In the ED, their vitals/exam are as above. Given the patient’s altered mental status and GCS of 8 or less, the patient was intubated upon arrival.
Differential is very broad and includes infection (such as UTI, PNA, meningitis, or viral encephalitis), intercranial process (such as ICH, CVA, mass), cardiopulmonary processes, electrolyte abnormalities (such as hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, hypokalemia, or uremia), intoxication/overdose, and withdrawal syndromes. Lower suspicion for a primary psychiatric process, elevated ammonia, CO poisoning, thyroid abnormality, or primary psychiatric process but also on differential.
– Labs/Tests: VBG plus, Lactate, CBC, CMP, Lipase, TSH, CK, ESR, CRP, Trops x2, BNP, serum toxicology, Ammonia, urinalysis with reflex culture. Consider serum osms, urine osms, volatile panel, urine pain management profile, HIV 1/2 antigen/antibody, HIV-1 viral load, LDH, procalcitonin, Viral studies (CMV, EBV, VZV, HSV 1/2, HHV-6 PCR), Tick studies (Lyme, erlichia, anaplasma), Fungal studies (Galactomannan, 1-3 BDG), Syphilis (RPR, VDRL), LP w/ CSF studies
– Imaging: CXR, CT pan scan including CTA head/neck. Consider MRI if previous studies negative
– Treatments: Consider IVF, O2, Head of bed to 30 deg, antibiotics, empiric acyclovir 10mg/kg IV q8h, antihypertensives, D50, Naloxone, Thiamine, AEDs, Hypertonics, tPA, toxin antidote
– Consults: Neuro. Consider NSGY if potentially interveneable surgical process discovered
– Dispo: Likely admission to ***
***-Toxicologic causes of AMS (more common to less common):
— Withdrawal syndromes such as alcohol withdrawal/benzo withdrawal/opiate withdrawal
— Alcohols including EtOH +/- wernicke’s encephalopathy & toxic alcohols such as methanol/ethylene glycol/isopropyl alcohol
— Opioids
— GABA agonists such as benzos/barbiturates/GHB/GBL/baclofen/14 butanediol/chloral hydrate/sodium thiopental
— Phenethylamines including amphetamine/methamphetamine/MDMA
— Synthetic cannabinoid receptor agonists (SCRAs)
— Hallucinogens such as mushrooms/LSD/PCP/ketamine/mescaline/morning glory/DMT/foxy-methoxy/N-BOMB
— SSRIs
— Atypical antipsychotics
— Lithium
— Clonidine
— Antiepileptics such as valproic acid/phenytoin/carbamazepine/Keppra/Onfi)
— Hypoglycemic agents such as insulin/sulfonamides
— Hydrocarbons
— Anticholinergics such as diphenhydramine/TCAs/antipsychotics/jimson weed/belladonna
— Cholinergics such as pesticides/malathion/carbamate/VX/Sarin
Methylxanthine such as caffeine/theophylline
— Salicylates
— INH
— Botulism
— Heavy metals such as lead/arsenic/thallium
— Tetrodotoxin
— Ergots
— Hemlock
— Paraquat
— Hydrogen peroxide
— Hydrogen sulfide
