THE ALTERED PATIENT
From Topics in Emergency Medicine, sponsored by the University of California, San Francisco, School of Medicine
Barry C. Simon, MD, Associate Clinical Professor of Medicine, University of California, San Francisco, School of Medicine, and Chairman, Department of Emergency Medicine, Alameda County Medical Center
| Organic vs functional disorders: functional (psychiatric) vs organic (structural, toxic, or metabolic); organic— delirium vs dementia; functional—take care not to label patient with psychiatric disease they really do not have |
| Delirium: important to identify patient with delirium because of morbidity and mortality (many treatable); patient with dementia not as treatable, unless episode acute on chronic (eg, elderly patient with dementia and urinary tract infection); many etiologies |
 | Signs and symptoms: patient with delirium tremens (DTs) prototypical of patient with delirium; one minute patient making sense, next minute thrashing on bed, diaphoretic, hypertensive, and febrile, and half hour later patient fine; acute onset with fluctuating course; often no good history available; patients have difficulty focusing and easily distracted; altered level of consciousness (ALOC); visual hallucinations (as opposed to auditory hallucinations seen in psychiatric disease); abnormal vital signs common at some point during course |
| Dementia: insidious onset (unless acute on chronic problem); patients disoriented but have normal level of alertness and no hallucinations; normal vital signs; dementia with acute on chronic process difficult to distinguish from delirium; patients can have hypertension, tachycardia, agitation, and fever (not as high as in patient with delirium); patients usually oriented if they decide to talk |
| Summary: patients with delirium have wildly fluctuating course; auditory hallucinations seen with functional psychosis, visual hallucinations with delirium; disorientation hallmark of delirium; normal level of consciousness with psychosis; abnormal vital signs seen in both groups of patients; terminology—terms such as alert, lethargy, stupor, and coma may have different meanings to different people; descriptive terminology clearer (eg, “patient unresponsive even to deep painful stimuli”) |
| Case: man 32 yr of age found running naked in field; known alcohol and drug abuser; during booking process, man falls, hits head, and becomes unconscious; police provide history known to them; physical examination (PE)—hypotensive, tachycardic, temperature 107°F, unresponsive to painful stimuli, small contusion, pupils 4 mm and sluggish, decreased gag and equivocal plantar reflexes; remainder of PE normal; diagnosis not made in emergency department (ED), despite aggressive resuscitative efforts and studies; differential broad; diagnosis thyrotoxicosis (large thyroid missed); records show patient had presented to ED 2 mo before with symptoms consistent with hyperthyroidism, but was lost to follow- up |
| Development of differential diagnosis: textbook—pneumonic alcohol, other toxins, drugs; endocrine, electrolytes; insulin; oxygen, opiates; uremia (renal, including hypertension); trauma; infection; psychiatric, porphyria; subarachnoid, space-occupying lesion (AEIOU TIPS; takes long time to go through associations) |
| Alternative method: start at head and work way down through each organ system; head—anything not supposed to be there or anything not there that should be; no blood or less blood (cerebrovascular accident); blood in epidural, subdural, subarachnoid, intracerebral, or intraventricular space; masses; infections (meningitis; encephalitis); abscess (in brain or brain stem); seizure (postictal period; nonconvulsive status epilepticus); mouth—toxins; medications; cocaine delirium—chronic cocaine use changes way norepinephrine stored and metabolized, so have much norepinephrine around; agitation (eg, being chased by police) or increased sympathetic activity causes syndrome of rhabdomyolysis, dehydration, disseminated intravascular coagulation (DIC), acute respiratory distress syndrome, renal failure, and death; rapid rehydration and cooling necessary; γ-hydroxybutyrate (GHB)—date rape drug; difficult to recognize (no easy test); patients lose consciousness suddenly and start hypoventilating (anesthetic; intubation required in some cases); seizure possible; patients unconscious for ≈3 hr and wake up not knowing where they are; flunitrazepam (Rohypnol)—also date rape drug; causes profound amnesia; short- to medium-acting benzodiazepine (lasts ≈8 hr); odorless, tasteless, dissolves readily; level of consciousness profoundly decreased; neck—high or low thyroid activity; consider import of scar or mass; parathyroid (hypercalcemia); chest—hypercarbia (PCO 2 ≥100 mm Hg) causing ALOC; hypoxia; emboli from atrial fibrillation; abdomen—liver; Wernicke’s encephalopathy can develop in anyone who becomes malnourished, (eg, alcoholics. women with hyperemesis gravidarum, patients on hyperalimentation for long periods, patients with HIV infection or malignancy); give thiamine; pancreas (high or low blood glucose); adrenal insufficiency; kidney (hyponatremia; hypernatremia; hyperosmolality); other—sepsis; heat stroke; hypothermia; hyperviscosity syndromes (history of malignancy); vasculitis |
| Case: girl 14 yr of age found down near bus stop ≈11 AM ; no family members to provide history; gurgling respirations; hypotensive; tachycardic; low O2 saturation (hypoventilating); pupils equal, round, reactive to light and accommodating (PERRLA), 3 mm and sluggish; disconjugate gaze; alcohol on breath; neurologic examination—responded appropriately to deep painful stimuli; poor gag reflex; moved extremities equally; deep tendon reflexes within normal limits; plantar reflexes equivocal; blood glucose 119 mg/dL; no response to naloxone (Narcan); flumazenil—patient given 0.2 mg x 3 and regained consciousness; diagnosis mixed ingestion of alcohol and benzodiazepine; literature states flumazenil dangerous and should be used only to awaken patient given benzodiazepine for procedure; article showed if flumazenil given in 0.2-mg aliquots, no seizures; flumazenil given to person with no benzodiazepine in system has no effect (competitive inhibitor of benzodiazepine); use carefully in mixed ingestions or benzodiazepine addiction (seizure possible); if seizure occurs, give benzodiazepine and add phenobarbital to help suppress seizures |
| Vital signs: respiratory rate and pattern—if abnormal, (eg, ataxic, Cheyne-Stokes) most of time ALOC due to structural lesion; heart rate and rhythm—Cushing’s reflex makes blood pressure go up and causes bradycardia; digoxin toxicity causes paroxysmal atrial tachycardia with 2-to-1 block; β-blockers and calcium channel blockers change QRS complex, rate, and rhythm; blood pressure—look for wide pulse pressure, high systolic pressure; rectal temperature— hyper- or hypothermia provide clues to diagnosis |
| Pertinent general PE: head—look for signs of trauma; smell breath for toxins (arsenic smells like garlic; insecticides [organophosphates] smell like onion; glue has hydrocarbon odor; cyanide smells like almonds); neck— thyroid; scars; chest—signs of atrial fibrillation, end stage chronic obstructive pulmonary disease (COPD); abdomen—organomegaly (liver, spleen, kidney); skin—hot; cold; clammy; dry; moist axilla, hypoglycemia; dry axilla, hyperglycemia; tracts (intravenous drug use); petechiae (meningococcemia); jaundice; vascular spiders; bullae (phenobarbital toxicity) |
| Observation: autisms—clue that patient has nonconvulsive status epilepticus; repetitive behaviors that include lip smacking, eyes rolling, protruding and retracting tongue; hiccupping, frequent yawning, pronounced dramatic swallowing ; posturing—look for and identify cause (most likely structural, rarely toxic or metabolic) |
| Motor examination: predictive of outcome; look at whether movements purposeful (indicates level of consciousness), response to painful stimuli, and tone; increased tone—neuroleptic malignant syndrome; tetanus; strychnine poisoning; serotonin syndrome |
| Eyes: pupil—nonreactive (almost always structural problem; lesion on same side as dilated pupil ≈85% of time); unilateral, dilated, fixed pupil in awake alert person caused by aneurysm pushing on posterior communicating nerve (parasympathetic fibers compressed, unopposed sympathetic activity); funduscopic examination—diabetic retinopathy; hypertensive retinopathy; acute bleeding; previous bleeding; central retinal artery occlusion; central retinal venous occlusion; methanol ingestion (methanol metabolized to formic acid and formaldehyde; formaldehyde causes retina to have “blood and thunder” appearance as seen in central retinal venous occlusion); toxins that prevent body from using O2 (eg, aspirin and hydrogen sulfide overdoses, cyanide ingestion, and carbon monoxide) cause veins to stay oxygenated, and color differential between artery and vein lost; eye and eyelid movements—help distinguish person with conversion reaction from person truly comatose; when opened, eyes of comatose person lazily roll to one side or other while eyes of person with conversion reaction stare straight ahead or move quickly from place to place; if eyelids of comatose person opened and let go, they do not close much, while eyelids of person with conversion reaction stay open or shut quickly |
| Calorics: if cold water squirted into ear and eyes do nothing, bad sign; if eyes react, brainstem and cortex working; if eyes do something and stop, brainstem fine, problem in cerebral cortex |
| Mental status examination: mini mental status examination best, but takes long time; good interobserver reliability; confusion assessment method (CAM)—easier; faster (done while doing rest of examination); excellent interobserver reliability; need 3 things to diagnose delirium, 1) acute onset with fluctuating course, 2) difficulty focusing, and 3) disorganized thinking or ALOC |
| Standard: ≤10-min studies; blood glucose; pulse oximetry; arterial blood gas (acidosis, hypercarbia, or hypoxemia); urinalysis by dipstick (shows dehydration, infection, hyperglycemia, or blood); breathalyzer; electrocardiography (look for shortened QT with hypercalcemia, long QT with hypocalcemia, terminal component of QRS for tricyclic ingestions; blocks); naloxone; thiamine; flumazenil; physostigmine—acceptable if used in person who has taken noncardiotoxic anticholinergic drug; competitive inhibitor of anticholinergic drugs; give 0.5-mg doses up to maximum of 2 mg; either nothing happens, or they develop typical cholinergic symptoms (salivation, lacrimation, urination, defecation, gastric irritation, and emesis) if they had no anticholinergic on board, or they wake up; keep atropine nearby for bradycardia |
| Additional studies: electrolytes; serum urea nitrogen (BUN) and creatinine; serum osmolality; calcium (malignancy; Paget’s disease; parathyroid disease); complete blood count (CBC); carboxyhemoglobin level; lumbar puncture (central nervous system infection); directed toxicology screen; thyroid function studies; head computed tomography (CT); peritoneal tap (for ascites) |
| Case: man 18 yr of age called 911 for severe headache; man refuses to let paramedics into house on arrival; mother calls 911 30 min later; man comatose; man diabetic and frequently forgets to take insulin; paramedics give dextrose; vital signs—hypertension; otherwise, vitals normal; comatose; appears otherwise healthy; PE—skin moist (not hyperglycemic); pupils PERRLA and 6 mm; neurologic examination nonfocal, except for bilateral upgoing toes; blood glucose 19 mg/dL; second bolus of glucose given with no change in mental status; second bolus of glucose—study shows blood glucose raised average of 130 mg/dL (range 30 to 300 mg/dL) after single dose of D-50-W; second dose appropriate if blood sugar low and increased only small amount with first dose; CT showed subdural bleeding |
| Case: man 28 yr of age; had slurred speech and became unconscious 15 min before arrival; tachypneic; most of examination normal; pupils PERRLA; deep tendon reflexes 3+ and equal; plantar reflexes extensor; intermittent bilateral decerebrate posturing; fine after D-50-W; here posturing did not mean structural lesion; 5% of patients who become hypoglycemic have focal abnormalities on PE; always check blood glucose |
| Review: garlic odor of breath in someone who ingested arsenic; absence of response to light indicates structural defect; 130 mg/dL average increase in blood glucose after D-50-W; avoid flumazenil in patients with mixed ingestion; assume patient delirious because morbidity and mortality associated with delirium states (80% reversible); start from head and work down (have system); eyes, ears, and mental status examination key; flumazenil and physostigmine have role; forgetting basics most common error (glucose; O2 ; thiamine); avoid treatment delay, failure to reexamine, incomplete differential diagnosis |
Educational Objectives
| The goal of this program is to provide the listener with information on the assessment of a patient with an altered level of consciousness (ALOC). After hearing and assimilating this program, the clinician will be better able to: |
| 1. Distinguish between organic and functional causes of ALOC. |
| 2. Develop a differential diagnosis for a patient with ALOC. |
| 3. Discuss important points in the physical examination of patient with ALOC. |
| 4. Describe the neurologic examination of a patient with ALOC. |
| 5. Discuss critical tests needed for diagnosis of a patient with ALOC. |
Discussed on This Program
Digoxin [Digitek, Lanoxicaps, Lanoxin] Flumazenil [Romazicon] Flunitrazepam [Rohypnol] Naloxone HCl [Narcan] Phenobarbital [Bellatal, Luminal Sodium, Solfoton] Physostigmine salicylate [Antilirium] Thiamin (B1 ) [Thiamine HCl, Thiamilate]
Suggested Reading
Arnold E: Sorting out the 3 D’s: delirium, dementia, depression: learn how to sift through overlapping signs and symptoms so you can help improve an older patient’s quality of life. Holist Nurs Pract 19:99-104, 2005; Cakir M, et al: A case of rhabdomyolysis associated with thyrotoxicosis. J Natl Med Assoc 97:732-4, 2005; Freeman WD, Chabolla DR: 36-Year-old woman with loss of consciousness, fever, and tachycardia. Mayo Clin Proc 80:667-70; Gaudreau JD, et al: Impact on delirium detection of using a sensitive instrument integrated into clinical practice. Gen Hosp Psychiatry 27:194-9, 2005; Kaineg B, Hudgins PA: Images in clinical medicine. Wernicke’s encephalopathy. N Engl J Med 352:e18, 2005; Kulh MA, et al: Management of delirium: a clinical governance approach. Aust Health Rev 29:246-52, 2005; Lynch M: Caring for the patient with delirium tremens. J Pract Nurs 55:21-2, 2005; Minden Sl, et al: Predictors and outcomes of delirium. Gen Hosp Psychiatry 27:209-14, 2005; Oyama K: When delirium takes hold. RN 68:52-6, 2005; Pierre JS: Delirium: a process improvement approach to changing prescribing practices in a community teaching hospital. J Nurs Care Qual 20:244-50, 2005; Reischies FM, et al: Electrophysiological and neuropsychological analysis of a delirious state: the role of the anterior cingulate gyrus. Psychiatry Res 138:171-81, 2005; Takeuchi T, et al: Delirium in inpatients with respiratory diseases. Psychiatry Clin Neurosci 59:253-8, 2005; Tote S, Mulleague L: The role of flumazenil in self harm with benzodiazepines: to give or not to give? Hosp Med 66:308, 2005; Washburn LA: Altered mental status: cause determines treatment. JAAPA 18:16-22, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. For this issue there is nothing to report.
Dr. Simon was recorded at Topics in Emergency Medicine, held October 26, 2004, in San Francisco, and sponsored by the University of California, San Francisco, School of Medicine. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.
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