Overview of the diagnosis and management of metabolic encephalopathy for third year medical students in the Personalized Education Program portion of the third year curriculum at SIU Medicine
5. 77 YEAR OLD LOST IN PARKING LOT
• Wandering
• Does not know how he got there
• Cannot find car
• Oriented to person
• Knows address
• Brought to ED by EMS for evaluation
6. 77 YEAR OLD LOST IN PARKING LOT
Diagnosis
History
Exam
Tests
8. 77 YEAR OLD LOST IN PARKING LOT
Diagnosis
History
Exam
Tests
9. 77 YEAR OLD LOST IN PARKING LOT
• CT Head
• CBC
• BMP
• UA
• Urine toxicology
• Blood alcohol level
• Chest X-ray
• EKG
• Cardiac enzymes
10. 77 YEAR OLD LOST IN PARKING LOT
• CT Head
• CBC
• BMP
• UA
• Urine toxicology
• Blood alcohol level
• Chest X-ray
• EKG
• Cardiac enzymes
• Discuss patient with primary care provider
16. CAM (CONFUSION ASSESSMENT METHOD)
Features
Acute onset and fluctuating course
Inattention
Disorganized Thinking
OR
Altered level of consciousness
• Most common
assessment tool
• Superior to MMSE
• Sensitivity 94-100%
• Specificity 90-95%
J Am Geriatr Soc. 2008;56(5):823.
24. PRESCRIPTION DRUGS
• Take a thorough drug history
• Call pharmacies
• Review medication administration record (MAR)
• Pay close attention to drug changes
• Consider drug withdrawal
41. 62 YEAR OLD 2 DAYS POSTOP
• Metabolic Encephalopathy
• Drug history
• Narcotics for pain control (New)
• Possible chronic alcohol use
• Labs unremarkable
42.
43. 67 YEAR OLD IN ICU
• Admitted for septic shock and UTI
• On vent
• Reducing sedation
• Agitated
• Combative
48. CAM-ICU – ONSET AND COURSE
Is there evidence of an acute change in mental status
from the patient’s baseline?
OR
Has the patient had any fluctuation in mental status in
the past 24 hours as evidenced by fluctuation on a
sedation/level of consciousness scale (i.e.,
RASS/SAS), GCS, or previous delirium assessment?
49. CAM-ICU – INATTENTION
Say to the patient, “I am going to read you a series of 10 letters.
Whenever you hear the letter ‘A,’ indicate by squeezing my hand.”
Read letters from the following letter list in a normal tone 3 seconds
apart.
S A V E A H A A R T or C A S A B L A N C A or A B A D B A D A A Y
Errors are counted when patient fails to squeeze on the letter “A” and
when the patient squeezes on any letter other than “A.”
Two or more errors qualifies for inattention.
50. CAM-ICU – DISORGANIZED THINKING
Ask the following Yes/No questions
Will a stone float on water?
Are there fish in the sea?
Does one pound weigh more than two pounds?
Can you use a hammer to pound a nail?
Say to patient: “Hold up this many fingers” (Hold 2
fingers in front of patient) “Now do the same thing
with the other hand”
More than one error qualifies for disorganized
thinking
51. CAM – ALTERED LEVEL OF
CONSCIOUSNESS
Present if the RASS score is anything other than alert
and calm (zero)
60. HALOPERIDOL + QUETIAPINE
Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter,
randomized, double-blind, placebo-controlled pilot study *.
Devlin, John; Roberts, Russel; Fong, Jeffrey; Skrobik, Yoanna; Riker, Richard; Hill, Nicholas; Robbins, Tracey;
Garpestad, Erik
Critical Care Medicine. 38(2):419-427, February 2010.
DOI: 10.1097/CCM.0b013e3181b9e302
61. HALOPERIDOL VS. QUETIAPINE
Maneeton B, Maneeton N, Srisurapanont M, Chittawatanarat K.
Quetiapine versus haloperidol in the treatment of delirium: a double-blind, randomized, controlled trial.
Drug Des Devel Ther. 2013 Jul 24;7:657-67.
62. HALOPERIDOL VS. NEWER
NEUROLEPTICS
Hyung-Jun Yoon, Kyoung-Min Park, Won-Jung Choi, Soo-Hee Choi, Jin-Young Park, Jae-Jin Kim and
Jeong-Ho Seok
Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of
delirium
BMC Psychiatry 2013, 13:240
75. MALE FOUND UNRESPONSIVE
• Brought to ED by police
• Unknown identity
• No history
• Disheveled
• Smells strongly of alcohol
• Snoring
• No signs of trauma
• Vitals stable
79. MALE FOUND UNRESPONSIVE
• Brought to ED by police
• Unknown identity
• No history
• Disheveled
• Smells strongly of alcohol
• Snoring
• No signs of trauma
• Vitals stable
• Alcohol Intoxication
80. MALE FOUND UNRESPONSIVE
• Brought to ED by police
• Unknown identity
• No history
• Disheveled
• Smells strongly of alcohol
• Snoring
• No signs of trauma
• Vitals stable
• Alcohol Intoxication
• Thiamine deficiency
81. MALE FOUND UNRESPONSIVE
• Brought to ED by police
• Unknown identity
• No history
• Disheveled
• Smells strongly of alcohol
• Snoring
• No signs of trauma
• Vitals stable
• Alcohol Intoxication
• Thiamine deficiency
• Aspiration pneumonia
82. MALE FOUND UNRESPONSIVE
• Brought to ED by police
• Unknown identity
• No history
• Disheveled
• Smells strongly of alcohol
• Snoring
• No signs of trauma
• Vitals stable
• Alcohol Intoxication
• Thiamine deficiency
• Aspiration pneumonia
• Subdural hematoma