Altered Mental Status

David T. Matero, M.D.

Assistant Professor
Emergency Medicine
University of Colorado Denver

Overview
Altered mental status: It Could Be

[almost] Anything! requires a thorough

work-up
What is the differential for altered
mental status?
What is the type of problem that could
cause it?
What is the organ system(s) that could
be involved?

Example
63 yo female found down next to park

bench. Bystander called EMS who are now

moving patient from gurney onto bed.
You ask for history: There is none
You ask for ROS: There is none
You ask for PMH, Meds, Anything!: There is
none

WELCOME TO
EMERGENCY

What Could Be Wrong With

Her?
Tramua: Brain laceration/injuryConcussionDepressed skull fractureHead traumaBrain, contusionBrain injury, massiveDiffuse axonal injury/Acute brain trauma
Shaken Baby SyndromeElectromagnetic, Physics, trauma, Radiation CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea water
Drowning/Near- drowningHeat exhaustion/prostrationHeat strokeEncephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposure
Electrocution/lightning strikeHigh altitude cerebral edemaDecompression sicknessHigh altitude pulmonary edemaIatrogenic, Self Induced Disorders
Water intoxicationHypothermic anesthesiaHyponatremia correction, rapidSurgical, Procedure ComplicationAnesthesia, general
Brain surgeryInfectious Disorders (Specific Agent)Pneumonia, bacterialAIDS MeningoencephalitisEncephalitis, herpes simplexEncephalitis, secondary viral
Encephalitis, viralMeningitis BacterialMeningitis, aseptic/viralMeningitis, HemophilusMeningitis, pneumococcalMeningococcal meningitis
Pneumonia/BronchopneumoniaPneumonia, acute lobarPneumonia, pneumococcalTyphoid feverMeningitis, tuberculosisAmebic (Naegleria) meningoencephalitis
Bacterial overwhelming sepsisCandidiasis systemicChickenpox encephalitisEncephalitis, bacterial/cerebritisEncephalitis, Dawsons/inclusion body
Encephalitis, Eastern equineEncephalitis, mumpsEncephalitis, Murray valleyEncephalitis, non-viralEncephalitis, St Louis BEncephalitis, Western equine
Gram negative (e coli) meningitisHistoplasmosis meningitisKunjin viral encephalitisLa Crosse viral encephalitisLegionella meningoencephalitis
Leptospiral meningitisLeptospirosis/severe (Weils) typeListeria meningitisLyme meningoencephalitisMalaria, cerebralMeningitis, candida
Meningitis, Coxacki viralMeningitis, echo viralMeningitis, staphylococcus aureusMononucleosis encephalitisPlague meningitis
Post-viral/infectious encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes syndromeRussian tick-bourne encephalitisToxic shock syndrome
Trichinella meningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisLegionaires diseaseListeria monocytogenes/listeriosis
Meningitis, fungalRocky mountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosis
Sleeping sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, CaliforniaEncephalitis, equine, VenezuelanEncephalitis, Japanese B
Encephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acute
Fungus brain abscessLeptospirosis IctohemorrhagicaInfected organ, AbscessesInfectionsAbscess, intracranialBacteremia/SepticemiaBrain abscess
Embolism, septic, cerebralEndocarditis, infectiveMeningoencephalitisPneumonia, aspirationSepsisSepsis, overwhelmingSeptic shockUrosepsis/septicemia
Encephalomyelitis, acuteEncephalopathy/secondary/toxic/sepsisNecrotizing fasciitis/mixedBrain stem encephalitisEncephalitisMeningitis
PneumoniaGranulomatous, Inflammatory DisordersHemorrhagic pancreatitis, necrotizingPancreatitis/resp distress syndromeNeoplastic Disorders
Hypercalcemia of malignancyMetastatic brain diseaseBrain stem tumorBrain tumorFrontal lobe tumorMedulloblastomaMeningeal carcinomatosis
Parietal lobe tumorPrimary CNS lymphomaTemporal lobe tumorBrain tumor , malignant (astrocytoma)CraniopharyngiomaGlioblastoma multiforme
Insulinoma/Islet cell tumorMeningiomaPontine gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune DisordersEncephalitis, hemorrhagic, acute
Encephalitis, post viralEncephalomyelitis, necrotizing hem. ac.Encephalomyelitis, post-infectiousStevens-Johnson syndromeTransfusion reaction, hemolytic
Lupus cerebritisPolyarteritis nodosaBehcet's syndromeHashimotos EncephalitisMetabolic, Storage DisordersHypoglycemia, reactive diabetic
Diabetic ketoacidosis/comaHyperosmolar hyperglycemic coma, nonketNeonatal hyperbilirubinemiaMetabolic disordersMethemoglobinemia, Hereditary
Porphyria, acute intermittentGlutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical Disorders
Encephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHypercalcemiaHypercapnea HypercarbiaHypernatremiaHyperosmolality
HypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontine myelinolysis, centralDeficiency Disorders
Dehydration and feverDehydrationWernicke's encephalopathyMalnutrition/StarvationPellagra/niacin deficiency
Marchiafava-Bignami syndromeCongenital, Developmental DisordersNephrogenic diabetes insipidusHereditary, Familial, Genetic Disorders
MELAS EncephalopathyVan Bogaert encephalitisUsage, Degenerative, Necrosis, Age Related DisordersAlzheimer's syndromeDementia, Lewy-body type
Multiple sclerosisRelational, Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia, factitiousCatatonia
Manic deleriumAnatomic, Foreign Body, Structural DisordersAcute subdural hematoma/hemorrhageBrain compressionEpidural hematoma
Intracerebral hematomaIntraventricular brain hemorrhageSubdural hematomaTamponade, cardiacBrain stem herniation/peduncle/tonsilsFat embolism
Superior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolism
Cerebral hemorrhageCerebral vein thrombosis/phlebitisIntracerebral hemorrhageMyocardial infarction, acuteSubarachnoid hemorrhage
Transient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosisCerebral/Venous sinus thrombophlebitis
Superior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexia
Sleep deprivationVegetative, Autonomic, Endocrine DisordersCardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shock
Convulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotension
Orthostatic hypotensionPost-ictal statusThyrotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignant
Malignant hyperthermiaMyxedema comaMyxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart block
Inappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, juvenileNarcolepsyPickwick's syndromeReference to Organ SystemShock
Cerebral edemaDisseminated intravascular coagulopathyHepatic encephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndrome
Brain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic thrombocytopenia
Hepatorenal syndromeRenal Failure ChronicUremic encephalopathyEncephalopathyHyperviscosity syndromePernicious anemiaPontine lesion/disorder
Thrombotic thrombocytopenic purpuraCombined system disease/pernicious an.Fever Unknown Origin

From Vertebrobasilar migraine syndrome to

Hyponatremia
Its TOO MUCH
You need a clue:
-EMS report
-Cell phone (call family members)
-Bystander account
-PMH from meds, alert bracelet, wallet, PhysEx
(e.g fistula)
-Phys Exam for current physiological state of
patient
-Labs
-Imaging

Physiologic Reserve Determines How

Readily the Patient Will Have AMS!
Frail Old Patient: A simple Urinary Tract

Infection can put this patient in a coma.

Young Healthy Patient: Likely to be
something significant that has gone wrong
Patient With Obvious Comorbidities: Other
causes (than primary medical problem) will
more readily alter this patient (less
reserve!)

You May Get Frustrated at this

Patient and Say (ddx):
M: MetabolicB12 or thiamine deficiency, serotonin
syndrome
O: Hypoxemia (pulmonary, cardiac, anemia); high
CO2
V: Vascular causeshypertensive emergency,
ischemic/hemorrhagic CVA, vasculitis, MI
E: Electrolytes and endocrine
S: Seizures / status epilepticus, post-ictal
T: Tumor, trauma, temperature, toxins ( lead,
mercury, CO, toxidromes )
U: Uremia. Renal or hepatic dysfuction with hepatic
encephalopathy
P: Psychiatric, porphyria
I: Infection (inflammatory-see vasculitis above)

M: MetabolicB12 or thiamine
deficiency, serotonin syndrome
Glucose metabolism uses up even more

thiamine
Serotonin syndrome=serotonin toxicity and
caused by various drugs, medicines and
combinations thereof
-increased heart rate, shivering, sweating,
dilated pupils, myoclonus, as well as
overresponsive reflexes

O: Hypoxemia (pulmonary,
cardiac, anemia); high CO2
Purely Hypoxic patient is anxious/agitated

-PE
Purely Hypercarbic patient is sleepy
-Jet Insufflation in kids or bad COPDer

V: Vascular causeshypertensive
emergency, ischemic/hemorrhagic
CVA, vasculitis, MI
All of these cause poor perfusion of the

brain either focally or globally through local

effects (CVA) or through loss of forward
flow to brain (MI)

E: Electrolytes and
endocrine
Electrolyte shifts can cause swelling in the

brain
High Na or Ca global depression (any
electrolyte involved in ion-channel
transmission in the brain can cause a
problem)
Hypoglycemia most common cause of
endocrine-related MS depression

S: Seizures / status epilepticus,

post-ictal
Post-ictal state typically resolves in 20-

40minutes
Non-epileptiform seizures can be cause of
depressed mental status
-No tonic-clonic activity
-Ultimately diagnosed with EEG
-Eye movement, hx, trial of Ativan may
give clue

T: Tumor, trauma, temperature, toxins

(lead, mercury, CO, toxidromes )
Tumor causes compression or diffuse

edema
Hypothermia: Global depression of ionchannels
Toxins: Wide range of responses depending
on individual and their reserve
Look for Toxidromes- A symptom
constellation specific to a given toxin (e.g.
Slurred speech, B lateral-gaze nystagmus,
cerebellar deficits, altered mood is the
toxidrome for Ethanol)

U: Uremia. Renal or hepatic dysfuction

with hepatic encephalopathy
Electrolyte Abnormalities
Uremia-Urea build-up AND electrolyte

abnormalities
Hepatic Encephalopathy- elevated
Ammonia (level should be high but poorly
correlated with actual degree of AMS)

P: Psychiatric, porphyria
Catatonia: no focal neurological deficits but

unresponsive (responds to Ativan!)

Porphyria: A group of enzyme deficiencies
in hematologic biosynthesis pathway that
results in accumulation of Porphyrins (or
precursors): Multiple s/sx including various
MS effects

I: Infection (inflammatory-see
vasculitis above)
Meningitis (A constant concern in all

patient, esp at extremes of age)

Cerebritis

D: Drugs, including withdrawal

(anticholinergics, TCA;s, SSRIs,
BZDs, barbiturates, alcohol)
Learn and look for Toxidromes (withdrawal

states are usually essentially opposite in

symptoms)

In Summary: It ALL Boils Down to

One of Two Things
Both cerebral hemispheres are

depressed
The Reticular Activating
System is not functioning.

In Summary: It ALL Boils Down to

One of Two Things
Both cerebral hemispheres are

depressed
The Reticular Activating
System is not functioning.
Diffuse Process
most of
the cases arise
from this

In Summary: It ALL Boils Down to

One of Two Things
Both cerebral hemispheres are

depressed
The Reticular Activating
System is not functioning.
Diffuse Process
most of
the cases arise
from this

In Summary: It ALL Boils Down to

One of Two Things
Both cerebral hemispheres are

depressed
The Reticular Activating
System is not functioning.
Stroke,
Seizure or
Trauma to
this region

Diffuse Process
most of
the cases arise
from this

Approach the Patient Covering Most

Urgent Bases First
ABCs
Intravenous access, oxygen

therapy, cardiac monitoring with

pulse oximetry
Accu-check / glucose / thiamine
Cervical spine precautions
Naloxone

Approach the Patient Covering Most

Urgent Bases First
EKG / cardiac monitoring
ABG with carboxyhemoglobin
CBC, electrolytes, Ca, Mg
Drug screen, EtOH, serum osmolarity
Urinalysis
Imaging
lumbar puncture
liver, thyroid

Approach the Patient Covering Most

Urgent Bases First
EKG / cardiac monitoring
ABG with carboxyhemoglobin
CBC, electrolytes, Ca, Mg
Drug screen, EtOH, serum osmolarity
Frail Old
Urinalysis
Imaging
lumbar puncture
liver, thyroid

Patient: A
simple Urinary
Tract Infection
can put this
patient in a
coma.

63 yo female found down next to

park bench
You have no information: You do a physical

exam
-A: Breath sounds CTAB, +gag, trachea
midline, no pooling of secretions,
-B: Spontaneous respirations
-C: Regular rhythm , tachycardia, B femoral
pulses, diminished DP pulses (but present)
-VS:101, 88/45, T- 35.6, 92% RA

63 yo female found down next to

park bench
-HEENT: PERRL, TMs clear, MM slightly dry
-Neck: Supple, no JVD
-Chest: no crepitus, atraumatic
-GI: soft, BS present/normal; rectal no gross blood,
NL tone
-Extrem: UE and LE with no clubbing, cyanosis,
edema pulses present except as noted in ABCs
-Back: Atraumatic, no step-offs
-Neuro: CN grossly intact, MAE, withdraws to pain,
no gross focal neurol deficits, reflexes symmetrical,
does not answer Qs or follow commands, moaning
-Skin: well perfused
-GU: Perineum atraumatic, no discharge or lesions

What Was Abnormal?

What Could It Mean?

What Was Abnormal?

What Could It Mean?
You have no information: You do a Physical

Exam
-A: Breath sounds CTAB, +gag, trachea
midline, no pooling of secretions,
-B: Spontaneous Respirations
-C: Regular rhythm , tachycardia, B Femoral
pulses, diminished DP pulses (but present)
-VS:101, 88/45, T- 35.6, 92% RA

63 yo female found down next to

park bench
-HEENT: PERRL, TMs clear, MM slightly dry
-Neck: Supple, no JVD
-Chest: no crepitus, atraumatic
-GI: soft, BS present/normal; rectal no gross blood,
NL tone
-Extrem: UE and LE with no clubbing, cyanosis,
edema, pulses present except as noted in ABCs
-Back: Atraumatic, no step-offs
-Neuro: CN grossly intact, MAE, withdraws extrem
to pain,no gross focal neurol def, reflexes
symmetrical, does not answer Qs or follow
commands, moaning
-Skin: well perfused
-GU: Perineum atraumatic, no discharge or lesions

Putting the Physical Exam Findings

Together:
Do you think this is a Global or a Focal

Process?

How would you summarize the state of the

patient based on PEX?

What could cause this state?

What is more likely now?

M: MetabolicB12 or thiamine deficiency, serotonin
syndrome
O: Hypoxemia (pulmonary, cardiac, anemia); high
CO2
V: Vascular causeshypertensive emergency,
ischemic/hemorrhagic CVA, vasculitis, MI
E: Electrolytes and endocrine
S: Seizures / status epilepticus, post-ictal
T: Tumor, trauma, temperature, toxins (lead,
mercury, CO, toxidromes)
U: Uremia. Renal or hepatic dysfuction with hepatic
encephalopathy
P: Psychiatric, porphyria
I: Infection (inflammatory-see vasculitis above)

What is more likely now?

M: MetabolicB12 or thiamine deficiency, serotonin
syndrome
O: Hypoxemia (pulmonary, cardiac, anemia); high
CO2
V: Vascular causeshypertensive emergency,
ischemic/hemorrhagic CVA, vasculitis, MI
E: Electrolytes and endocrine
S: Seizures / status epilepticus, post-ictal
T: Tumor, trauma, temperature, toxins ( lead,
mercury, CO, toxidromes )
U: Uremia. Renal or hepatic dysfuction with hepatic
encephalopathy
P: Psychiatric, porphyria
I: Infection (inflammatory-see vasculitis above)

Next Step: Diagnostic Studies

Prioritize acute life threats first
Get high-yield, easy items first: Glc, EKG
Keep modifying testing as DDX changes

with results
Shotgun Approach (parallel processing)
Is patient stable to go to imaging or to
wait for lab result before making
treatment decision?

How Do I Know What to

Order?
Balance these two things to

determine what tests/priority:

-Shotgun approach (intended to
move things along quickly and cast
wide net)
-What youve learned from your
H&P

LABS
141
4.1

14.5
380

101
26
17
1.1

14.
4
41.
9

LFTs- Normal
ASA, APAP, Coags Normal

10
1
UA:
Spec grav
1.026
pH 6.0
Ketones +
Glucose
Bile
Blood +
Bacteria +
+
WBC ++
Nitrite +
Leuk. Est +

LABS
141
4.1

14.5
380

101
26
17
1.1

14.
4
41.
9

LFTs- Normal
ASA, APAP, Coags Normal

10
1
UA:
Spec grav
1.026
pH 6.0
Ketones +
Glucose
Bile
Blood +
Bacteria +
+
WBC ++
Nitrite +
Leuk. Est +

Do We Know Whats Going

On?
We know the patient has a UTI
Is this enough to explain the patients

sepsis?
Can we stop our work-up?
Could the UTI be a red herring?

Do We Know Whats Going

On?
We know the patient has a UTI
Is this enough to explain the patients

sepsis? YES
Can we stop our work-up?
Could the UTI be a red herring?

Do We Know Whats Going

On?
We know the patient has a UTI
Is this enough to explain the patients

sepsis? YES
Can we stop our work-up? NO
Could the UTI be a red herring?

Do We Know Whats Going

On?
We know the patient has a UTI
Is this enough to explain the patients

sepsis? YES
Can we stop our work-up? NO
Could the UTI be a red herring? YES

What Else Should We Do?

Pt does have Sepsis and a UTI, this could

be Urosepsis. HOWEVER, it could also be

something else (and there just happens to
be a UTI)

What Else Should We Do?

EKG MI, Intervals (Toxins), OtherCXR PNA (Sepsis), Edema, TraumaHead CT Bleed, Swelling, Mass Lumbar Puncture Bleed, Infection Urine Drug Screen Drugs of Abuse

What Else Should We Do?

EKG MI, Intervals (Toxins), Other-

NORMAL
CXR PNA (Sepsis), Edema, TraumaNORMAL
Head CT Bleed, Swelling, Mass NORMAL
Lumbar Puncture Bleed, Infection NORMAL
Urine Drug Screen Drugs of Abuse
- NORMAL

We THINK We Know the

Cause
Urosepsis

We THINK We Know the

Cause
Urosepsis
Re-Examine the patient and make

sure nothing has changed and that

the exam is consistent w Dx
Dont become emotionally
attached to a Dx, as the clinical
picture can change and start
looking like something else
The only atypical presentation is
a typical presentation

CONCLUSION
Maintain a wide differential
Get a Grip on the Diagnosis through

systematic clue finding

Remember: Its focal in the RAS, or diffuse
in the Bilateral Hemispheres
Re-evaluate patient frequently and do
frequent hypothesis-testing in your mind