Approach to Altered

LOC
Gabriel Piper
March 31st, 2011

Objectives
Background
Assessment
Approach

to the diagnosis
Managing the undifferentiated altered
LOC patient
Cases!

What is not included?

An

exhaustive review of the work-up or

management of specific causes of
altered LOC (these are covered
elsewhere)

Definitions Altered LOC

Hypervigilence - abnormally increased arousal, responsiveness to

stimuli, and scanning of the environment for threats.

Obtundation - awake but not alert. Psychomotor retardation is

present

Drowsiness or lethargy - simulates light sleep. The patient is

arousable by touch or noise and can maintain alertness for a
period of time.

Stupor - can be aroused only by vigorous stimuli. Efforts to avoid

stimulation are displayed. Little or no spontaneous activity, and
shows little motor or verbal activity once aroused.

Coma - the patient is not arousable at all to verbal or physical

stimuli, and no attempt is made to avoid painful or noxious stimuli.

DSM IV TR criteria for

delirium

1. Disturbance of consciousness with reduced

ability to focus, sustain, or shift attention
2. Evidence from the Hx, PE, Labs that the
disturbance is caused by a general medical
condition, medication or other substance exposure,
substance withdrawal or multiple etiologies
3. A change in cognition (memory deficit,
disorientation, language disturbance) or the
development of a perceptual disturbance that is not
accounted for better by a pre-existing, established,
or evolving dementia
4. The disturbance develops over hours to days
the tends to fluctuate during the course of the day

Pathophysiology

Recognizing Altered LOC

The evaluation of a patients mental
status
involves an assessment of two factors:
1) level of consciousness
2) content of consciousness or cognitive
function

Assessing Level of
consciousness
Several

scales have been created to

assess LOC
GCS, AVPU, ACDU, SMS
GCS most common in Calgary

Glascow Coma Score

Simplified Motor Score

SMS

is as good as GCS for predicting important

clinical outcomes (emergency intubation,
clinically significant brain injury, neurosurgical
intervention, and mortality) and has been
found to have higher inter-rater reliability
3 point scale:
obeys commands=2
localizes pain=1
withdrawals to pain or worse=0

Assessing Delirium
ED

docs arent very good at

diagnosing delirium
Study by Lewis of 385 emergency
patients aged >65
physician had noted altered mental
status in only 17% of patients with
delirium

Confusion Assessment
Method
1) acute onset and fluctuating course
2) inattention
3) disorganized thinking
4) altered level of consciousness.
A diagnosis of delirium according to the
CAM requires the presence of features
1, 2, and either 3 or 4

Beware the hypoalert patient

Hypoactive delirium makes
up 50% of delirious patients
vs 25% for hyperactive (25%
are mixed)

Now that you have made the

diagnosis what next?

Differential diagnosis
I: Infection - Sepsis, encephalitis, meningitis, syphilis, central nervous system (CNS)
abscess, malaria
W: Withdrawal - Alcohol, barbiturates, sedative-hypnotics
A: Acute Metabolic and endocrine - Acidosis, electrolyte disturbance, hepatic or
renal failure, magnesium, calcium, porphyria; endocrinopathies: diabetes,
adrenal, thyroid
T: Trauma head trauma, burns, abuse
C: CNS dz Hemorrhage (EDH, SDH, SAH, intracerebral), stroke, vasculitis(TTP),
seizures, tumor (benign, malignant primary vs metastatic)
H: Hypoxia/Hypercarbia chronic lung dz (ie COPD), acute (Pneumonia, CO,
Methemoglobinemia), global hypoperfusion
D: Deficiencies- Vitamin B12, hypovitaminosis, niacin, thiamine
E: Environmental: Hypothermia, hyperthermia;
A: Acute Vascular - Hypertensive emergency, subarachnoid hemorrhage, sagittal
vein thrombosis
T: Toxins/Drugs - Medications, street drugs, alcohol, pesticides, industrial poisons
(e.g., carbon monoxide, cyanide, solvents), serotonin syndrome, NMS
H: Heavy Metals - Lead, mercury, Iron

Other mnemonics
DIM

TOPS

Drugs/withdrawal
Infection
Metabolic
Trauma
Other (endocrine, environmental)
Psych
Structural, seizure

AEIOU
Find

TIPS

one that works for you!

However..
Lets create an
approach we can use
in the ED

Airway
GCS

<8 then intubate

Important to take entire clinical picture
into context
In the abscence of other indications,
defer intubation until hypoglycemia
and opioid toxicity have been excluded
maintain C-spine collar if history
unknown

Breathing
Hypoxia:

pneumonia, CHF, PE, COPD

Respiratory depression: opioids, brainstem
injury
Hyperpnia:
Profound Met Acidosis
Methanol/EG
DKA/AKA/SKA
Sepsis - Pulmonary source
Respiratory Stimulation
Salicylates

Circulation
Tachy

and Alteredtoo broad

Brady and Altered

BB
Li
Organophosphates
Uremic encephalopathy
Hyperkalemia
Ischemia
shock

Circulation cont
Hypotension:

volume/blood loss
Sepsis
cardiogenic shock
Addisonian crisis

Hypertension:

hypertensive encephalopathy
hyperadrenergic crises

Hot and Altered

Meningitis/Encephalitis/Abscess
Thyroid

storm
Hyperthermia
CVA/CNS bleeds
Tox

Sympathomimetics/Anticholinergics
Withdrawal
NMS/SS/MH
Cholinergics
ASA

Cold and Altered

Environmental
Infection
Thyroid
Wernickes

(hypothalamic dysfunction)

Glucose
Consider

it the 5th vital sign

If hypoglycemic, treat with 1-2 amps of
D50

Coma cocktail - DONT

Dextrose
Oxygen
Naloxone
Thiamine
Flumazanil?

Raised ICP?
deep

coma
unilateral dilated pupil (unexplained by
drug effect or eye disease)
abnormal posturing
abnormal breathing patterns
+/- hypertension and bradycardia

Treat Fever
Acetominophen
Cooling
Benzodiazepines

Consider early antibiotics

for sepsis/menigitis
Early

Abx shown to be important in

severe infections
Draw blood cultures prior to starting
Abx
Give Abx before sending to CT if high
suspicion of infection

Agitated delirium
Clear

association exists between illicit

drug use and the syndrome but not
universal.
Non-drug related causes are almost
always psychotic (schizophrenia, bipolar)
Treat if:
Presence of excited delirium
Continued maximal struggle despite
attempts at maximal restraint

Agitated delirium and SCD

Mechanism of death
No definite etiology usually found at autopsy
Catecholamine excess leading to stress
cardiomyopathy Vs Profound metabolic
acidosis likely leading to cardiac arrest?
Hyperthermia often contributory
Convulsions often contributory
Hyperkalemia often contributory
Restraint asphyxia unlikely explanation

Drug therapy for agitated

patients
Drug induced: benzodiazepines
Drug withdrawal: benzodiazepines
Psychiatric: antipsychotic
Dementia: antipsychotic
Unknown: benzodiazepines
Lorazepam

1-2 mg IV
Midazolam 2.5-5 mg IM
halperidol 0.5-1.0 mg IV => double the dose
every 20-30 minutes prn

Now that you have treated

life threatening emergencies
and have calmed the patient
down..
Time to figure out what is
going on

History
Collateral
Baseline
Change

in mental status

PMHx
Medications/toxins
Social
ROS

history

Collateral
EMS:

onset, location, evidence of

trauma, information about home
environment, medications in home
Family/friends: focal signs prior to LOC,
prodromal symptoms (fevers, HA, etc),
ingestions, access to medications
Other: Old charts, net care, medic alert
bracelet

Baseline
mental

and behavioural status; normally fully

oriented, cognitively intact, attentive and
capable of normal social functioning.
if the patient has an abnormal baseline
mental status => try and semi-quantitate the
degree and time course of any mental status
changes (when he last drove a car, balanced
a checkbook, fed himself, dressed himself,
had a coherent conversation and so on)
social functioning, occupational status,
physical status

Change in Mental Status

time of onset
course and lability
precipitating events (seizure, head injury)
presence of lucid intervals
changes in sleep-awake cycle; Disturbance in the sleep-wake
cycle often occurs early in the course of delirium.
"sundowning" phenomenon
degree of attentiveness and distractability; the ability to
sustain a conversation or a task
short term memory changes
perceptual disturbances -illusions, hallucinations, delusions
emotional lability and poor capacity to modulate emotional
behaviour
psychomotor disturbances - asterixis, myoclonus, motor
restlessness

PMHx

Chronic illnesses (hepatic or renal failure,

endocrinopathies, COPD, DM, CHF)
immunosuppression
Previous history of alcoholism or Wernicke's
encephalopathy
Physical, emotional, mental disabilities
Recent hospitalisations
Recent surgery
Recent cancer treatment (paraneoplastic syndrome)
Recent outpatient therapy or dialysis
Recent depression or suicide ideation

Meds/toxins

Overt/occult alcohol or illicit drug abuse

Any sudden withdrawal from alcohol or sedative drugs
Any new psychotropic drugs (inluding over-the-counter
medications with anti-cholinergic properties eg.
decongestants and cough preperations)
Any new drugs or drug dose changes; clue to recent
medication changes can be that the patient was recently in
the office or admitted to the hospital before the onset of
delirium.
Any salicylate abuse
Use of nutritional supplements or alternative medicines
Intentional/accidental exposure to pesticides, heavy metals,
plant toxins
Intentional/accidental exposure to extreme enviromental
temperatures

Meds to watch for

antibiotics
anticholinergic drugs
Anticonvulsants
anti-inflammatory agents (corticosteroids)
cardiovascular medications (beta-blockers,
antidysrhythmics, antihypertensives, cardiac
glycosides)
Sympathomimetics
sedative-hypnotics
Narcotics
Psychiatric medications (antidepressants,
antipsychotics, mood stabilizers)

Social History
ability

to dress and groom oneself , ability to

feed onself and ability to perform social tasks
such as shopping and house-keeping
Home enviroment and social support systems
nutritional status (thiamine deficiency, Vit B12
and folate deiciency)
Any recent life-altering social or emotional
events
any recent scuba diving (? air embolism) or
foreign travel (malaria)

Review of Symptoms

Recent physical illness

recent head injury (subdural hematoma)
constitutional symptoms
fever (infectious process)
weight loss (malignancy)
night sweats (infections, TB)

Specific neurological symptoms suggesting neurological disease

gait problems (hydrocephalus, frontal strokes)
incontinence (hydrocephalus, frontal strokes)
focal neurological signs (suggestive of a SAH, subdural hematoma,
CVA or tumor)
headache
abrupt changes in language facility
psychomotor automatisms (complex partial seizures)

Specific disease symptoms suggestive of acute organ

dysfunction (AMI, CHF, pneumonia, UTI, thyrotoxicosis)

Physical Exam
Complete

physical exam
Look for physical evidence of diseases
that may have precipitated altered
LOC
Mental status exam to diagnose subtle
delirium and to help differentiate
delirium from dementia

Neuro

Pupils (brainstem lesion, toxidromes)

nystagmus (Wernicke's encephalopathy, PCP intoxication,
alchohol (s) intoxication)
cranial nerves (CVA, CNS tumor, Wernicke's opthalmoplegia)
muscle strength, tone, clonus, abnormal movements (CVA,
space-occupying lesions, NMS or serotonin syndrome)
pathologic primitive reflexes (frontal lobe tumor, strokes or
subdural)
gait apraxia (hydrocephalus, chronic subdural)
peripheral neuropathy (alcoholic, porphyria, paraneoplastic,
vitamin B12 deficiency)
circumoral and distal limb paresthesias and tetany
(hypocalcemia)
Reflexes: generalized hyperreflexia can be found in serotonin
syndrome, tetanus, rabies and strychnine poisoning; while
delayed "hung up" reflexes are found in myxedema coma

Skin

increased pigmentation
Jaundice, spider nevi, caput medusa
Needle tracks
cyanosis unresponsive to oxygen (methemoglobinemia)
feathering burns (lightning injury)
Petechiae and Ecchymosis:

Confined to head and neck seizure or strangulation or emesis

Bleeding diathesis thrombocytopenia, DIC
Vasculitis
menigococcemia

perspiration: Fevers, Hypoglycemia, pheochromocytoma

- dry, warm, flushed - think tox
Cellulitis/nec fasc
uremic frost, anasarca (renal failure)

HEENT
Stiff

neck, positive Jolt test

Cherry red lips: CO
skull - scalp hematoma, Battle's sign,
hemotympanum, CSF otorrhea, raccoon
eyes, diffuse subconjunctival hemorrhage,
epistaxis, CSF rhinorrhea (traumatic head
injury); palpable shunt (shunt malfunction)
Tongue bitten on lateral aspect (seizures)
odor of breath alcohol, almonds (cyanide),
acetone (DKA), ammonia (fetor hepaticus)

Cardiac/Resp/Abdo
cardiac

ischemia/AMI (abnormal heart

sounds, murmurs)
CHF (tachypnea, abnormal heart
sounds, murmurs, rales,
hepatomegealy, pedal edema)
pneumonia (tachypnea, rales,
bronchial breathing)
Intra-abdominal infections (peritonitis,
ascites)

Syndromes
liver

failure - jaundice, spider nevi, caput

medusae, ascites, hepatomegaly or shrunken
hard liver, genital atrophy, gynecomastia, fetor
hepaticus
Thyrotoxicosis - enlarged thyroid, autonomic
hyperactivity, exopthalmos, pretibial myxedema
toxidromes eg. anticholinergic toxicity (red
flushed skin, mydriasis, tachycardia,
hypertension, urinary retention, decreased
bowel sounds)

Mental Status exam?

Do

I have to do a MMSE?
Exam should include assessment of:
the patient's ability to focus and sustain
attention
the patient's capacity to think in an
organized manner
the patient's short-term memory
* A change in baseline in any of these
should make you think of delirium

Comatose patients
Clues

to help determine cause of

coma:

Pupils
Eye Movements
Breathing
Posturing

Bloodwork

CBC
Extended Lytes including Ca, Mg
Osmolality
Cr, BUN
LFTs
CK
TSH, T3, T4
TnT
Serum drug levels: ASA, APAP, Li, anti-epileptics, digoxin
RPR, HIV
Heavy metal testing

Blood gas
pH/pCO2/pO2/HCO3
Lactate
CO

level
Methemoglobin

Urine
Urinalysis
Urine

pregnancy
Urine drugs of Abuse?

Ancillary studies
ECG
CXR
CT

head

LP
Blood
EEG

cultures

when is it okay to defer the CT

scan?
metabolic

cause of the coma that is

readily reversible
if drug intoxication is definitely the
known cause of the coma
carefully observe the patient's mental
status for any unexpected lack of
improvement, or unexplained
deterioration, during treatment of a
particular etiology

Differential diagnosis
I: Infection - Sepsis, encephalitis, meningitis, syphilis, central nervous system
(CNS) abscess, malaria
W: Withdrawal - Alcohol, barbiturates, sedative-hypnotics
A: Acute Metabolic and endocrine - Acidosis, electrolyte disturbance, hepatic or
renal failure, magnesium, calcium, porphyria; endocrinopathies: diabetes,
adrenal, thyroid
T: Trauma - Head trauma, burns, abuse
C: CNS dz - Hemorrhage, stroke, vasculitis(TTP), seizures, tumor
H: Hypoxia/Hypercarbia chronic lung dz (ie COPD), acute (Pneumonia, CO,
Methemoglobinemia), global hypoperfusion
D: Deficiencies- Vitamin B12, hypovitaminosis, niacin, thiamine
E: Environmental: Hypothermia, hyperthermia;
A: Acute Vascular - Hypertensive emergency, subarachnoid hemorrhage, sagittal
vein thrombosis
T: Toxins/Drugs - Medications, street drugs, alcohol, pesticides, industrial poisons
(e.g., carbon monoxide, cyanide, solvents)
H: Heavy Metals - Lead, mercury, Iron

Managing Delirium
minimize

sensory overload by limiting

the number of care-givers and
ensuring a quiet enviroment
allow family members to remain in
constant/frequent attendance
do not leave patients unattended in
the hallway and ensure that the bed
side-rails are up

Cases

Case 1
51

yo M from home
Found by wife in morning to be
unresponsive in bed.
Last seen normal last night.
No known trauma.
Past few days has felt unwell with
fever, chills, increase fatigue. N/V/D
for past 24 hrs

 Brought

in by EMS - LMA placed

O/E: 36.9, 75, 90/50, 8, 100% O2
PERL 3mm sluggish
None-verbal; No eye response
fluctuating motor exam No limb
movement-withdrawing from pain
Otherwise normal exam

 PMHx:

refractory HTN
R frontal
cavernoma incidental finding,
no symptoms in
past
Paroxysmal SVT
Depression according to wife,
untreated, no
previous SA/OD
Chronic HA

Medications:
Pantoloc 40
amitriptylene
ramipril 5 BID
Avalide 300/25
metoprolol 50 BID
Zopiclone 7.5 hs
ditropan xl 5
clonazepam 1 hs
melatonin HS

Hgb 161
WBC 17
Plts 262
Na 138, K 5.1, Cl 105, HCO3 24
Cr 113
BUN 4.5
glucose 7.4
PTT/INR N
Ca, Mg, PO4 normal
Osm 294
Alb 39
APAP, ASA, EtOH, urine tox Neg
Urine R+M neg

 CT

head no change from previous

LP normal
EEG Normal

Case 2
It

is 15 mins after handover and the

nurse tells you she is concerned about
a 22 year old Female patient
handed over as a case of found down
at a party" with normal CXR, ECG and
labs, urine is pending.

 HR

= 100 BP = 120/70 RR = 12 T =
36.0
no response to pain, eyes do not open,
un-intelligible sounds
you also note a rapid, mild, but
prominent twitching of upper and
lower extremities.

Non-convulsive Status
epilepticus
ongoing

subtle status epilepticus

should be suspected if there any
ongoing subtle twitching, jerking
movements, fluttering eyelids especially if the patient has a history
of seizures + evidence of tongue
biting, urinary incontinence

Case 3
32

yo M with presents with with fever,

altered mental status, and vomiting.

patient was too altered to provide a history. history

from family members
3 days before admission, when he developed fevers
and confusion, and began vomiting. He complained of
a headache and neck stiffness.
HIV positive. Has never been on antiretroviral therapy.
He was not taking any medications before the onset
of his illness and had no known drug allergies. His last
CD4 count of 146 cells/L was measured a month and
a half before admission. The patient smokes tobacco
and reportedly has a history of significant alcohol
intake.

General: ill-appearing, thin man; somnolent but arouses

to touch,moaning incomprehensibly, intermittently opens
eyes in
response to stimuli
Vital signs: 39.0C; 100/60; 90; 16 O2 sat 98%
Neurological: Glasgow Coma Score (GCS)--11 (motor
responsiveness = 5, eye opening = 4, verbal
performance = 2); moving all extremities spontaneously;
pupils equal, round, reactive to light (PERRL); extraocular
movement (EOM) intact except for limitation on lateral
gaze with right eye only (consistent with right 6th cranial
nerve palsy)
HEENT (head, eyes, ears, nose, throat): mild scleral
icterus;
Neck: no jugular venous distention; positive neck
stiffness; positive jolt sign; no cervical lymphadenopathy
Chest: rhonchi breath sounds bilaterally, no wheezes or
rales
Cardiovascular: normal
Abdomen: normal

White blood count (WBC): 4.5

Hemoglobin: 134
Platelets: 245
lytes N
Creatinine: 124.5 mol/L (reference range: 53-133
mol/L)
Total bilirubin: 29 mol/L (reference range: 0-17
mol/L)
Direct bilirubin: 25.9 mol/L (reference range: 0-5.1
mol/L)
Liver enzymes N
Albumin: 34 g/L (reference range: 35-50 g/L)
Chest X ray: bilateral fluffy infiltrates, left side greater
than right side

Differential Diagnosis in the

altered HIV pt

infectious

Cryptococcus neoformans*
toxoplasmosis
bacterial meningitis
histoplasmosis
cytomegalovirus (CMV)
progressive multifocal leukoencephalopathy
herpes simplex virus (HSV)
neurosyphilis
tuberculosis

non-infectious

HIV encephalopathy
central nervous system (CNS) lymphoma.*

* Cryptococcus and CNS lymphoma are seen with CD4 <100

W/U in the altered HIV pt

Usual

tests
Syphilis serology, serum cryptococcal antigen
CT with contrast +/- MRI
LP, collect extra fluid for Acid-fast stain, India
ink stain, Cryptococcal antigen and herpes
antigen testing, culture for M tuberculosis
(50-80% of known cases of TBM yield
positive results), Polymerase chain reaction
(PCR), Syphilis serology

Case 4
88

yo M, brought into ED by family

because he is less responsive than
usual
Fell out of bed last night

 36.5,

70, 130/80, 16, 94%

Patient is somnolent and does not
answer questions appropriately
Exam is unremarkable except for
patient is somnolent and does not
answer questions appropriately
According to family he is normally able
to sustain a conversation

Delirium vs. Dementia

both

delirium and dementia are

characterized by a global impairment
in cognitive functioning
meticulous history-taking is sometimes
required to differentiate between these
two entities
Beware hypoactive delirium in the
demented patient!

Dementia
DSM

IV TR
1. Memory impairment (impaired ability to
learn new info or to recall previously learned
info)
2. One or more of the following cognitive
disturbances
aphasia (language disturbance)
apraxia (impaired motor activity)
agnosia (failure to recognize and identify
objects)
disturbance in executive functioning (ie.
planning, organizing, sequencing, abstracting
3. The course is gradual and continuing decline

Clinical feature

Delirium

Dementia

Nature of onset

Abrupt

Gradual, ill-defined
onset

Rapidity of
progression

Rapid (hours)

Slow(months)

Duration

Temporary (days)

years

Variability of
symptoms

Fluctuations

stable

Lucid intervals

Common

none

Attention

short, varies

Unaffected in early
disease, stable

Memory changes

Short-term memory
markedly affected

Long term memory

poor

Disturbed sleepwake cycle

Common

rare

Clouding of
consciousness

Defining feature

none

Marked
psychomotor

Common

absent

Case 5
50

yo M found unconscious in
downtown park. Brought to ED by
EMS. Patient appears unkempt with a
noted smell of EtOH and urine. Empty
wine bottle found at scene.
Previous ED visits for EtOH
intoxication, falls

 Vitals

- 36.5, 90, 24, 140/90 O2 95%

glucose 5.1
No eye opening, unintelligble sounds,
non-specific withdrawal movements
Pupils non-reactive with a 6mm dilated
R pupil.
Exam otherwise normal
What do you do now? What is your
Differential diagnosis?

Investigations
CT

head: large R parietofrontal SDH

EtOH 32

References:
Rosens
EM

clinics of NA: Volume 28, Issue 3,

Pages 439-718 (August 2010).
Alterations of Consciousness in the
Emergency Department
Others as noted in presenters notes