Altered Mental Status in the Emergency Department

2017 ◽  
pp. 209-232 ◽  
Author(s):  
Austin T. Smith ◽  
Jin H. Han
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Altered Mental Status

scholarly journals Recurrent noncirrhotic hyperammonemia causing acute metabolic encephalopathy in a patient with a continent ileocecal pouch: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
T. M. Skipina ◽  
S. Macbeth ◽  
E. L. Cummer ◽  
O. L. Wells ◽  
S. Kalathoor
Keyword(s):  
Emergency Department ◽  
Metabolic Acidosis ◽  
Mental Status ◽  
Rare Case ◽  
Liver Function Tests ◽  
Altered Mental Status ◽  
Potassium Citrate ◽  
Metabolic Encephalopathy ◽  
History Of ◽  
Normal Urine

Abstract Introduction Acute encephalopathy, while a common presentation in the emergency department, is typically caused by a variety of metabolic, vascular, infectious, structural, or psychiatric etiologies. Among metabolic causes, hyperammonemia is relatively common and typically occurs in the setting of cirrhosis or liver dysfunction. However, noncirrhotic hyperammonemia is a rare occurrence and poses unique challenges for clinicians. Case presentation Here we report a rare case of a 50-year-old Caucasian female with history of bladder cancer status post chemotherapy, radical cystectomy, and ileocecal diversion who presented to the emergency department with severe altered mental status, combativeness, and a 3-day history of decreased urine output. Her laboratory tests were notable for hyperammonemia up to 289 μmol/L, hypokalemia, and hyperchloremic nonanion gap metabolic acidosis; her liver function tests were normal. Urine cultures were positive for Enterococcus faecium. Computed tomography imaging showed an intact ileoceal urinary diversion with chronic ileolithiasis. Upon administration of appropriate antibiotics, lactulose, and potassium citrate, she experienced rapid resolution of her encephalopathy and a significant reduction in hyperammonemia. Her hyperchloremic metabolic acidosis persisted, but her hypokalemia had resolved. Conclusion This case is an example of one of the unique consequences of urinary diversions. Urothelial tissue is typically impermeable to urinary solutes. However, when bowel segments are used, abnormal absorption of solutes occurs, including exchange of urinary chloride for serum bicarbonate, leading to a persistent hyperchloremic nonanion gap metabolic acidosis. In addition, overproduction of ammonia from urea-producing organisms can lead to abnormal absorption into the blood and subsequent oversaturation of hepatic metabolic capacity with consequent hyperammonemic encephalopathy. Although this is a rare case, prompt identification and treatment of these metabolic abnormalities is critical to prevent severe central nervous system complications such as altered mental status, coma, and even death in patients with urinary diversions.

scholarly journals Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane

2012 ◽  
Vol 3 (4) ◽  
pp. 270 ◽  
Author(s):  
Hai-yu Xiao ◽  
Yu-xuan Wang ◽  
Teng-da Xu ◽  
Hua-dong Zhu ◽  
Shu-bin Guo ◽  
...  
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Altered Mental Status ◽  
Fast Lane

Altered Mental Status in the Emergency Department

2019 ◽  
Vol 39 (01) ◽  
pp. 005-019 ◽  
Author(s):  
Austin Smith ◽  
Jin Han
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Altered Mental Status ◽  
Detailed History ◽  
Radiographic Testing ◽  
Life Threatening ◽  
Secondary Survey ◽  
Acute Changes ◽  
Department Evaluation ◽  
The Brain

AbstractAltered mental status is an umbrella term that covers a broad spectrum of disease processes that vary greatly in chronicity and severity. Causes can be a primary neurologic insult or a result of a systemic illness resulting in end-organ dysfunction of the brain. Acute changes in mental status are more likely than chronic changes to be immediately life-threatening and are therefore the focus of this review. Given the potential time-sensitive nature, acute changes in mental status must be addressed immediately and with urgency. We recommend a primary survey followed by a secondary survey with special attention to immediate life-threatening reversible causes. We then recommend a systems-based approach searching for any other life-threatening or reversible causes. Because the differential for altered mental status is broad, a comprehensive emergency department evaluation including a detailed history and physical exam as well as laboratory and radiographic testing is needed.

scholarly journals 1111. Characterization of Antibiotic Ordering in Patients with Mental Status Changes and Presumed Urinary Tract Infection in Patients 65 and Older

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S395-S396
Author(s):  
Nicole Harrington ◽  
Jessica Leri ◽  
Scott Shoop
Keyword(s):  
Internal Medicine ◽  
Emergency Department ◽  
Urinary Tract ◽  
Mental Status ◽  
Asymptomatic Bacteriuria ◽  
Altered Mental Status ◽  
Practice Change ◽  
Antibiotic Selection ◽  
Common Diagnosis ◽  
Tract Infections

Abstract Background Altered mental status (AMS) is the most common diagnosis among those 65 and older who present to the emergency department (ED). Urinary tract infections (UTIs) account for 15.5% of hospitalizations in this population. The purpose of this study was to determine the incidence of initiation of antibiotics in the ED in patients 65 years and older with mental status changes and asymptomatic bacteriuria or negative urine cultures. Methods A retrospective chart review was performed to evaluate patients aged 65 and older from January 2017 through June 2018 who presented to the ED from home with AMS, a urinalysis that reflexed to culture, and were admitted to an internal medicine unit. The primary outcome was defined as the percentage of patients with AMS who received antibiotics in the ED with asymptomatic bacteriuria or negative urine cultures. Secondary outcomes included adherence to the CCHS UTI antibiotic guideline, incidence of early discontinuation of antibiotics, culture sensitivity to ordered antibiotic, and disposition after discharge. Results A total of 91 patients were included in this study. Seventy-five patients had asymptomatic bacteriuria and antibiotics were started in the ED in 63 (84%) of these patients. Fourteen patients had no growth on culture and seven of these patients (50%) had antibiotics initiated in the ED. Of those who received antibiotics (n = 82), there was 81.7% adherence to the Christiana Care UTI antibiotic selection guideline. Sensitivities were available for 41 isolates and 65.9% were sensitive to the initial antibiotic administered. Antibiotics were discontinued early in 29/82 (35.4%) of patients. Thirty-one patients (33.7%) were discharged to a skilled nursing facility. Conclusion These results indicate that the majority of patients aged 65 and older who presented to the emergency department with altered mental status and no other UTI symptoms such as dysuria, urinary frequency, or urgency were treated with antibiotics. When antibiotics are initiated the majority of providers are adhering to organizational guidelines for antibiotic selection and duration. The results will be shared with Emergency Department and Internal Medicine leadership to foster practice change. Disclosures All authors: No reported disclosures.

scholarly journals Automated detection of altered mental status in emergency department clinical notes: a deep learning approach

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Jihad S. Obeid ◽  
Erin R. Weeda ◽  
Andrew J. Matuskowitz ◽  
Kevin Gagnon ◽  
Tami Crawford ◽  
...  
Keyword(s):  
Emergency Department ◽  
Deep Learning ◽  
Mental Status ◽  
Altered Mental Status ◽  
Automated Detection ◽  
Learning Approach ◽  
Clinical Notes

Neuroimaging and outcome of patients with altered mental status in the emergency department of a comprehensive cancer center.

2014 ◽  
Vol 32 (15_suppl) ◽  
pp. e20659-e20659
Author(s):  
Patricia A Brock ◽  
Andrew J Hall ◽  
Valda D Page ◽  
Kelly W. Merriman ◽  
Cielito C. Reyes-Gibby ◽  
...  
Keyword(s):  
Emergency Department ◽  
Mental Status ◽  
Altered Mental Status ◽  
Comprehensive Cancer Center ◽  
Cancer Center
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