidosis

  • Glucose

    • Hypoglycemia

    • Hyperglycemia: DKA vs. HHS

  • Hyperammonemia including hepatic encephalopathy

• Toxicity and Withdrawal

  • Iatrogenic

    • Sedation: Consider obtaining antiepileptic, antipsychotic (e.g. lithium) levels

    • Serotonin syndrome

    • Neuroleptic malignant syndrome

  • Recreational

    • Alcohol use disorder, alcohol toxicity, and alcohol withdrawal

    • Opioid toxicity and withdrawal

Dementia

• Alzheimer's disease (review medications, behavioral intervention, aripiprazole)

• Lewy body dementia

• Vascular dementia

• Frontotemporal dementia