Altered Mental Status

With our current political climate, maybe this anxiometer post could have merit.

Just about every ER shift patients are brought in by family or by ambulance because they’re not thinking straight. They may be answering questions unusually or inappropriately, or they may be blathering and barely conscious. Our job in the ER is to determine what may be acute vs. chronic, and also to find ways to actually help.

The line between delirium and dementia can be subtle, but it’s a useful distinction. Frankly, I think we take more interest in delirium in the ER, perhaps because there are generally more opportunities to intervene and make lives better. Dementia lacks good solutions. Once patients improve, often with saline and antibiotics, they still leave with dementia and uncertainty.

Red Flags:

• Rapid deterioration
• Recent head injury/trauma
• Associated sudden headache
• Kids… altered mentation in kids is always concerning
• Recent intoxication
• Seizures especially with no previous history of seizures
• Brain cancer or other known brain masses
• Other cancers with suspected metastases
• Pregnant or postpartum
• Diabetic
• Fevers
• Hypothermia
• Neck stiffness
• Staggering
• Slurred speech
• One or both sided paralysis
• IV drug use
• Known or suspected overdose
• Known shunt or past neurosurgical conditions
• Hallucinations with no previous psychiatric illness
• Alcohol withdrawal
• Evidence for suicidality
• Recent travel
• Recent diving or high altitude climbing
• Recent long distance racing
• … and hyperhydration with just water
• Recent prolonged sun exposure
• Recent meth use, followed by a car chase, followed by a dog chase, followed by getting tazed, followed by getting hog tied face down.

Happy Words

• Frequent similar episodes that resolve spontaneously
• Still breathing, drinking, eating, peeing, pooping properly
• Recent alcohol use and already improving
• Recent medication change
• “Grandpa recognizes us and seems fine in the day, but at night he just paces around mumbling and can’t sleep.”
• “Junior just had dental surgery and really liked the nitrous.”
• (Not a lot of happy words with altered mental status.)

Expect IVs, EKGs, urine/blood tests, a drug screen, medication levels, a head CT, maybe even an MRI or spinal tap if you arrive altered with no obvious cause. Happily many conditions resolve with time +/- saline though. Sometimes antibiotics help if we find a source of infection. Occasionally simple medication tweaks do the trick, or naloxone if the problem is narcotic overdose, or sugar if it’s hypoglycemia. Unless there is a clear fixable cause, however, hospital admission is generally the path.

All that being said, clearly Pre-R is not your best bet for patients who are altered with no clear cause. But still feel free to call if you’d like to talk through the decision tree.

Lastly, and I don’t want to get too political here, but I’ve a hunch excessive Tweeting may one day be added to the red flags list. Though it will be challenging to tease out correlation vs. causation.

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