Altered Mental Status (AMS)

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

  • 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, DM

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

d

  • DDX:

  • 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:

  • 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

  • Hypoglycemia (glucose <54): symptoms include sweating, tremor, palpitations, anxiety. If awake, give 15–20 g oral glucose and recheck q15 min. If altered, give thiamine 100 mg IV (if at risk), then D50 25 g IV push; repeat up to 2–3 amps with glucose checks q5–10 min until >70. If persistent or high risk, start D10 infusion (100–200 mL/hr); if no IV access, give glucagon 1 mg IM, repeat once, then give D50 and transition to D10 (75–150 mL/hr). Target glucose 100–150; monitor q15–30 min → q1–2 hrs. Stop D10 once stable on repeated checks and tolerating PO. Common causes: insulin, sulfonylureas.

  • Opioid overdose: suspect with RR <12 / hypoventilation. Give naloxone starting low and titrate every 1–2 min: 0.04 → 0.1 → 0.2 → 0.4 → 1 → 2 mg. Goal: RR ≥10–12 and adequate ventilation (not full arousal). then start infusion at ~2/3 of total effective dose per hour until pt awake and rr>12 for several hours. Naloxone lasts 30–90 min, often shorter than opioid. In chronic opioid users, titrate carefully to avoid withdrawal. Once stable, resume opioids cautiously at lower dose if indicated.

  • Respiratory distress / hypoxemia: escalate support → NRB (100%) → HFNC → NIPPV (BiPAP for hypercapnia/COPD, CPAP for CHF) → intubation. Use HFNC if PaO₂ <60 despite NRB; start BiPAP if PaCO₂ >45 (hypercapnia); proceed to intubation if pH <7.25, worsening fatigue, or impending respiratory failure.

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