Approach to Altered Mental Status
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This is the acute alteration in brain function and may include alteration of arousal or awareness, thought content, memory or attention.
Clinical presentation
Depending on the cause but may include: agitated, Restlessness, Hemiparesis, visual deficit, dysphasia
Differential diagnosis
The mnemonic AEIOU TIPS is widely preferred in the emergency department when considering a broader differential. Alcohol/acidosis, Epilepsy/Electrolytes, Insulin/Inborn Errors of Metabolism, Oxygen/Overdose, Uremia, Trauma, Infection, Psychiatric/Poisoning, Stroke/Subarachnoid Hemorrhage/Shock
Investigations
POC Glucose, Rapid Malaria test, Blood gases, Serum Electrolytes, POC ECG, Bedside ultrasound, Serum Creatinine and Urea, Lactate, Complete Blood Count, Liver function tests, Head CT-scan, Chest Xray and/orToxicology screening (If highly suspiciousness of intoxication)
Non pharmacological treatment:
- If aggressive/ restless consider restraining- mechanical or chemical (medications)
- Obtain set of vital signs including random blood glucose
- Perform both primary and secondary assessment and provide necessary interventions.
- Give Oxygen if Hypoxic or dyspnoeic
- Connect the patient to the cardiac monitor to obtain vital signs
Pharmacological treatment
A: diazepam (IV):Adult 5-10mg loading dose, maintenance 0.03-0.1mg/kg every 30 minutes to 6 hours; Paediatrics 0.1-0.15mg/kg stat, may repeat after 3-5 minutes
OR
B: haloperidol (IV): Adult 0.5-10mg *** (If concerned about psychiatric disorder) Child: safety and effectiveness not established
OR
B: ketamine (IV) 1-2mg/kg and 2-4mg/kg for IM
OR
D: midazolam (IV): Adults 5mg stat, maintenance 20-100mcg/kg/hr. infusion; Paediatrics 0.05-0.1mg/kg stat
Note:
Additional pharmacological treatment will depend on the cause of the altered mental status Consult/refer to a higher center with a psychiatrist if concerned about psychiatric disorder