Altered Mental Status

Introduction

Altered mental status is the acute alteration in brain function and may include alteration of arousal or awareness, thought content, memory or attention.

Clinical presentation of altered mental status

The presentation of this condition is dependent on the cause but may include:

  1. Agitated
  2. Restlessness
  3. Hemiparesis
  4. Visual deficit
  5. Dysphasia

Differential diagnosis

The mnemonic AEIOU TIPS is widely preferred in the emergency department when considering a broader differential.

  1. Alcohol/acidosis,
  2. Epilepsy/Electrolytes,
  3. Insulin/Inborn
  4. Errors of Metabolism,
  5. Oxygen/Overdose,
  6. Uremia,
  7. Trauma,
  8. Infection,
  9. Psychiatric/Poisoning,
  10. Stroke/Subarachnoid
  11. Hemorrhage/Shock

Investigations

  • Point of Care 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/or
  • Toxicology screening (If highly suspiciousness of intoxication)

Treatment for altered mental status

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

C: 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.

Referral

Consult/refer to a higher center with a psychiatrist if concerned about psychiatric disorder