On every Emergency medicine shift, without fail, you will encounter at least one patient with a chief complaint of "AMS".

Altered Mental status is an all encompassing term with a large differential. All of which must be considered even if only briefly so as to not miss something potentially life threatening.

The focus of this Haiku deck is to provide you with a strategy of approach to this patient to help you quickly rule in or rule out the most common causes of AMS.

This will help to streamline your diagnostic and therapeutic strategies.

First thing's first
Always stabilize your Patient

Check the Airway.
Check the Breathing.
Check the Circulation.

Hook the patient up to a monitor to trend their vitals.

Once you have done this. Calculate their Glasgow Coma scale score and remember-

"Less than 8, Intubate".

Once the patient has been stabilized, its time figure out what the underlying problem is.

The AMS patient is unique because they are unable to provide a detailed and accurate HPI and may not be accompanied by someone who can speak for them.

Without a history the differential is wide open. Therefore its important to know the causes of AMS to help you identify whats wrong through your physical exam and diagnostic testing.

So how do we remember them all?

Luckily there is yet another useful Medical Mnemonic to help us out.

Sadly not as "catchy" as MRSA (get it?) but still helpful!

A- Alcohol
E-Electrolytes, Encephalopathy, Epilepsy.
I- Insulin
0- Opiates or Oxygenation
U- Uremia

T- Trauma or temperature
I- Infection
P- Poison or Psychogenic
S- Shock, Stoke , Subarrachnoid Hemorrhage, Space Occupying Lesion.

Alcohol is by far the most common cause of AMS. Both alcohol intoxication and withdrawn can cause AMS. The alcohol intoxicated patient is usually very easy to identify both in and out of the hospital setting.


CAUTION: This patient requires a a full diagnostic work up! Alcohol does a great job in not only dampening the patient's senses but can also cause health care professionals to let their guard down. Alcohol intoxication does a great job in masking other causes of AMS and potential medical emergencies, such as head trauma, electrolyte abnormalities, encephalopathy etc. So never just stop at 'A'. Always consider what else can be going on with your patient.

Both Hypo- and Hyperglycemia can result in an Altered mental status.

A glucose level finger stick should be preformed on all patients presenting with AMS.

Opiate intoxication:
Patients can present with a profound AMS. Look for the the classic signs- Constricted pupils, Bradycardia and Bradypnea.

Oxygenation issues:
Hypoxemia and Hypercarbia can be caused by a number of conditions. They can be detected by looking at O2 saturations and Blood gas measurements.

Uremia: A Basic Metabolic Panel along with serum Calcium and phosphate levels will help you identify whether a patient is uremic and will also allow you to determine if the cause is prerenal vs renal/postrenal. These patients will need dialysis so the quicker you can identify them the better.

Trauma: Expose and examine your patient to look for signs of trauma, especially head trauma. A quick non contrast head CT can be useful in ruling out any intracranial hemorrhagic processes.
Think subdural vs epidural until proven otherwise.
Likewise excess blood loss can lead to hypovolemic shock resulting in AMS.

Temperature:
Hypothermia and hyperthermia can result in AMS.
Quick and constant monitoring of your patients vitals will help you recognize these patients.

Infection:

Caution: Remember that infections are not always as easy to recognize right away in some patient populations such as the elderly and the Immunocompromised.

Psychogenic:
Acute vs chronic psychiatric disorders. Remember not to immediately attribute the AMS to a psychiatric condition. As psychosis can mask underlying pathologies that can also be attributing to the AMS.

Poison:
Consider Toxin exposure, Pharmacological overdose and Illicit drugs.

Shock:
Consider all causes of Hypoperfusion states-
1. Cariogenic
2. Neurogenic
3. Hypovolemic
4. Hemorrhagic
5. Distributive

Stroke:

Space occupying lesion:


Sub Arachnoid Hemorrhage: