Altered Mental Status - Rapid Response

First Impression
-- Mental Status, acute distress, general appearance (facial droop)
-- Tachypnea increased WOB (flaring, retraction, tripod, cyanosis) - protecting airway? 
-- Current oxygenation, what are they currently hooked up to, are they getting better? Do you need to intubate?

Initial Stabilization
-- If non-responsive (GCS<8), check pulse, intubate
‍-- Hypoglycemia - push D50
-- Opioid Overdose - Naloxone - 0.1mg IV, repeat q3-5 minutes if no response (RR <12 is best indicator, miosis vs normal pupils is not reliable
-- If in respiratroy distress or hypoxic - NRB 100% --> HFNC --> NIPPV if COPD (BIPAP), or CHF (CPAP) --> intubate; PaO2 <60 despite NRB, get on HFNC; PaCO2 >45, put on BIPAP; pH <7.25, will likely tire out trying to blow off CO2
-- Seizure - ativan 2mg, call neuro, likely load Keppra
-- Hypotension/Infection - give LR, send basic and infectious workup, start antibiotics, pressor if needed
-- Concern for Wernicke’s Encephalopathy - IV thiamine
-- Hyperactive Delirium/Agitation - haldol 2-5mg IV vs. 0.5-1mg PO, seroquel PO
-- Hyponatremia - call renal, hypertonic saline if severe and concern for cerebral edema
-- Known CNS mass or edema - call NSGY, likely glucocorticoids

Intake and Summary
-- Reason in the hospital
-- Relevant comorbidities
-- Baseline Mental Status
-- Last known normal
-- Acuity of change
-- Recent meds
-- Current Access
-- Code Status and Decision-makers

Exam
‍-- Vitals - Hemodynamic, O2, RR
-- Red Flags for early intubation - pooling secretions, hemoptysis, respiratory distress
-- If awake - attention, follow commands, focal deficits
-- If not arousable - pupils, localize to pain, posturing
-- Other - movements, tongue biting, incontinence, asterixis

Differential and Workup - "MIST-D"
‍
Metabolic - POC glucose, VBG/ABG, CMP, TSH, Cortisol
Infection - CBC, BCx, lactate, CXR, UA/UCx
Structural - Head CT, stroke alert; consider EEG
Toxin - med rec (opioid, anticholinergic, antihistamine, benzo, anti-dopamine, insulin); consider UDS
Other - bladder scan, empirically tx for constipation
‍
Metabolic
-- Hypoglycemia - check POC, give amp of D50
-- Electrolyte/Uremia (hyponatremia, hypocalcemia, uremia) - BMP
-- Hypercarbia - VBG
-- Thyroid/Endocrine - TSH, cortisol
-- Hepatic Encephalopathy - exam, ammonia
‍
Infection
-- UTI - UA/UCx, bladder scan
-- Pneumonia - CXR
-- Bacteremia - BCx
-- Meningitis/Encephalitis - LP
‍
Structural
-- Ischemic Stroke - if focal deficits call stroke alert; CT
-- Hemorrhagic Stroke / SDH
-- Seizure or Postictal - 2mg ativan, call neuro
-- CNS Tumor
‍
“Toxin”
-- Opioids - push narcan
-- Alcohol or Benzo (intox and withdrawal) - UDS
-- Iatrogenic - med rec for anticholinergic, antihistamine, benzo, anti-dopamine, insulin
‍
Delirium - acute, fluctuating, inattention
-- Elderly, h/o Dementia, CVA, visual/hearing impairment, depression
-- Remove possible offending meds