Alterations of Consciousness in the Emergency Department, An Issue of Emergency Medicine Clinics (The Clinics: Internal Medicine) PDF
Preview Alterations of Consciousness in the Emergency Department, An Issue of Emergency Medicine Clinics (The Clinics: Internal Medicine)
AlterationsofConsciousnessintheEmergencyDepartment Foreword Alterations of Consciousness in the Emergency Department AmalMattu,MD ConsultingEditor Sincethetimeofancientcivilizations,philosophersandscientistshavetriedtodefine and understand “consciousness.” A simple internet search using this term reveals morethan47millionsites,manyofthemvariousdefinitionsorquotesbyphilosophers, fromAristotletoFreud,aboutthisterm.Aconsistentdescriptionofconsciousnessthat emergedfromacursoryreviewofthosesiteswasthedescriptionofconsciousnessas a sense of one’s own identity. It is therefore arguable that an altered or loss of consciousness represents one of the most heinous medical presentations we encounter in emergency medicineda loss of one’s identity. Not surprisingly, one of the most basic and also most vital components of any medical student or resident curriculuminemergencymedicineandoneofthecriticalchaptersineverymajortext- book of emergency medicine address the assessment and management of patients with altered levels of consciousness. This topic may be, in fact, the second thing studentsandresidentsinemergencymedicinearetaught,rightafterA-B-C. InthisissueofEmergencyMedicineClinicsofNorthAmerica,GuestEditorDrChad Kesslerandanoutstandinggroupofauthorshavedoneanexcellentjobofaddressing thevariouscausesandpresentationsassociatedwithalteredstatesofconsciousness. An initial article addresses the mental status examination, after which an article addressesperhapsthemostvexingofallemergencydepartmentpresentationsdthe dizzypatient.Threearticlesaredevotedtosyncopeinadultsandpediatricpatients. Other “bread-and-butter” causes of altered consciousness are addressed as well, includingtrauma,infections,psychiatriccauses,metaboliccauses,anddrugtoxicities. An entire article is devoted to the most common toxic cause of altered conscious- nessdethanol,andanentirearticleisdevotedtowhatisperhapsthemostcommonly overlooked,deadlycauseofalteredconsciousnessddeliriumintheelderlypatient. ThisissueofEmergencyMedicineClinicsisaninvaluableadditiontothelibraryof emergencyphysiciansandotherhealthcareprovidersthatcareforacutelyillpatients. EmergMedClinNAm28(2010)xiii xiv doi:10.1016/j.emc.2010.06.008 emed.theclinics.com 07338627/10/$ seefrontmatter(cid:1)2010ElsevierInc.Allrightsreserved. xiv Foreword Moreimportantly,thisismust-readingforstudentsandresidentstraininginemergency medicine. Dr Kessler and colleagues have provided a comprehensive curriculum addressing the care of patients with altered consciousness. The contributors are to becommendedforprovidingthisoutstandingresourcetousall. AmalMattu, MD DepartmentofEmergency Medicine University ofMarylandSchool ofMedicine 110 S.Paca Street, 6th Floor,Suite200 Baltimore,MD21201, USA E-mail address: [email protected] AlterationsofConsciousnessintheEmergencyDepartment Preface Alterations of Consciousness in the Emergency Department ChadKessler,MD GuestEditor Youknowthatawesomefeeling,theoneyougetwhenyouwalkuptotherack(now computertrackingboard)tofindoutwhoyournextpatientis?Whatdiseaseprocess are you up against next? How can you use your detective skills to solve the next mystery,whetheryouareInspectorClouseauorInspectorGadget?Thatinvestigation mightbeoneofthebestpartsofemergencymedicine,unlessthepatienthappensto havealteredmentalstatus,perhapsthemostdreadedchiefcomplaint.NowIcouldbe wrong,butIdonotrecallhearinganyofmycolleaguesorresidentsscreamingforjoy whentheypickupthatchart.WhatIdoknowisthatalteredmentalstatusisanalltoo commonpresentingcomplaintinemergencydepartments(EDs)acrosstheglobeand for an astounding 25% of patients more than 70 years old.1 I believe that much of emergencyphysicians’angststemsfromuncertaintyaboutthesepatients’presenta- tions,ourinsecurediagnoses,andourtentativetreatmentplans.Itisthereforevitalthat wehaveafirmgrasponallthedifferentcauses,presentations,andtreatmentoptions foranypatientwithalteredmentalstatus.AfterreadingthisissueofEmergencyMedi- cine Clinics of North America, you will have a firmer grasp of this once fearful, now manageable,chiefcomplaint. This issue of Emergency Medicine Clinics of North America provides you with a framework for how to approach ED patients with a change in mental status. My goalasGuestEditoristobringtoyouarticleswrittenanddeliveredbyateamofexpert authors,bothmastercliniciansandoriginalresearchers.Wepresenttimelyandnovel contentandcurrentcontroversiesintochallengingandcomplexissues.Thesetalented authorsandresearcherspresenttheirarticlesinadiverseformat,rangingfromcase- basedscenariostoin-depthanalysesandliteraturereviewson13varioustopics.This amazing team draws its talent from across the country and truly represents national EmergMedClinNAm28(2010)xv xvi doi:10.1016/j.emc.2010.06.007 emed.theclinics.com 07338627/10/$ seefrontmatter(cid:1)2010ElsevierInc.Allrightsreserved. xvi Preface andinternationalleadersintheirrespectivefields.Wehopeyoufindthismaterialclin- icallyrelevantandeasilytranslatableintoeverydaypractice. Inthisissue,wewillwalkyoudownthepathtoalteredmentalstatusenlightenment. Itbeginswithalookatthementalstatusexaminemergencypractice.Thenwedive intothedizzyandconfusedpatient.Followingthat,wepresent3articlesonsyncope: itsdiagnosisandevaluation,theEDapproachtoit,andcasesinvolvingchildren.Next, welookatseizuresandcentralnervoussysteminfectionsascausesofalterationsof consciousness.Anextensivereviewoftraumaticbraininjuryinrelationtochangein mental status is followed by psychiatric considerations in patients with decreased levelsofconsciousnessandanarticleondelerium.Weroundouttheissuewithmeta- bolicandtoxiccausesofalteredmentalstatus,includingabrilliantreviewofalcohol abuseandwithdrawal. This issue would not be complete if I did not take the time to thank so many wonderful people for making this a reality. First and foremost, to a mentor, a true idol in emergency medicine, and a friend, I would like to thank Dr Amal Mattu, the ConsultingEditorforEmergencyMedicineClinicsofNorthAmerica,fortheopportu- nitytosharethisissuewithyou.PatrickManleyandtheentireElsevierstaffwereabso- lutely amazing in organizing, preparing, editing, and walking everyone through the process seamlessly and effortlessly. It was a pleasure and honor to work with the best of the best in the preparation of these articles. All the authors, experts in their fields, were gracious in sharing their knowledge and expertise to bring this issue to life. The contributors made my job quite easy by delivering exceptional material, meeting deadlines, and putting an extraordinary amount of effort into each master- piece. Their clever titles and writing styles along with the case-based writing truly givethereaderauniqueexperience.Thankyouall. Finally,andmostimportantly,afewwordstomyfamily.My2littleangels,Kiranand Shaan,werealwaystheretoputahugesmileondaddy’sface,evenwhenIbecame nauseatedbythesightofthewords“alteredmentalstatus.”Idedicatethisissuetomy wife, Sonal, who must have been altered when she said, “I do,” 6 years ago. She remains supportive of my craziness, and without her I could not do half the things I setouttodo.Sonalisalwaysthereforafewwordsofeditingwisdomorjustashoulder tolieonwhenmyeyeswillnotopenmanuallyanylonger.Thankstomy2sistersand myparentsfortheloveandinspirationonlythehometeamcanprovide.Finally,thank you,thereaders.IhopeyouhaveasmuchfunreadingthisissueasIdid,andaswedid writingit. ChadKessler,MD Jesse BrownVAMC Departmentof EmergencyMedicine 820South Damen,M/C 111 Chicago,IL 60612, USA E-mail address: [email protected] REFERENCE 1. HusteyF,MeldonS.Theprevalenceanddocumentationofimpairedmentalstatus inelderly emergencydepartmentpatients. Ann Emerg Med2002;39:248e53. AlterationsofConsciousnessintheEmergencyDepartment Contributors CONSULTING EDITOR AMALMATTU,MD,FAAEM,FACEP ProgramDirector,EmergencyMedicineResidency;Professor,Department ofEmergencyMedicine,UniversityofMarylandSchoolofMedicine,Baltimore, Maryland GUEST EDITOR CHADKESSLER,MD,FACEP,FAAEM SectionChief,EmergencyMedicine,JesseBrownVeteransAffairsHospital; AssistantProfessor,DepartmentsofInternalMedicineandEmergencyMedicine; AssociateProgramDirector,CombinedInternalMedicine/EmergencyMedicine Residency,TheUniversityofIllinoisSchoolofMedicineatChicago,Chicago,Illinois AUTHORS STEVENE.AKS,DO,FACMT,FACEP Director,ToxikonConsortium;DivisionofToxicology,DepartmentofEmergency Medicine,CookCountyHospital(Stroger);AssociateProfessorofEmergencyMedicine, RushUniversity,Chicago,Illinois JEFFREYJ.BAZARIAN,MD,MPH AssociateProfessor,DepartmentofEmergencyMedicine,CenterforNeural DevelopmentandDisease,UniversityofRochesterSchoolofMedicineandDentistry, Rochester,NewYork BRIANJ.BLYTH,MD AssistantProfessor,DepartmentofEmergencyMedicine,CenterforNeural DevelopmentandDisease,UniversityofRochesterSchoolofMedicineandDentistry, Rochester,NewYork SEANM.BRYANT,MD AssociateProfessor,DepartmentofEmergencyMedicine,CookCountyHospital (Stroger);AssistantFellowshipDirector,ToxikonConsortium;AssociateMedicalDirector, IllinoisPoisonCenter,Chicago,Illinois JENNIFERJ.CASALETTO,MD,FACEP AssociateProfessor,DepartmentofEmergencyMedicine;ResidencyProgram Director,VirginiaTech-CarilionSchoolofMedicine,Roanoke,Virginia CHRISTINES.CHO,MD,MPH,FAAP HSAssistantClinicalProfessor,DepartmentofPediatrics,UniversityofCalifornia, SanFrancisco;DivisionofEmergencyMedicine,Children’sHospital&ResearchCenter Oakland,Oakland,California iv Contributors COLROBERTDELORENZO,MD,MSM,FACEP,MC,USA ProfessorofMilitaryandEmergencyMedicine,UniformedServicesUniversity oftheHealthSciences,Bethesda,Maryland;Chief,DepartmentofClinicalInvestigation, MCHE-CI,BrookeArmyMedicalCenter,FortSamHouston,Texas E.WESLEYELY,MD,MPH DivisionofAllergy,Pulmonary,andCriticalCare,DepartmentofInternalMedicine, CenterforHealthServicesResearch,VanderbiltUniversityMedicalCenter,Nashville, Tennessee JASONW.J.FISCHER,MD,MSc EmergencyMedicineUltrasoundFellow,DepartmentofEmergencyMedicine,Alameda CountyMedicalCenter;PediatricEmergencyMedicineFellow,DivisionofEmergency Medicine,Children’sHospital&ResearchCenterOakland,Oakland,California JINH.HAN,MD,MSc DepartmentofEmergencyMedicine,VanderbiltUniversityMedicalCenter,Nashville, Tennessee BLAINEHANNAFIN,MD AttendingPhysician,DepartmentofEmergencyMedicine,ChandlerRegionalHospital, Chandler,Arizona ANDYJAGODA,MD,FACEP ProfessorandChairofEmergencyMedicine,MountSinaiSchoolofMedicine, NewYork,NewYork CHADKESSLER,MD,FACEP,FAAEM SectionChief,EmergencyMedicine,JesseBrownVeteransAffairsHospital; AssistantProfessor,DepartmentsofInternalMedicineandEmergencyMedicine; AssociateProgramDirector,CombinedInternalMedicine/EmergencyMedicine Residency,TheUniversityofIllinoisSchoolofMedicineatChicago,Chicago,Illinois JASMINEKOITA,MD DepartmentofEmergencyMedicine,MountSinaiSchoolofMedicine,NewYork, NewYork CHRISTINEKULSTAD,MD AssistantProgramDirector;ClinicalAssistantProfessor,DepartmentofEmergency Medicine,AdvocateChristMedicalCenter,OakLawn,Illinois SHARONE.MACE,MD Professor,DepartmentofEmergencyMedicine,ClevelandClinicLernerCollege ofMedicineofCaseWesternReserveUniversity;Faculty,EmergencyMedicine ResidencyProgram,MetroHealthMedicalCenter;Director,PediatricEducation/Quality Improvement;Director,ObservationUnit;ResearchDirector,RapidResponseTeam, ClevelandClinic,Cleveland,Ohio TIMOTHYJ.MEEHAN,MD,MPH FellowinMedicalToxicology,ToxikonConsortium;ClinicalInstructor,Department ofEmergencyMedicine,UniversityofIllinois-Chicago,Chicago,Illinois Contributors v HELENOUYANG,MD,MPH DepartmentofEmergencyMedicine,BrighamandWomen’sHospital;Massachusetts GeneralHospital,DepartmentofEmergencyMedicine,Boston,Massachusetts HENRYZ.PITZELE,MD AssociateDirector,SectionofEmergencyMedicine,JesseBrownVeteransAffairs MedicalCenter;ClinicalAssistantProfessor,DepartmentofEmergencyMedicine, UniversityofIllinoisatChicago,Chicago,Illinois CHARLESV.POLLACKJr,MA,MD,FACEP,FAAEM,FAHA ProfessorandChairman,DepartmentofEmergencyMedicine,PennsylvaniaHospital, UniversityofPennsylvania,Philadelphia,Pennsylvania JAMESQUINN,MD,MS AssociateProfessorofSurgery/EmergencyMedicine,DivisionofEmergencyMedicine, StanfordUniversity,PaloAlto,California SYLVANARIGGIO,MD ProfessorofPsychiatryandNeurology,MountSinaiSchoolofMedicine,NewYork, NewYork DOUGLASRUND,MD Professor;ChairoftheDepartmentofEmergencyMedicine,OhioStateUniversity MedicalCenter,Columbus,Ohio DAVIDE.SLATTERY,MD,FACEP,FAAEM AssistantProfessor,DepartmentofEmergencyMedicine,UniversityofNevadaSchool ofMedicine,LasVegas,Nevada VAISHALM.TOLIA,MD,MPH AssistantProfessor,DepartmentofEmergencyMedicine,UniversityofCalifornia SanDiego,SanDiego,California JENNYM.TRISTANO,MD InternalMedicine/EmergencyMedicineResidencyProgram,UniversityofIllinoisat Chicago,Chicago,Illinois AMANDAWILSON,MD DepartmentsofPsychiatryandEmergencyMedicine,VanderbiltUniversityMedical Center,Nashville,Tennessee JAMESL.YOUNG,MD ClinicalAssistantProfessor;AssociateChairforClinicalServices,Department ofPsychiatry;DirectorofPsychiatricEmergencyServices,OSUHardingHospital, OhioStateUniversityMedicalCenter,Columbus,Ohio AlterationsofConsciousnessintheEmergencyDepartment Contents Foreword:AlterationsofConsciousnessintheEmergencyDepartment xiii AmalMattu Preface:AlterationsofConsciousnessintheEmergencyDepartment xv ChadKessler TheMentalStatusExaminationinEmergencyPractice 439 JasmineKoita,SylvanaRiggio,andAndyJagoda Asystematicapproachtoassessingmentalstatusintheemergencyde- partmentiskeytoidentifyingalterationsinmentalstatusandtodirecting diagnostictestingandmanagement.Afterinitialstabilizationofthepatient, itiscritical toassessa patient’salertness, attention,and cognition, and performabriefpsychiatricassessmenttofullyevaluateapatientwithmen- talstatuschanges.Thisarticleoffersanapproachtoallowbettermanage- mentofapatientwithalteredmentalstatus. DizzyandConfused:AStep-by-StepEvaluationoftheClinician’sFavorite ChiefComplaint 453 ChristineKulstadandBlaineHannafin This article covers the general approach to patients who present to the emergency department with a complaint of dizziness or vertigo, and al- tered mentation. Patients’ histories and physical examination findings are discussed first, then a pertinent differential diagnosis, ranging from neurologicalcausesandpoorperfusionstatestotoxicologiccauses,isde- scribedalongwiththedistinguishingfeaturesandpotentialdiagnosticpit- fallsofeachproblem.Casescenariosarepresentedandthetreatmentand dispositionofpatientsfromtheemergencydepartmentarediscussed. DiagnosisandEvaluationofSyncopeintheEmergencyDepartment 471 HelenOuyangandJamesQuinn With a careful history, physical examination, and directed investigation, physicianscandeterminethelikelycauseofsyncopeinmorethan50% andperhapsupto80%ofpatients.Understandingthecauseofsyncope allows clinicians to determine the disposition of high- and low-risk pa- tients.Patientswithapotentialmalignantcause,suchasacardiacorneu- rologic condition, should be treated and admitted. Those with benign causes can be safely discharged. This article reviews the diagnosis and EDwork-upofsyncope,thedifferentclassificationsofsyncope,andprog- nosis.Theuseofspecificdecisionrulesinriskstratificationandsyncopein thepediatricpopulationarediscussedinanotherarticle. viii Contents TheEmergencyDepartmentApproachtoSyncope:Evidence-basedGuidelines andPredictionRules 487 ChadKessler,JennyM.Tristano,andRobertDeLorenzo Syncopeisasudden,transientlossofconsciousnessassociatedwithin- abilitytomaintainposturaltonefollowedbyspontaneousrecoveryandre- turn to baseline neurologic status. Global cerebral hypoperfusion is the finalpathwaycommontoallpresentationsofsyncope,butthissymptom presentationhasabroaddifferentialdiagnosis.Itisimportanttoidentify patientswhosesyncopeisasymptomofapotentiallylife-threateningcon- dition. This article reviews the current status of syncope from the emer- gencydepartmentperspective,focusingonthecurrentevidencebehind thevariousclinicaldecisionrulesderivedduringthepastdecade. PediatricSyncope:CasesfromtheEmergencyDepartment 501 JasonW.J.FischerandChristineS.Cho Pediatricsyncopeisacommonpresentationintheemergencydepartment. Mostcausesarebenign,butanevaluationmustexcluderarelife-threatening disorders.Thelackofobjectivefindingscanposeachallenge.Thiscase- basedreviewemphasizestheimportanceofadetailedhistoryandphysical examinationwithelectrocardiogramindetermininghigh-riskpatients. SeizuresasaCauseofAlteredMentalStatus 517 DavidE.SlatteryandCharlesV.PollackJr Thedifferentialdiagnosisandempiricmanagementofalteredmentalstatus andseizuresoftenoverlap.Alteredmentalstatusmayaccompanyseizures orsimplybethemanifestationofapostictalstate.Thisarticleprovidesan overviewofthe numerouscausesof altered mentalstatus andseizures: metabolic,toxic,malignant,infectious,andendocrinecauses.Thearticle focusesonthoseagentsthatshouldprompttheemergencyphysiciantoini- tiateuniquetherapytoabatetheseizureandcorrecttheunderlyingcause. CentralNervousSystemInfectionsasaCauseofanAlteredMentalStatus? WhatisthePathogenGrowinginYourCentralNervousSystem? 535 SharonE.Mace Thereareseveralcentralnervoussystem(CNS)infections(meningitis,en- cephalitis,andbrainabscess),anyofwhichmaypresentwithanaltered levelofconsciousness.BecauseCNSinfectionscanhaveadevastating outcome, it is important to recognize the presence of a CNS infection and begin treatment as soon as possible because early appropriate therapymay,insomecases,limitmorbidityandmortality. TraumaticAlterationsinConsciousness:TraumaticBrainInjury 571 BrianJ.BlythandJeffreyJ.Bazarian Mildtraumaticbraininjury(mTBI)referstotheclinicalconditionoftransient alterationofconsciousnessasaresultoftraumaticinjurytothebrain.The Contents ix priorityofemergencycareistoidentifyandfacilitatethetreatmentofrare but potentially life-threatening intracranial injuries associated with mTBI throughthejudiciousapplicationofappropriateimagingstudiesandneu- rosurgicalconsultation.Althoughpost-mTBIsymptomsquicklyandcom- pletely resolve in the vast majority of cases, a significant number of patientswillcomplainoflastingproblemsthatmaycausesignificantdis- ability.Simpleandearlyinterventionssuchaspatienteducationandap- propriate referral can reduce the likelihood of chronic symptoms. Althoughdefinitiveevidenceislacking,mTBIislikelytoberelatedtosig- nificantlong-termsequelaesuchasAlzheimerdiseaseandotherneurode- generativeprocesses. PsychiatricConsiderationsinPatientswithDecreasedLevelsofConsciousness 595 JamesL.YoungandDouglasRund Whenpatientspresenttotheemergencydepartmentwithchangesinbe- haviorandlevelsofconsciousness,psychiatriccausesoftenmovetothe topofthelistofdiagnosticconsiderations.Itisimportanttothoroughlyas- sess such patients for medical causes. Although it is not common for primarypsychiatricconditionstopresentwithalteredlevelsofconscious- ness,severecasesmaypresentinthisfashion.Alteredmentalstatesmay also be caused by adverse reactions to psychiatric medications. In this article, the authors review some of the psychiatric causes of decreased levelsofconsciousness,aswellascertainadversedrugreactionstopsy- chotropicmedications. DeliriumintheOlderEmergencyDepartmentPatient:AQuietEpidemic 611 JinH.Han,AmandaWilson,andE.WesleyEly Deliriumisdefinedasanacutechangeincognitionthatcannotbebetter accounted forbyapreexisting orevolving dementia.Thisformof organ dysfunctioncommonlyoccursinolderpatientsintheemergencydepart- ment(ED)andisassociatedwithamultitudeofadversepatientoutcomes. Consequently, delirium should be routinely screened for in older ED patients. Once delirium is diagnosed, the ED evaluation should focus onsearchingfortheunderlyingcause.Infectionisoneofthemostcommon precipitantsofdelirium,butmultiplecausesmayexistconcurrently. IsSalt,Vitamin,orEndocrinopathyCausingthisEncephalopathy?AReview ofEndocrineandMetabolicCausesofAlteredLevelofConsciousness 633 JenniferJ.Casaletto Altered level of consciousness describes the reason for 3% of critical emergency department (ED) visits. Approximately 85% will be found to have a metabolic or systemic cause. Early laboratory studies such as abedsideglucosetest,serumelectrolytes,oraurinedipsticktestoftendi- recttheEDprovidertowardendocrineormetaboliccauses.Thisarticleex- aminescommonendocrineandmetaboliccausesofalteredmentationin
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