The Mid-Shift Rush

This is our 1st of 3 cases exploring the care of patients with altered mental status in the Emergency Department.  Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

Working overnight in a busy community hospital, you’re starting to hit a mid shift wall.  There are some shifts in the ED where your job is glorious, where every patient has obvious pathology, where your interventions and treatments provide immediate relief of pain and suffering, and where the volume is steady though never overwhelming.  This is not one of those shifts.  Seemingly every patient has had a myriad of vague complaints to the point where you’re considering contacting the local health department to inform them of an exploding epidemic of “weak and dizzy” patients arriving in your ED.  Taking a breath between patients, contemplating whether or not to consume your 5th cup of coffee, you glance over to the triage desk to see 4 squads lined up.  Looking at the EMR you see all 4 of them carry the chief complaint of altered mental status…

Patient 1

29-year-old male who was found down outside a bar. He has no known medical history and will awaken to loud verbal stimuli but quickly falls back asleep. There is a small hematoma over the right forehead. FSBG in the field is 110. Vitals are T 98.8, HR 72, RR 8, BP 110/70, SaO2 95% on RA. 

Patient 2

54-year-old female with a history of hypertension, morbid obesity, OSA, and COPD last seen normal 9 hours ago. Her husband came home from work to find her lying on the floor at the bottom of 5 steps extremely lethargic and slurring her words. She is able to move all extremities and has no overt complaints or evidence of trauma. FSBG in the field 110. Vitals are T 98.6, HR 92, RR 22, BP 140/90, SaO2 90% on RA.  

Patient 3

37-year-old-male with a history of depression on multiple psychiatric medications who is a transfer from a mental health facility for confusion and agitation. He is mildly agitated and appears to be having auditory hallucinations. FSBG in the field is 110. Vitals are T 99.0, HR 110, RR 14, BP 110/70, SaO2 100% on RA. ECG shows a QTc of 500 and a QRS of 130ms. No priors available for comparison. 

Patient 4

72-year-old female with a history of poorly controlled DM and alcohol abuse who presents from a nursing facility for confusion and agitation. Per EMS, she is normally AAOx4 and pleasant. A chart biopsy reveals she was recently discharged to a SNF after a short admission for pneumonia. FSBG in the field is 110. Vitals are T 100.3, HR 105, BP 110/70, RR 16, SaO2 95% on RA.

As you hop from squad to squad getting a brief story from the EMS providers, you try to formulate a differential diagnosis for all 4 patients. You harken back to your days as a medical student and use the comprehensive (albeit tedious) AEIOU TIPS mnemonic that has served you so well since your days as a EM AI. 

You get back to your workstation feeling confident about your assessments and rattle off your standard AMS workups for each of the 4 patients. You take a moment to consider how far you’ve come from your days as a medical student when the chief complaint of altered mental status elicited anxiety and uncertainty, and you can’t help but feel a sense of accomplishment.

But as you think past the initial diagnostics you start to develop of some logistical questions pertaining to each of these patients that have no true evidence-based answers…and that old familiar sense of anxiety and uncertainty creeps back in, eroding at your new-found sense of achievement. The questions are…

Please respond to a single question and note in the discussion section which question you are responding by beginning your post with Q1, Q2, etc.

Question 1

In patient 1 you suspect EtOH toxicity, but you also suspect narcotic overdose. He is stable and cooperative at this point. When do you reach for Narcan? Narcan can certainly be diagnostic in his case and potentially obviate the need for further testing.  But if it works he will likely be agitated and inhibit you from getting a HCT. If you give it, how much should you give? 0.1mg? 0.4mg? 2.0mg?

Question 2

In patient 2 the differential is broad, ranging from ischemic CVA to CO2 narcosis. There is at least a suggestion of trauma, however. Do you slap a C-collar on her knowing full well you will be unlikely to clear her even with a negative CT given her AMS? Will the C-collar pose more harm than benefit regarding her tenuous respiratory status? What if the EMTs have already placed a C-collar…what then?

Question 3

In patient 3 there is clearly a concern for anti-depressant toxicity. When do you reach for sodium bicarbonate? Every time? Only with prolonged QRS? Only when Prolonged QRS in the absence of RBBB/LBBB? What is the QRS cut off? 100? 120? What about the prolonged QTc? When do you reach for Magnesium? 

Question 4

In patient 4 the differential is broad. You suspect alcohol withdrawal but you also are concerned for infectious causes. When would you perform and LP in this case? Only if the standard workup is unrevealing? Every time? Would you start empiric antibiotics? What antibiotics would you choose and why?  

Case Written by Ben Ostro, MD PGY-4 Resident

Edited and Uploaded by Jeffery Hill, MD MEd