ALTERED LEVEL OF

CONSCIOUSNESS
Barry Simon M.D.
Chairman, Department of Emergency Medicine
Highland General Hospital
Alameda County Medical Center
Oakland California
UCSF Topics in Emergency Medicine - 2006
We will cover

Terminology & definitions

Terminology & definitions

Developing a thorough differential

Developing a thorough differential

Identifying the delirious patient

Identifying the delirious patient

A variety of challenging cases

A variety of challenging cases

Focused H&P highlights

Focused H&P highlights

Key lab and imaging studies

Key lab and imaging studies

Avoiding errors
Avoiding errors
Scope / Spectrum
2002 data from a University
2002 data from a University
Hospital
Hospital
ALOC pts - 5% of the ED volume
64% got admitted
28% neuologic 21% toxicologic
14% trauma 14% psychiatric
10% infectious 5% endocrine / metabolic
3% pulmonary 3% oncologic
Altered Mental Status
Approach
Functional (psychogenic)

Organic

Toxi c / metaboli c (di ffuse di sease), i nfecti ous

Structural (focal di sease)

Dementi a

{
Delirium
Bottom Line

Psychiatric / functional
Psychiatric / functional
Pt gets labeled /
Pt gets labeled /
treatable but not reversible
treatable but not reversible

Delirium
Delirium
80% reversible and up to 15% mortality
80% reversible and up to 15% mortality

Dementia
Dementia
20% reversible
20% reversible
Delirium
Organi c Di sease
Acute onset with a wildly fluctuating course.

Difficulty focusing, easily distracted.

Disorganized thinking, rambling, hard to

follow.

Altered level of consciousness.

Visual hallucinations are common.

Abnormal vital signs.

Dementia
Organi c Di sease
Insidious, gradual onset.

Normal alertness and attentiveness.

Disorientation is the baseline.

No hallucinations.

Vital signs - normal.

Acute Psychosis
Functi onal Di sease
Abrupt onset with a stable course.

Normal level of consciousness.

Auditory hallucinations.

Orientation usually normal.

Vital signs may be elevated.

Lets Review

Wildly fluctuating
Wildly fluctuating
course
course

Auditory
Auditory
hallucinations
hallucinations

Disoriented
Disoriented

Normal LOC
Normal LOC

Abnormal Vital Signs
Abnormal Vital Signs
Delirium
Psychosis
Delirium
Psychosis
Both
Levels of Consciousness
Nomencl ature - termi nol ogy
Traditional Descriptive (AVPU)
Alert Awake and Aware

Lethargy Responds to verbal stim

Stupor Responds to painful stim

Coma Unresponsive

The Naked Man

Hi st or y
32 year ol d male was found runni ng nude i n a fi eld
near a school. He was well known to the poli ce and
the medi cal communi ty as an alcohol and speed
abuser. Whi le bei ng booked by the poli ce he fell off a
bench, hi t hi s head and became unconsci ous. No
other acute hi story was avai labl e.

ALOC - Naked Man

Physical
BP 70/ p HR 200 RR 16 T 41.6 C (106.9 F)
Comatose - unresponsive to painful stimuli
HEENT - small contusion on his forehead. Pupils
were 4 mm and sluggishly reactive to light. He had a
decreased gag reflex, and equivocal plantar reflexes
bilaterally. The rest of his exam was WNL.

ALOC - Naked Man

Fol l ow up
Despite aggressi ve resuscitati ve efforts the patient
expi red several hours later. All ED studi es were
unhelpful i n maki ng a di agnosis.

The differential was broad (toxi ns, hypothalami c

dysfunction, such as tumors, bleeds, CNS infecti ons).

A thorough head-to-toe exam would have

keyed-in the exami ner to the diagnosi s.

*
ALOC - Naked Man
Postmortem di agnosi s:
Thyrotoxicosis

DDX - Altered Consciousness

AEIOU TIPS
A. Alcohols T. Trauma, Tox, temp, Thyroid
E. Endocrine, lytes I. Infections
I. Insulin (diabetes) P. Psychiatric
O. Oxygen, Opiates S. SAH, Seizures
U. Uremia
, ASA
St ar t f rom t he head and wor k down
DDX - Altered Consciousness
Cent ral ner vous syst em
Bl eeds (t rauma and nont rauma)
Infarct s
Infect i ons
Sei zures
Conversi on react i on / psych
DDX - Altered Consciousness
Mouth: Toxins / Meds
Alcohols Opiates
Anticholinergics Phenothiazines
Anticonvulsants Salicylates
Barbiturates Sedative Hypnotics
Carbon Monoxide SSRIs
Cyanide Sympathomimetics
Hallucinogens Tricyclic antidepressants
Heavy Metals
Cocaine delirium and sudden death.
Gamma hydroxybutyrate (GHB) = (GBH)
Grievous bodily harm.
An anesthetic with euphoric and sexual
enhancement properties.
Short acting benzodiazepines - Rohypnol
(Roofies, Ruffies, Love Drug)
Special Case Toxins
DDX - Altered Consciousness
Neck and Chest
Neck
Thyroid & parathyroid disease
Chest
Hypoxia
Hypercarbia
Emboli
DDX - Altered Consciousness
Abdomen
Li ver
Hepat i c encephal opat hy
Werni ckes syndrome
Pancreatic disease
Adrenal insufficiency
Renal disease: electrolyte and metabolic
disorders

Heat Stroke
Heat Stroke

think of while getting rectal temp

think of while getting rectal temp

Hypothermia
Hypothermia

rectal temp
rectal temp

Sepsis
Sepsis

Vasculitis
Vasculitis

may consider as part of renal

may consider as part of renal
causes
causes

Hyperviscosity
Hyperviscosity

ALOC as it affects the CNS

ALOC as it affects the CNS
DDX - Altered Consciousness
Skin Other??
To Tube or not to Tube
Hi stor y
14 year old gi rl found down near a bus stop near her
school.

No one came with the gi rl to the hospital, so initially,

there was no other history available.

ALOC - Tube?
Physi cal exam
Gurgli ng respi rati ons.
BP - 98/ 74 HR - 110 RR - 10 Pulse ox 89% RA.
HEENT - PERRL 3 mm sluggi sh - di sconjugate gaze
++AOB.

Neck, chest, abdomen, extremi ti es - all WNL.

ALOC - Tube?
Physi cal exam - conti nued
Neurologic
Comatose - responds appropri atel y to deep
pai nful sti mul i

Poor gag refl ex, moves al l 4 extremi ti es equal l y to

pai nful sti mul i

DTRs 1-2+ equal

Pl antar refl exes equi vocal
ALOC - Tube?
Medi cal deci son maki ng
(for codi ng purposes onl y)
Possibly all secondary to alcohol ingestion in a young
girl, but airway control was needed. The glucose was
119 mg / dl. No response to 2 mg of narcan.

Prior to CT she would need RSI.......however

*
ALOC - Tube?
Outcome
She woke up after 3 doses of 0.2 mg (total of 0.6mg)
of flumazenil to the point of spontaneously talking
(although she was dysarthric). Her blood alcohol was
190mg / dl.

FLUMAZENIL
Benzodiazepine competitive antagonist
Dose 0.2 - 2.5 mg
Duration 40-60 min
Controversial in:
Mixed ingestions
Chronic benzodiazepine users
Patients with seizure disorders
Altered Mental Status
History Sources
Patient
Patient
Pill bottles
Pill bottles
Medics
Medics
Hospital & Psych
Hospital & Psych
records
records
Relatives
Relatives
Friends
Friends
Medic alert tag
Medic alert tag
Personal physician
Personal physician
Wallet
Wallet
Pockets
Pockets
Altered Mental Status
Physical exam
Respiratory rate and pattern
Heart rate and rhythm
Blood pressure
Rectal temperature
-Vital Signs
Altered Mental Status
Physical Exam - General
Head - signs of trauma
Breath odor - alcohol, fruity, almond, garlic, onion, +
Neck - thyroid, scar, meningismus
Altered Mental Status
Physical Exam - General
Chest - breath sounds, murmurs, rhythm
Abdomen - organomegaly, ascites, peritonitis
Skin - jaundice, petechiae, moisture, temperature,
color, needle tracks, spider angiomatas

Altered Mental Status

Neurol ogi c exam
General obser vat i ons
Aut i sms
Yawni ng
Hi ccups
Swal l owi ng
Respi rat or y pat t erns
Post uri ng

Spontaneous movements
Spontaneous movements

Purposeful movements
Purposeful movements

Response to painful stimuli

Response to painful stimuli

Tone
Tone
Altered Level of Consciousness
Motor Exam
Neurologic Exam
Eyes

Ear s

Ment al St at us Exam

Keys
Altered level of consciousness
The eye exam
Pupils

Funduscopic exam

Eye movements

Eyelids

Caloric Testing
Cold Water < 30
0
C
Normal - deviation away with nystagmus
Cerebral dysfunction - tonic deviation to
one side
Brainstem dysfunction - no response
Mini-mental status exam
Confusion assessment method (CAM)
Altered Mental Status
Confusion Assessment Method
To di agnose del i ri um:
1) Acute onset with fluctuating course

2) Inattention - difficulty focusing

and
1) Disorganized thinking
or

2) Altered level of consciousness

Diagnosis in < ten minutes

Bedsi de studi es
Hi story and physi cal
Glucometer / dextrosti ck - dextrose
Pulse oxi metry
ABGs - Hypoxi a / Hypercarbi a / aci dosi s
.
Istat
Rapid diagnostic studies
Bedside studies - interventions
Urinalysis
Infection, hyperglycemia, dehydration
Breathalyzer
Electrocardiogram / rhythm strip
Narcan, thiamine
Flumazenil, physostigmine
Physostigmine
Reversible inhibitor of acetylcholinesterase
Used to RX, or DX severe anticholinergic syndrome
Useful in GHB ingestion?
DO NOT use in tricyclic overdoses
Dose - 0.5 mg slow IVP up to a total of 2 mg
Keep atropine nearby
Altered Level of Consciousness
Addi ti onal studi es to consi der
Lytes, BUN, Cr, osmolality, calcium

Complete blood count

Carboxyhemoglobin

Lumbar puncture

Altered Level of Consciousness

Directed drug screen

Thyroid function tests

Head CT scan

Peritoneal tap

...and more studi es to consi der

Osmolar Man
History
An 18 year old male calls 911 for a severe headache.
Upon arrival he refuses to let the medics in his home
and they leave. Thirty minutes later his mother calls
911 and the medics arrive to find a comatose male.
His mother explains that he is diabetic and frequently
forgets to take his insulin. The medics transport and
administer 25 gms of dextrose en route.

ALOC - Osmolar Man

Physical
BP 170/ 70 HR 92 RR 14
Comatose male who appears otherwise healthy. Skin
is moist, pupils are PERRL at 6 mm, neurologic exam
is non-focal except for bilateral upgoing toes. The
general exam is otherwise normal.

ALOC - Osmolar man

Blood glucose on his pre-hospital dextrose
blood was 19 mg/ dl. A second bolus of
dextrose did not change his mental status.

Early labs
Do we ever really need a second amp of glucose?

ALOC - Osmolar Man

Follow-up
Repeat exam noted an unmeasurable amount of
anisocoria unnoticed before. CT scan found a large
subdural with midline shift; the patient was taken to
the OR and did well.

*
A 28 year old man was brought unconscious to the
emergency department. Fifteen minutes earlier, with
slurred speech, he had instructed a taxi driver to take
him to the hospital. He passed out before arriving at
the hospital.

A Taxi ing Case

History
ALOC - Taxi man
Physi cal
BP 130/ 90 HR 100 RR 40
Most of the physical exam was within normal limits.
On neurologic exam: Pupils were PERRL at 3 mm,
DTRs were 3+ and equal, plantar reflexes were both
extensor and he had intermittent bilateral
decerebrate posturing.

*
ALOC - Taxi man
Follow up
Hypoglycemia commonly presents with focal
neurologic findings that can mimic structural lesions.
It is obviously important not to skip the basics. This
patients blood glucose was 20 mg/ dl and he awoke
after receiving 25 grams of dextrose.

Mid Term Review

Odor of breath
Odor of breath

arsenic
arsenic

Absent pupil
Absent pupil
response to light
response to light

Average inc. in BS
Average inc. in BS
after 1 amp D50
after 1 amp D50

Flumazenil is avoided
Flumazenil is avoided
in which patients?
in which patients?
Garlic
Garlic
Structural defect
130 mg/dl
Mixed ingestions
ALOC - SUMMARY
Take back to the ER points
Assume the patient is delirious
DDX - start from the head and work your
way down

Think like a detective

The eyes, ears, and mental status are keys
Dont be afraid of flumazenil or physostigmine
Common Errors
Failure to consider the basics (glucose, oxygen,
thiamine)

Treatment delay during the evaluation

Failure to re-examine at frequent intervals

Incomplete differential ddx

Not So - Funny Man?
Hi story
911 called for a pt. exhibiting bizarre behavior. No
similar past history. Friends stated he had been
acting funny, agitated, and not sleeping for several
days. No hx of drug use but the family had
suspicions. No other significant past or present
history.

Not So - Funny Man?

Physical exam
Hyper-alert and agitated. Talking very fast but not
making much sense.

BP 160/ 110 HR 124 RR 18 T 101 F

HEENT - PERRL 5 mm Mucous membranes - moist
No distinctive breath odor
Skin - warm and dry
Rest of the exam was WNL
Not So - Funny Man?
Confusion assessment exam
++ Acute onset with a fluctuating course.
++Inattentive - could not focus on the questions.
+Disorganized thinking - speech / subject was hard
to follow.

+- ALOC - hyperalert.
Not So - Funny Man?
ED differential and course
Tox, CNS infection, thyroid disease.
Blood glucose was 97 mg/ dl.
Tox was positive for amphetamine.
To tap or not to tap?
Sleeping Beauty
Hi story
A 20 year old woman is found unconscious in her
room two hours after a fight with her parents. She
was well prior to the incident. She has a history of
emotional problems and occasional migraine
headaches. Medications include Tylenol and
Vicodin for her headaches

ALOC - Sleeping Beauty

Physical
BP 108/ 64 HR 68 RR 12
The general PE was within normal limits. When left
alone she appeared to be sleeping. Pupils were
PERRL at 3mm. There was no response to painful
stimuli but there was some resistance to passive
elevation of her eyelids. Cold calorics elicited tonic
deviation of the eyes with no nystagmus.

ALOC - Sleeping Beauty

Follow up
The history and physical suggested light coma or
simulated coma. However, caloric testing indicated
organic cerebral dysfunction. The patient remained
stable and gradually awakened over 48 hours. She
admitted to ingesting a handful of phenobarbital.

Pathophysiology of Coma
Structural causes
Bilateral cortical disease.
Suppression of the Reticular Activating System.
Supratentorial lesions
Infratentorial lesions
Intrinsic brainstem lesions
Brainstem torque