Altered Mental Status

Methemoglobinemia results from increased amounts of oxidized hemoglobin in the blood with an ensuing change in oxygen dissociation curve and lack of oxygen delivery to tissue. A previously well, male toddler was brought to the Pediatric Emergency Department (PED) by Emergency Medical Services (EMS) with abrupt onset of altered mental status and cyanosis after a suspected ingestion of “Rush” nail polish remover. He was quickly diagnosed with methemoglobinemia by both clinical presentation and chocolate-colored blood appearance. He emergently received intravenous (IV) methylene blue (MB) with immediate and sustained improvement requiring no further doses. Though inhalation of nitrites and subsequent methemoglobinemia is frequently reported in adolescents, we were unable to find any cases in the literature detailing ingestion of this product and the resulting clinical manifestations. Our objective with this report is to describe a rare case of a toddler with an accidental ingestion of “Rush” nail polish remover, a nitrite compound. Our patient presented to the PED with abrupt onset of altered level of consciousness, hypotension, and cyanosis resulting from acquired methemoglobinemia. This case report demonstrates the importance of emergency clinicians being able to make clinical judgements and decisions based on the history and physical exam when methemoglobinemia is suspected.

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Altered mental status is a predictor of poor outcomes in COVID-19 patients: A cohort study

PLoS ONE ◽

10.1371/journal.pone.0258095 ◽

2021 ◽

Vol 16 (10) ◽

pp. e0258095

Author(s):

Abdallah S. Attia ◽

Mohammad Hussein ◽

Mohamed A. Aboueisha ◽

Mahmoud Omar ◽

Mohanad R. Youssef ◽

...

Keyword(s):

Mechanical Ventilation ◽

Cohort Study ◽

Mental Status ◽

Delayed Diagnosis ◽

Clinical Manifestations ◽

Kidney Injury ◽

Altered Mental Status ◽

Neurological Manifestations ◽

Icu Admission ◽

Poor Outcomes

Introduction Several studies have described typical clinical manifestations, including fever, cough, diarrhea, and fatigue with COVID-19 infection. However, there are limited data on the association between the presence of neurological manifestations on hospital admission, disease severity, and outcomes. We sought to investigate this correlation to help understand the disease burden. Methods We delivered a multi-center retrospective study of positive laboratory-confirmed COVID-19 patients. Clinical presentation, laboratory values, complications, and outcomes data were reported. Our findings of interest were Intensive Care Unit (ICU) admission, intubation, mechanical ventilation, and in-hospital mortality. Results A total of 502 patients with a mean age of 60.83 ± 15.5 years, of them 71 patients (14.14%) presented with altered mental status, these patients showed higher odds of ICU admission (OR = 2.06, 95%CI = 1.18 to 3.59, p = 0.01), mechanical ventilation (OR = 3.28, 95%CI = 1.86 to 5.78, p < 0.001), prolonged (>4 days) mechanical ventilation (OR = 4.35, 95%CI = 1.89 to 10, p = 0.001), acute kidney injury (OR = 2.18, 95%CI = 1.28 to 3.74, p = 0.004), and mortality (HR = 2.82, 95%CI = 1.49 to 5.29, p = 0.01). Conclusion This cohort study found that neurological presentations are associated with higher odds of adverse events. When examining patients with neurological manifestations, clinicians should suspect COVID-19 to avoid delayed diagnosis or misdiagnosis and lose the chance to treat and prevent further transmission.

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Neurotoxicity after high-dose melphalan.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.6546 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 6546-6546 ◽

Cited By ~ 1

Author(s):

Jose Eugenio Najera ◽

Tummala Sudhakar ◽

Qaiser Bashir ◽

Nina Shah ◽

Richard E. Champlin ◽

...

Keyword(s):

Mental Status ◽

Epileptiform Activity ◽

Clinical Manifestations ◽

Altered Mental Status ◽

Cancer Center ◽

High Dose ◽

Loss Of Consciousness ◽

Hematopoietic Stem ◽

Neurologic Recovery ◽

High Dose Melphalan

6546 Background: High dose melphalan (HDM) at 200 mg/m2 is the standard preparative regimen for patients with multiple myeloma (MM) and light-chain amyloidosis (AL) undergoing autologous hematopoietic stem cell transplantation (auto-HCT). Neurotoxicity has been seen with HDM. In this report we describe the incidence, clinical manifestations and outcome of HDM- associated neurotoxicity. Methods: We performed a chart review of all patients who received HDM and auto-HCT for MM or AL between January 2007 to December 2009 at the University of Texas MD Anderson Cancer Center (MDACC). HDM- associated encephalopathy was defined as altered mental status, seizure or unexplained loss of consciousness within 30 days of auto-HCT. Patients with documented hemorrhagic or embolic stroke, or metabolic abnormalities were excluded. Results: 451 patients were included. Median age at auto-HCT was 59 years (range: 35-80). Thirty patients (6.6%) had AL and 61 patients (13.5%) had a pre-transplant serum creatinine of > 1.5 mg/dl. Nine patients (2.0%) developed HDM-associated encephalopathy with a median of 13 days (range 4-22) from auto-HCT. Among patients with encephalopathy, 8 (89%) developed changes in mental status ranging from drowsiness and confusion to loss of consciousness, while one patient had tonic-clonic seizures (11%). Of the affected patients there were 6 (66%) females, 8 patients (89%) > 59 years of age and only 2 patients (22%) had a creatinine clearance of < 60 ml/min. One patient was dialysis-dependent. A CT scan or MRI was obtained in all 9 patients. Only one patient had imaging abnormalities reported as posterior reversible encephalopathy syndrome (PRES). Electroencephalogram (EEG) was performed on 6 patients. Epileptiform activity was seen in one patient with clinical seizures. Mild generalized slowing was noted in 2 other patients with mental status changes. Cerebrospinal fluid was obtained in 2 patients and did not show any abnormalities. Complete resolution of neurologic symptoms was seen in all patients prior to hospital discharge, and there were no deaths. Conclusions: HDM-induced encephalopathy was seen in only 2% patients, and it is associated with complete neurologic recovery without any increase in transplant-related mortality.

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Thiamine supplementation in hospitalized patients with altered mental status: does it help?

Hospital Practice ◽

10.1080/21548331.2021.2014737 ◽

2021 ◽

Author(s):

Daniel J. Zhou ◽

Kaeli K. Samson ◽

Navya Joseph ◽

Ismail Fahad ◽

Matthew V. Purbaugh ◽

...

Keyword(s):

Mental Status ◽

Altered Mental Status ◽

Hospitalized Patients

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Postoperative cognitive dysfunction: A case report and literature review

Case Reports in Internal Medicine ◽

10.5430/crim.v4n4p37 ◽

2017 ◽

Vol 4 (4) ◽

pp. 37

Author(s):

Gurpreet Singh ◽

Margaret M Cinicola ◽

Naveen R Parva ◽

John T Cinicola ◽

Venkat G Muvva ◽

...

Keyword(s):

Cognitive Dysfunction ◽

Mental Status ◽

Artery Bypass ◽

Bypass Graft ◽

Postoperative Cognitive Dysfunction ◽

Clinical Manifestations ◽

Altered Mental Status ◽

Major Surgery ◽

Postoperative Cognitive Decline ◽

Prolonged Hospital

Background: Postoperative cognitive dysfunction (POCD) is loss of cognition especially in memory and executive function that can extend from a few days to a few weeks after surgery. It is more common in older adult patients. We present a case featuring a typical progression of POCD along with its associated preoperative risk factors.Case report: A 65-year-old male patient with an extensive past medical history including generalized anxiety disorder, hypertension and hyperlipidemia initially presented to the emergency department for chest pain. Coronary artery bypass graft (CABG) was performed under general anesthesia with Propofol, Fentanyl, Rocuronium and Midazolam. The patient tolerated the procedure well. After the procedure, his stay was complicated by delirium and altered mental status. All reversible causes were investigated and eliminated as likely causes. Later, the patient was sent home after a prolonged hospital stay. Following discharge, he had multiple admissions to the hospital for altered mental status, and his mental status has not reached baseline again. Family has been confident that the patient’s psychological and cognitive symptoms began following the CABG.Conclusion: We present this case to highlight the heightened incidence of postoperative cognitive decline in patients over sixty undergoing major surgery. We also present a comprehensive review of the current literature on the risk factors, clinical manifestations, and pathogenesis of POCD.

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Delirium Associated with Salicylate and Acetaminophen Overdose in a Patient with COVID-19: A Case Report

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2020.8.48559 ◽

2020 ◽

Vol 4 (4) ◽

pp. 517-520

Author(s):

Tyler Wen ◽

Jason Chu ◽

Danielle Allenspach ◽

David Van

Keyword(s):

Emergency Department ◽

Central Nervous System ◽

Nervous System ◽

Case Report ◽

Mental Status ◽

Clinical Manifestations ◽

Altered Mental Status ◽

Psychosocial Stressors ◽

Acetaminophen Overdose ◽

Wide Range

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has created numerous clinical challenges for physicians, in part due to its wide range of clinical manifestations and associated complications. Case Report: Here we present the case of a 69-year-old man who was admitted to the emergency department with fever, dyspnea, and altered mental status. We believe the patient’s condition was precipitated by a COVID-19 infection-induced delirium, a setting in which he ingested aspirin and acetaminophen in overdose that required lifesaving interventions. Conclusion: This case illustrates the potential for neuropsychiatric effects in COVID-19 patients due to both direct viral central nervous system pathology and pandemic-related psychosocial stressors.

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466. Symptom Profile of Hospitalized, Adult Patients with COVID-19 – Findings From COVID-Net Database

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.665 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S335-S335

Author(s):

Chun T Siu ◽

Amogh Joshi

Keyword(s):

Retrospective Analysis ◽

Mental Status ◽

Signs And Symptoms ◽

Altered Mental Status ◽

Hospitalized Patients ◽

Shortness Of Breath ◽

Neurologic Manifestation ◽

Symptom Profile ◽

Patient Reported ◽

Control And Prevention

Abstract Background According to the Center for Disease Control and Prevention (CDC), there is a disproportional number of COVID-19 deaths in hospitalized patients that increases based on age. Among COVID-19 related deaths in hospitalized patients, 8 of 10 patients are age 65 years and older. By looking at the latest data, the objective of this retrospective analysis is to evaluate the symptom profile in patients hospitalized with COVID-19 and determine if certain symptoms are seen more in older patients. Methods We performed a retrospective analysis using the COVID-Net database. This database contains information involving COVID-19 laboratory-confirmed hospitalization across 14 states. Medical history, signs, and symptoms at admission were collected by COVID-NET surveillance officers and reported during the period of March 1st to May 31st. For our analysis, we only included adults patients age 18 and above. Further descriptive statistics were stratified by age into two groups: age 18-64, and age ≥ 65. Results We identified 60,363 patients age 18 and above with COVID-19 confirmed hospitalizations. Cough, shortness of breath, and fevers/chills were the most common symptoms at respectively 67%, 66%, and 65%. Patients age ≥ 65, when compared to patients age 18-64, were less likely to have cough (56.7% vs 73.8%), shortness of breath (58.1% vs 72.1%), fever/chills (54.7% vs 71.%), dysgeusia (2.3% vs 7%), and anosmia (1.2% vs 6%). The only presentation that was more common in patients age 65+, than in patients age 18-64, was altered mental status (26.9% vs 5.2%). Overall inpatient mortality was higher in the age ≥ 65 group (8.9% vs 2%). Among the 2,922 COVID-19 decedents, 75.3% were age ≥65. Conclusion Published in April 2020, preliminary data from COVID-Net on approximately 180 patient reported that only 8.2% of patients age ≥ 65 had altered mental status2. Since then, our analysis noted that altered mental status is more commonly seen in the age group ≥ 65 than previously reported. The percentage of decedents age ≥ 65 in this analysis is similar to the 74.8% (N= 10,647) reported in a large study that focused specifically on COVID-19-related deaths3. Our analysis highlights that altered mental status is a common neurologic manifestation in elderly patients hospitalized with COVID-19. Disclosures All Authors: No reported disclosures

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Approach to Acute Altered Mental Status and Seizures (DRAFT)

10.1093/med/9780190612474.003.0007 ◽

2018 ◽

Author(s):

Jody Manners ◽

Kiruba Dharaneeswaran ◽

Ruchira Jha

Keyword(s):

Mental Status ◽

Altered Mental Status ◽

Hospitalized Patients ◽

Morbidity And Mortality ◽

Rapid Evaluation ◽

Metabolic Derangement ◽

Medical Comorbidities ◽

Life Threatening

Altered mental status (AMS) is a common presenting symptom or complication in hospitalized patients. The etiology of AMS includes potential primary neurologic entities as well as systemic disturbances such as infection, intoxication, or metabolic derangement. A systematic and rapid evaluation of potentially life threatening conditions is necessary to guide appropriate management. Seizures (particularly non-convulsive episodes) are an important cause of AMS frequently encountered in acutely ill patients with multiple medical comorbidities and need to be recognized and treated early to minimize morbidity and mortality. This chapter outlines an approach to the evaluation of acute altered mental status with an emphasis on seizure management.

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Inappropriate Testing for Urinary Tract Infection in Hospitalized Patients: An Opportunity for Improvement

Infection Control and Hospital Epidemiology ◽

10.1086/673449 ◽

2013 ◽

Vol 34 (11) ◽

pp. 1204-1207 ◽

Cited By ~ 31

Author(s):

Sarah Hartley ◽

Staci Valley ◽

Latoya Kuhn ◽

Laraine L. Washer ◽

Tejal Gandhi ◽

...

Keyword(s):

Urinary Tract Infection ◽

Urinary Tract ◽

Tract Infection ◽

Mental Status ◽

Urinary Catheter ◽

Altered Mental Status ◽

Hospitalized Patients ◽

Orthopedic Procedures ◽

Clinical Scenarios ◽

Current Guidelines

Urine cultures are frequently obtained for hospitalized patients. We reviewed documented indications for culture and compared these with professional society guidelines. Lack of documentation and important clinical scenarios (before orthopedic procedures and when the patient has altered mental status without a urinary catheter) are highlighted as areas of use outside of current guidelines.

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Overtreatment of Asymptomatic Bacteriuria: Identifying Targets for Improvement

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2014.73 ◽

2015 ◽

Vol 36 (4) ◽

pp. 470-473 ◽

Cited By ~ 23

Author(s):

Sarah Hartley ◽

Staci Valley ◽

Latoya Kuhn ◽

Laraine L. Washer ◽

Tejal Gandhi ◽

...

Keyword(s):

Mental Status ◽

Antimicrobial Therapy ◽

Urine Culture ◽

Asymptomatic Bacteriuria ◽

Altered Mental Status ◽

Hospitalized Patients ◽

Infect Control Hosp ◽

Alternative Source

Treatment of asymptomatic bacteriuria contributes to antimicrobial overuse in hospitalized patients. Indications for urine culture, treatment, and targets for improvement were evaluated in 153 patients. Drivers of antimicrobial overuse included fever with an alternative source, altered mental status, and leukocytosis, which led 435 excess days of antimicrobial therapy.Infect Control Hosp Epidemiol 2014;00(0): 1–4

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