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🌱 來自: Huppert’s Notes
Altered Mental Status🚧 施工中
Altered Mental Status
There are many approaches to altered mental status (AMS). Here is one of them:
• Step 1: First assess for acute/emergent situations
- Is the patient protecting their airway? If not, intubate.
- Does the patient have signs of elevated intracranial pressure (ICP) such as acute loss of brainstem reflexes, particularly with fixed and dilated pupils? If so, perform NCHCT and consult neurosurgery stat. Consider the need for intubation, mannitol, hypertonic saline.
- Concern for opioid overdose? Administer naloxone.
- Check a fingerstick glucose? If <70 mg/dL, administer D50 and thiamine.
• Step 2: Consider the differential diagnosis using the mnemonic “MISTO”:
- Metabolic:
• Electrolyte abnormalities: Check sodium, calcium
• Endocrine abnormalities: Check TSH, glucose (hypoglycemia or hyperglycemia [consider DKA/HHS])
• Organ dysfunction: Kidney, liver, heart (ACS), lung (low oxygen, high CO2)
• Vitamin deficiencies: B1 (thiamine), B12
• Other: Urinary retention, constipation
- Infection:
• CNS infection: Meningitis, encephalitis, abscess
• Non-CNS infection: UTI, pneumonia, bacteremia
- Structural/seizure:
• Structural: Stroke, hemorrhage, tumor
• Seizure
- Toxin:
• Medications
- Perform a complete medication reconciliation; polypharmacy is a common cause of AMS in elderly patients
- Consider drug overdose, drug withdrawal, associated syndromes (e.g., serotonin syndrome)
• Alcohol/substances
- Check serum alcohol level and serum osms
- Check urine toxicology screen
- Oxygenation:
• Low O2
• High CO2
• Step 3: Based on this differential, perform diagnostic tests to further evaluate. Diagnostics to consider:
- Labs: CBC, BMP, LFTs, TSH, serum alcohol level, serum osms, ABG/VBG, ammonia, Utox
- Imaging: Choose based on differential diagnosis – NCHCT, contrast-enhanced head CT, MRI brain