Neurology
Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.
Altered Mental Status
- Rapid response differential: stroke (ischemic or hemorrhagic), sepsis, hypoglycemia, cardiac arrhythmia (check pulse), seizure, medication side effect, hypercarbia, delirium
- Rapid response diagnostics: consider finger stick, head CT/MRI, infectious workup, telemetry, medication list review, Ativan (lorazepam) and Keppra (levetiracetam) IV load, or ABG
- Other differential diagnoses: dialysis disequilibrium syndrome, alcohol or drug withdrawal, carbon monoxide poisoning, hypoxia, hypo or hypernatremia, alkalemia, hypercalcemia, sundowning
- Differential similar to altered mental status differential, worse with prolonged ICU or hospital stay and with patients who already have neurologic impairments
- Nonpharmacologic treatments: reorientation, open the blinds during the day and turn off lights at night, minimize mind altering medications, reduce overnight vital signs
- Pharmacologic treatments: IV Haldol (haloperidol) if agitated acutely or PO Seroquel (quetiapine) if more subtle though no good data
- Red flag symptoms: new or different headache in age > 50, develops within minutes (thunderclap or worst of your life), unilateral weakness, wakes you up from sleep, visual changes, neck stiffness, fever, HIV, clotting disorder, cancer, worse with Valsalva
- Differential: tension headache, migraine, caffeine withdrawal, dehydration, cluster headache, hypertensive emergency, carbon monoxide poisoning, closed angle glaucoma, trigeminal neuralgia, meningitis, venous sinus thrombosis, stroke, tumor, giant cell arteritis
- First line: Tylenol (acetaminophen), Motrin (ibuprofen) or Aleve (naproxen), IV fluids, Excedrin (aspirin-acetaminophen-caffeine)
- Second line: Fioricet (butalbital-acetaminophen-caffeine), Toradol (IV ketorolac) with Reglan (metoclopramide), Imitrex (sumatriptan, careful in stroke and seizure patients)
- Symptoms/signs: fever, neck stiffness, headache, altered mental status, nausea, photophobia, phonophobia, Brudzinski’s sign (flexing the neck causes the hips/knees to flex), Kernig’s sign (hip/knee start flexed, extending the knee causes pain)
- Diagnosis: head imaging (CT or MRI) followed by lumbar puncture (look for positive culture, leukocytosis (neutrophil or lymphocyte predominant), xanthochromia, bleeding, low or normal glucose, high protein)
- Treatment may include ceftriaxone (Streptococcus pneumoniae, Haemophilus influenzae, MSSA), vancomycin (MRSA), ampicillin (Listeria, sometimes reserved just for kids or neutropenic or older adults), acyclovir (HSV)
- UPHS Antibiotic Stewardship Guidelines for Empiric Treatment/Sensitivities
- Differential: hemorrhagic (bleed especially subarachnoid or stroke), infectious (meningitis or encephalitis), metabolic (hyponatremia or hypoglycemia, fever, hyperglycemic hyperosmolar nonketotic sysndrome, dialysis disequilibrium syndrome), medication/toxin (missing anti-epileptic, alcohol/benzodiazepine withdrawal, PRES or posterior reversible encephalopathy syndrome, tacrolimus), or neoplasm
- Diagnostic workup: fingerstick, metabolic labs, head imaging, EEG, lumbar puncture, urine toxicology, anti-epileptic drug levels
- Initial treatment: consider Ativan (lorazepam) 1-2mg IV and Keppra (levetiracetam) 750mg-1gm IV load
- If ischemic and not hemorrhagic, then determine tPA eligibility (usually about 0-3hrs from symptom onset), if no tPA give aspirin +/- Plavix (clopidogrel), atorvastatin, head of bed flat for at least the first day to maximize perfusion to the brain, permissive hypertension (often up to BP 220/120) to maximize perfusion, and discuss imaging with neurology (may include carotid imaging and echocardiogram), review telemetry (for Afib)
- Differential: cardiogenic (arrhythmia, pulmonary embolism, aortic stenosis, hypertrophic cardiomyopathy), neurovascular (situational such as cough, anxiety, vertebrobasilar steal syndrome, vasovagal), orthostatic (dehydration or bleed, autonomic failure, drug/toxin-induced)
- Workup: orthostatic vital signs, EKG, consider telemetry and echo and head CT