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Just because youre nuts, it doesnt mean youre not sick the ongoing search for organic causes
Brief review of Delirium, Seizures and Stroke
ICU Psychosis
How do you know if theyre confused? (J. Am. Ger. Soc. 2005) Why do they become delirious? (Critical Care 2001) Does delirium portend a poor outcome? (JAMA 2004) Geriatrics: Delirium plus dementia, what to do? (J. Am. Ger. Soc. 2005)
Disorders of Mentation
Abnormalities of mental function
Conciousness:
Arousal (awake?) Awareness (responsive?)
Cognition:
Orientation (accurate perception of experiences) Judgment and Reasoning (ability to process data and generate meaningful information) Memory (ability to store and retrieve information)
Levels of Conciousness
Awake: aroused and aware Somnolent: easily aroused and aware Stuporous: aroused with difficulty, impaired awareness Comatose: unarousable and unaware Vegetative state: aroused but unaware
Oriented
Confused
Inappropriate Incomprehensible
4
3 2 1
Motor Obeys Commands Localizes Withdraws Abnormal Flexion Abnormal Extension None 6 5 4 3 2 1
None
Eye Opening
Spontaneous 4
To Speech
To Pain None
3
2 1
Septic Encephalopahthy
Can be caused by any infection aside from CNS infections Early sign of sepsis Advanced cases progress to multiple abscesses throughout brain matter Similar biochemical changes to hepatic encephalopathy
Increased aromatic amino acids, decreased branched chain amino acids in plasma
Delirium
Most common mental disorder in the hospitalized geriatric patient Up to 87% of elderly pts As many as 75% are not recognized by the physician caring for the patient Characterized by: acute mental status change and inattention and disorganized thought or altered level of consciousness -- Hallmark: acute onset and fluctuating clinical course
Most often drug related (40%) - but all other organic causes must be ruled out
Delirium
Hypoactive delirium:
Characterized by lethargy rather than agitation Most common form in the elderly
Delirium
Management
identify and eradicate the cause Sedatives for patient protection Post-op use haloperidol
Maldonado Protocol AKA: H2A Recommends: 4am, 10am, 4pm, 10pm mild anxiety 0.5 to 2mg increased dose at 10pm for Moderate 5-10mg sleep-wake cycle preservation severe 10-20mg Double the dose if no response in typically start redose. 20 minutes and at 2&1mg
Valium: Onset 1-2 min, lasts as long as 12 hrs (active metabolite) 10/10/10 (q8 hrs x 3) Ativan: Slow onset (5-15 min) and longest duration (10-20hrs) Versed: Fast onset, short acting Lipid soluble, prolonged sedation if used long term
Blessed-Dementia Scale
Activity One point for each, unless otherwise indicated. CHANGES IN PERFORMANCE OF EVERYDAY ACTIVITIES Inability to perform household tasks Inability to cope with small sums of money Inability to remember shortlist of items; for example, in shopping list Inability to find way about indoors Inability to find way about familiar streets more
More.
CAM ICU SCORE 1. Acute Onset or Fluctuating Course Absent Present acute change in mental status from baseline? OR did the abnormal behavior fluctuate during the past 24 hours? 2. Inattention Absent Present Did the patient have difficulty focusing attention as evidenced by scores less than 8 on either the auditory or visual component of the Attention Screening Examination (ASE)? 3. Disorganized Thinking Absent Present Does the patient have disorganized or incoherent thinking as evidenced by incorrect answers to 2 or more of the following 4 questions and/or demonstrate an inability to follow commands? Questions (Alternate Set A and Set B): 2 sets of logic questions (does a stone float? Does a leaf float?) 4. Altered Level of Consciousness Absent Present Is the patients level of consciousness anything other than alert (e.g. vigilant, lethargic or stuporous), or is VAMASS < or > 3 (and not decreased due to sedation)?
Alert: Looks around spontaneously, fully aware of environment, interacts appropriately. Vigilant: Hyperalert. Lethargic: Drowsy but easily aroused. Unaware of some elements in the environment, or no appropriate spontaneous interaction with interviewer. Becomes fully aware and appropriate with minimal noxious stimulation. Stupor: Becomes incompletely aware with strong noxious stimulation. Can be aroused only by vigorous and repeated stimuli. As soon as stimulus removed, subject lapses back into unresponsive state.
Overall CAM ICU Score: If 1 + 2, and either 3 or 4 is present, patient has delirium.
Yes
No
Risk factors include: preexisting mental illness, severity of illness, advanced age, medical comorbidity, sleep deprivation and medications
Polderman Critical Care 2005
ICU psychosis was almost normalconsequence of prolonged ICU stay Diagnosis is challenging with hypoactive delirium (more common)
Many intensivists use a wait and see approach to treatment Others use Haldol liberally beware the side effects, EPS
Authors suggest:
Basic prevention: Avoid sleep deprivation, increase cognitive stimulation, talk to the patient, play music, early mobilization, avoid dehydration, electrolyte disturbances, and hypoxia High index of suspicion, frequent screening Treatment should be more prompt (prevent sequelae) Stop offending drugs (benzos and narcotics misused to treat confusion) Treat with antipsychotics drug of choice remains haloperidol Monitor for prolonged QT Interacts with multiple othe drugs common in ICU Neuroleptics not well studied in the ICU may be helpful in nonagtated delerium (risperdol, olanzapine, ziprasidone)
Seizures
Second most common neurologic complication in ICU Movements
Tonic contractions (sustained contractions) Atonic contraction (no movement) Clonic contraction (periodic contractions with regular frequency and amplitude) Myoclonus (periodic contractions with irregular amplitude and frequency) Automatisms (lipsmacking, chewing, etc)
Generalized Seizures
Symetric and syncrhonous electrical discharge of the entire cerebral cortex May or may not be accompanied by muscular contraction (if none, absence or petit-mal)
Partial Seizures
Electrical discharges that are confined to a restricted part of cortex Simple partial (does not impair consciousness) Complex partial (does impair consciousness) Temporal lobe seizures: motionless stare and automatisms Epilepsia partialis continua: persistent tonic-clonic movements of facial and limb muscles unilaterally
Status Epilepticus
more than 30 minutes of continuous seizure activity 2 or more sequential seizures without intervening consciousness
Evaluation:
Examination looking for lateralizing signs Review of medications Imaging (CT) Procedural diagnostics (LP, labs, blood cultures)
Management:
BZO Valium 0.2mg/kg IV stops 80% of seizures within 5 min, effect lasts 30 min Ativan 0.1mg/kg is as effective and lasts 12-24hrs Dilantin 20mg/kg following valium, aim for 20mg/l therapeutic serum level
Stroke
Acute neurologic disorder Nontraumatic brain injury, vascular origin Focal findings (not global) Persists for more than 24 hours 80% ischemic, 20% of which are embolic
Most thrombi are mural, LA, LV, DVT with PFO
TIA: transient ischemic attack, focal deficits resolve in less than 24 hours (ischemia rather than infarction) Minor Stroke = RIND (reversible ischemic neurologic deficit) resolves within 3 weeks of event Major Stroke = deficits persist for more than 3 weeks
Diagnostic Studies
Time is brain Coags, Chemistries: hypoglycemia, hyponatremia, ARF ECG: Afib? CT head: 70% sensitivity for infarct, 90% for hemorrhage - critical to distinguish btwn these Better if after 24 hours for infarct MRI: more sensitive esp for brainstem and cerebellar strokes