Acute Mental Status Changes in the Intensive Care Unit

Acute Mental Status Changes in the Intensive Care Unit
By:Danagra Georgia Ikossi, MD
Stanford General Surgery Resident


* Brief review of Delirium, Seizures and Stroke
* “ICU Psychosis”
o How do you know if they’re confused? (J. Am. Ger. Soc. 2005)
o Why do they become delirious? (Critical Care 2001)
o Does delirium portend a poor outcome? (JAMA 2004)
o Geriatrics: Delirium plus dementia, what to do? (J. Am. Ger. Soc. 2005)


Disorders of Mentation
* Abnormalities of mental function
* Levels of Conciousness

Etiology of depressed level of consciousness
In non head injured patients
o SMASHED
o Substrate deficiencies (glucose, thiamine)
o Meningoencephalitis or Mental illness (malingering, psychogenic coma)
o Alcohol or Accident (CVA)
o Seizures
o Hyper-capnia, -glycemia, -thyroid, -thermia OR Hypo-xia, -tension, -thyroid, -thermia
o Electrolyte abnormalities (hyperNa, hypoNa, hyperCa) and Encephalopathies
o Drugs

Eye Opening
Spontaneous
To Speech
To Pain
Verbal Oriented
Inappropriate
Incomprehensible
Abnormal Extension
Abnormal Flexion
Withdraws
Localizes
Obeys Commands
Motor
Glascow Coma Scale: GCS
“T” denotes intubation
Predictive value of GCS
* Septic Encephalopahthy
Delirium
DSM-IV Diagnosis of Delirium
A. Reduced ability to maintain and shift attention to external stimuli
B. Disorganized thinking, as indicated by rambling, irrelevant, or incoherent speech
C. At least two of the following:

1. Reduced level of consciousness
2. Perceptual disturbances: misinterpretations, illusions, or hallucinations
3. Disturbance of sleep–wake cycle with insomnia or daytime sleepiness
4. Increased or decreased psychomotor activity
5. Disorientation to time, place, or person
6. Memory impairment

D. Abrupt onset of symptoms (hours to days), with daily fluctuation

E. Either one of the following:
1. Evidence from history, physical examination, or laboratory tests of specific organic etiologic factor(s)
2. Exclusion of non-organic mental disorders when no etiologic organic factor can be identified

Delirium
* Hypoactive delirium:
* Dementia and Delerium:
* Management
THIS IS MUCH MORE THAN WE USE
Important to differentiate Delirium from DTs
* Delirium Tremens
Cocaine Related Delirium
Who becomes delirious?

Delirium, Dementia or Both?
* Delirium is a risk factor for increased ICU and Hospital length of stay
* In the geriatric population, becomes difficult to differentiate between underlying dementia and delirium
* Group at Brown did a prospective study of 118 patients in ICU
* Baseline dementia diagnosis given by family on Blessed Dementia Scale
* Delirium diagnosed by CAM and CAM-ICU scales
CAM ICU SCORE
Overall CAM ICU Score:
Delirium and mortality
Perspective on ICU Psychosis
AACM and SCCM Guidelines
Seizures
* Second most common neurologic complication in ICU
* Movements
* Generalized Seizures
* Partial Seizures
* Status Epilepticus
New Onset Seizures
* Drug intoxication
(amphetamies, cocaine, phenocyclidine, cipro, imipenam, lidocaine, PCN, theophylline, TCA)
* Drug withdrawal (EtOH, BZO, Barbiturates, Opiates)
* Infection (Meningoencephalitis, abscess)
* Ischemia (focal or diffuse)
* Space occupying lesion (tumors or bleeds)
* Metabolic derrangement
(hepatic encephalopathy, uremia, hypo-glycemia, -natremia, -calcemia)

* Evaluation:
o Examination looking for lateralizing signs
o Review of medications
o Imaging (CT)
o Procedural diagnostics (LP, labs, blood cultures)
* Management:
o BZO
o Valium 0.2mg/kg IV stops 80% of seizures within 5 min, effect lasts 30 min
o Ativan 0.1mg/kg is as effective and lasts 12-24hrs
o Dilantin 20mg/kg following valium, aim for 20mg/l therapeutic serum level

Stroke
* Acute neurologic disorder
* Nontraumatic brain injury, vascular origin
* Focal findings (not global)
* Persists for more than 24 hours
* 80% ischemic, 20% of which are embolic
o Most thrombi are mural, LA, LV, DVT with PFO
* TIA: transient ischemic attack, focal deficits resolve in less than 24 hours (ischemia rather than infarction)
* Minor Stroke = RIND (reversible ischemic neurologic deficit) resolves within 3 weeks of event
* Major Stroke = deficits persist for more than 3 weeks
* Evaluation: common things you’ll see at the bedside
o Full neuro exam, looking for focal deficits
o Seixures in 10% of cases, focal and within first 24 hours
o Fever in 50% of strokes (not with TIA) – look for other sources
o Coma and LOC are not common – more likely hemorrhage, massive infarct with edema, brainstem infarction, seizure (absence) or postictal state
o Aphasia – Left MCA distribution
o Weakness in contralateral limbs (can also have other metabolic causes)

Diagnostic Studies
* Time is brain
* Coags, Chemistries: hypoglycemia, hyponatremia, ARF
* ECG: Afib?
* CT head: 70% sensitivity for infarct, 90% for hemorrhage - critical to distinguish btwn these
* Better if after 24 hours for infarct
* MRI: more sensitive esp for brainstem and cerebellar strokes
Diagnostics and Treatment
* ICP: monitoring not recommended routinely
o Elevate HOB 30 degrees
o Do not use measures that will decrease CBF
o minimize suctioning (HTN)
o Do not hyperventilate (reduces CBF)
o Steroids not recommended
o Hyperosmolar therapy can be used if edema is severe (Mannitol, HTS)

Acute Mental Status Changes in the Intensive Care Unit.ppt