Effective October 2013

Clinical Management Guidelines for

ALTERED MENTAL STATE
Approach to differential diagnoses of altered mental state

ALTERED MENTAL STATE

 Airway Check SpO2

 Breathing Give 100% O2
 Circulation - Check pulse

 Vital signs / Temperature

 ECG monitor
 Bedside glucose

Targeted History and Physical Examination

 Head injury
 Neck stiffness
 Respiration rate/ Pupil size
 Focal neurological signs1
 Chronic organ failure signs

Structural Causes Toxic/ Metabolic Causes

Head Trauma Non-head Trauma Febrile Afebrile

 Intracranial  Intracerebral  Cerebral abscess  Poisons
haemorrhage haemorrhage  Meningitis - Drug Overdosage:
 Subarachnoid  Encephalitis opioids, BZD, barbiturate,
haemorrhage TCA, ketamine, ecstasy
 Cerebral malaria
 Brainstem stroke
- Alcohol intoxication
 Bacteraemia
- Wernicke’s
 Cerebellar stroke  Septicaemia encephalepathy
 Cerebral tumour  UTI in elderly - Carbon monoxide
 Heat stroke  Metabolic
- Hypoglycaemia, cerebral
hypoperfusion,
hypercarbia, diabetic
coma, hypothermia,
Note: dehydration, electrolyte /
1. Structural causes usually have focal neurological signs whereas the acid-base abnormalities
toxic/metabolic causes do not.  Organ failure
SAH usually does not have focal neurological signs. SAH and some of the toxic /
metabolic causes may have fever.
- Uraemia, hepatic,
respiratory, cardiac
2. Psychogenic stupor is a dissociative state in which the patient is apparently fully
conscious but makes no spontaneous movement and little response to external  Post-ictal state
stimuli, usually related to a major stressful event and the onset is sudden. It is a  Psychiatric
diagnosis of exclusion. - Psychogenic stupor2
- Dementia

 Clinical evaluation: the focus is on differentiating structural from toxicmetabolic causes of AMS (Table 2).

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 Altered mental state

 History: rarely clear-cut; utilize patient’s family, friends and belongings to look for clues, as well as
information at scene from paramedic/ambulance officer.

Clues from history and physical examination pointing to causes of AMS.

Non-structural causes Structural causes

 Empty pill containers
 Medical diseases eg. epilepsy, liver
disease, diabetes etc
 Possible CO exposure
 Absence of focal neurological signs
 Signs of metabolic acidosis
 Look for toxidromes as
sympathomimetics cause high fever
in large overdoses
 Complained of headache to family /
friends prior to altered mental state
 History of brain tumor
 Trauma
 Presence of focal neurological signs
 Head trauma

 Examination: brief external assessment of patient searching for stigmata of numerous disease
processes. While a head-to-toe examination is important, in AMS most attention should be paid to a
focused neurological examination.

AMS due to suspected structural causes

 Give supplemental oxygen to maintain SpO2 of at least 95%.
 Start IV at slow rate.
 Perform CT head scan.
 Lower intracranial pressure if indicated.
1. Controlled ventilation: works fastest. Aim: pCO2 of 35–40 mm Hg.
2. IV Mannitol useful in conjunction with neurosurgical consult. Dose is 1 g/kg body weight (BW), i.e.
BW X 5 mls/kg BW of 20% mannitol solution.
3. Steroids are debatable.

AMS due to suspected toxic–metabolic causes

 Do gastric lavage; to be performed with airway protection if required.
 In suspected drug overdoses. See Poisoning, General Principles.
 Check rectal temperature and consider heat stroke if temp >40°C and taking anticholinergics.
 If meningitis is suspected, consider early lumbar puncture (after CT head scan). Start empiric
antibiotics before either of the tests together with a neurological consult.

Disposition
 Admit all cases of AMS. Admit to ICU those who are intubated or with haemodynamic instability.

REFERENCES/FURTHER READING
1. Hamilton GC. Altered mental status: Depressed level of consciousness. In: Hamilton GC, ed., Presenting Signs and
Symptoms in the Emergency Department: Evaluation and Treatment. USA: William and Wilkins; 1993:528–536.
2. Peterson J. Coma. In: Rosen et al., eds. Emergency Medicine: Concepts and Clinical Practice. 3rd ed. USA: Mosby
Year Book; 1992:1747–1750.

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