Altered Mental Status (AMS)

  • Onset: (sudden / gradual)

  • Course: (constant / intermittent)

  • Progression: (worsening / improving / unchanged)

  • Associated symptoms: confusion, disorientation, decreased attention, lethargy, agitation, hallucinations, headache, fever, focal weakness, speech changes, seizure activity, nausea/vomiting, incontinence

  • Pertinent negatives: no focal neurologic deficits (if absent), no recent head trauma, no chest pain or dyspnea (ACS/PE), no fever/chills (if infection not suspected), no toxic ingestion (if denied), no seizure activity (if absent)

  • Pertinent Exam: A&O x ___, attention, level of consciousness (alert/lethargic/obtunded)

  • Pertinent Data: broad toxic, metabolic, and infectious workup: CBC, CMP, BCx, UA with reflex UCx, CXR, EKG, Glucose, TSH, UDS, Etho levels, VBG, consider Vit B1 (whole blood), Vitamin B12, +/- RPR, HIV, LP, CT Head noncontrast, Consider CTA head/neck and MRI if high concern for stroke. MRI if high concern for inflammatory changes or infection

  • Pertinent PMH/SH/FH: dementia, prior stroke, seizures, liver/kidney disease, psychiatric history, substance use (alcohol/drugs), recent infections, medication changes

  • Pertinent Home meds: sedatives (benzos), opioids, anticholinergics, antipsychotics, antidepressants, antihistamines, polypharmacy
    -- Etiology

  • Metabolic (Hypo/hypernatremia, Hypercalcemia, vitamin B12 or thiamine deficiency, hepatic encephalopathy)

  • Oxygen (Hypoxia,hypercarbia, anemia,decreased cerebral blood flow(low CO), CO poisoning)

  • Vascular (Ischemic stroke, hemorrhage, MI, CHF,vasculitis, TTP/HUS, DIC)

  • Endocrine (HypoCa, Thyroid, Adrenal)

  • Seizure (Postictal state)

  • Trauma or temperature

  • Uremia/dialysis (Cr,BUN)

  • Psychiatric,diagnosis of exclusion

  • Infection (sepsis,UTI,PNA,meningitis/encephalitis)

  • Drugs (Intoxication, withdrawal, or medications)

  • Delirium – see “Delirium” section in psychiatry

  • Degenerative diseases (Alzheimer’s, Parkinson’s, and Huntington’s,Lewy bodies)

  • Hospital course to date:

Plan:

  • If non-responsive (GCS<8), check pulse, intubate

  • D50 (25 g IV glucose) after thiamine 100 mg IV f(at risk (alcohol use, malnourished)) if hypoglycemic

  • Opioid Overdose - Naloxone - 0.1mg IV, repeat q3-5 minutes if no response (RR <12 is best indicator, miosis vs normal pupils is not reliable

  • If in respiratroy distress or hypoxic - NRB 100% --> HFNC --> NIPPV if COPD (BIPAP), or CHF (CPAP) --> intubate; PaO2 <60 despite NRB, get on HFNC; PaCO2 >45, put on BIPAP; pH <7.25, will likely tire out trying to blow off CO2

  • Seizure - ativan 2mg, call neuro, likely load Keppra

  • Hypotension/Infection - give LR, send basic and infectious workup, start antibiotics, pressor if needed

  • Concern for Wernicke’s Encephalopathy - IV thiamine

  • Hyperactive Delirium/Agitation - haldol 2-5mg IV vs. 0.5-1mg PO, seroquel PO

  • Hyponatremia - call renal, hypertonic saline if severe and concern for cerebral edema

  • Known CNS mass or edema - call NSGY, likely glucocorticoids

  • f/u labs and imaging

  • spot EEG if altered and seizure-like activity ( consult Neuro)

  • airway support if t needed

  • naloxone 0.4–2 mg IV if concern for opioid-related respiratory depression

AMS
Opioid toxicity


days of CC: with (sudden / gradual) onset, (constant / intermittent) course, and progressively (worsening / improving / unchanged) symptoms.

  • Associated symptoms: somnolence, lethargy, decreased level of consciousness, slurred speech, hypoventilation (↓ RR), shallow breathing, apnea, hypoxia, cyanosis, snoring/gurgling (airway obstruction), nausea/vomiting, ↓ bowel sounds

  • Pertinent negatives: no focal neurologic deficits (stroke), no fever/chills (infection), no signs of trauma or head injury, no seizure activity (if absent), no severe agitation (suggesting withdrawal or stimulant toxicity)

  • Pertinent Exam: CNS depression (lethargic → obtunded → comatose), pinpoint pupils (miosis), ↓ RR (<8–10), shallow respirations, hypoxia, bradycardia ± hypotension, decreased bowel sounds, possible signs of aspiration

  • Pertinent Data: RR <12, glucose (rule out hypoglycemia), ABG/VBG (hypercapnia, respiratory acidosis), CBC, BMP, lactate, UDS (may miss synthetic opioids), acetaminophen/salicylate levels, EKG (QT prolongation esp. methadone), CXR (aspiration, pulmonary edema)

  • Pertinent PMH/SH/FH: opioid use disorder, chronic pain on opioids, substance use (alcohol, benzos), prior overdose, psychiatric history, COPD/OSA (↑ respiratory risk)

  • Pertinent Home meds: opioids (oxycodone, morphine, fentanyl, methadone), benzodiazepines, gabapentin, sedatives, sleep aids

  • DDx: benzodiazepine overdose, alcohol intoxication, other sedative-hypnotic overdose, hypoglycemia, stroke/ICH, post-ictal state, sepsis, hypoxic respiratory failure, carbon monoxide poisoning

Plan

  • intubate if Failure of ventilation RR < 8 or apnea, Failure to protect airway GCS ≤ 8, Recurrent vomiting, Unresponsive despite escalating doses (up to ~4 mg) naloxone. Severe hypoxia

  • Start low (1-2 min) 0.04->0.1 → 0.2 mg → 0.4 mg → 1 mg → 2 mg to avoid WD in opioid-tolerant

  • Goal: RR ≥10–12, adequate ventilation (NOT full arousal)

  • infusion: 2/3 of total effective dose per hour Naloxone lasts 30–90 minutes, Many opioids last longer

  • chronic opioid user -> Once stable and alert -> estart home opioid cautiously and lower dose initially

  • Opioid use disorder -> consult addiction medicine (Buprenorphine/ Methadone)