These patients require admission.

� Discharge

Most patients with dental trauma can be discharged to

follow-up with a dentist. Patients with minor odontogenic

abscesses can be discharged after incision and drainage by

either the treating emergency physician or a consulting

oral surgeon. These patients will require oral antibiotics

and follow-up.

SUGGESTED READING

Beaudreau RW. Oral and dental emergencies. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 201 1, pp. 1 572-1583.

Costain N, Marrie TJ. Ludwig's angina. Am J Med. 20 1 1;124:

1 1 5-1 1 7.

Douglass AB, Douglass JM. Common dental emergencies. Am

Pam Physician. 2003;67:5 1 1-5 16.

Nguyen DH, Martin JT. Common dental infections in the

primary care setting. Am Pam Physician. 2008;77:797-802.

Altered Mental Status

Moses S. Lee, MD

Key Points

• Do not delay bedside glucose determination, administration of glucose, and naloxone, if indicated. These

interventions may prevent the need for endotracheal

intubation.

• Ta lk to the paramedics and fami ly; they can often

identify the cause of altered mental status (AMS).

INTRODUCTION

Altered mental status (AMS) may have an organic (ie,

structural, biochemical, pharmacologic) or functional (ie,

psychiatric) cause. AMS accounts for So/o of emergency

department (ED) visits. About 80% of patients with AMS

have a systemic or metabolic cause, and about l So/o have a

structural lesion.

Consciousness has 2 main components: arousal and

cognition. Arousal is controlled by the ascending reticular

activating system (ARAS) in the brainstem. Cognition is

controlled by the cerebral cortex. Lethargy, stupor, obtun ­

dation, and coma are imprecise terms used to describe

alterations of arousal. A description of the patient's arousal

level (eg, opens eyes to voice) is preferable. Delirium is an

alteration of both arousal and cognition. Patients exhibit

restlessness, agitation, and disorientation. Dementia is an

alteration of cognition, not arousal.

ARAS is a complex system of nuclei in the brainstem. It

may be impaired by small structural lesions in the brain -

stem such as ischemic or hemorrhagic stroke, shear forces

from head trauma, or external compression from brain

herniation. Severe toxic and/or metabolic derangements

( eg, hypoxia, hypothermia, drugs) can also cause impairment. Bilateral cerebral cortex dysfunction must occur to

cause decreased levels of arousal or profound AMS. This is

• Identify level of AMS, systemic conditions, and any focal

deficits with the physical examination.

• Re-examine your patients frequently and note any

cha nges in condition and response to therapy.

usually caused by toxic/metabolic derangements, infection,

seizures, subarachnoid hemorrhage (SAH), or increased

intracranial pressure (ICP). Unilateral lesions such as

stroke do not by themselves cause profound AMS.

CLINICAL PRESENTATION

� History

AMS represents a spectrum of disease presentations from

profoundly depressed arousal requiring emergent intubation to severe agitation and confusion requiring restraint

and sedation. Initial stabilizing measures are often needed

before a complete history and physical examination can be

performed.

If the patient is unable to give a coherent history, alternate sources of history should be sought. Prehospital providers should be questioned about the patient's condition

in the field, therapies given and the response, and the

condition of the home environment ( eg, pill bottles, sui ­

cide note). Family members should be contacted to ascertain past history of similar episodes, medical history,

trauma, substance abuse, and the last time the patient was

seen in a normal state. The patient's belongings should be

searched for medical identification bracelets, pill bottles,

phone numbers, or other potential sources of information.

332

ALTERED MENTAL STATUS

Patients presenting to the ED with AMS often include

the elderly, who are more prone to infection, have comorbid illnesses, and take multiple medications; substance

abusers ( eg, heroin, cocaine, alcohol withdrawal, and liver

failure); and psychiatric patients who may be on moodstabilizing drugs, which, when taken in excess, have t oxic

effects that cause abnormal arousal or cognition.

.... Physical Examination

Vital signs; airway, breathing, and circulation (ABCs);

pulse oximetry; and bedside glucose should be assessed,

looking for immediate life threats and treatable causes of

AMS (ie, hypoglycemia, hypoxia or abnormal respiratory

pattern, hyper- or hypotension, hyper- or hypothermia).

Naloxone (Narcan), glucose, and thiamine should be

administered, as dictated by history and examination.

A "head-to-toe" examination should follow, looking for

systemic causes of AMS and focal neurologic deficits. The

head should be examined for any signs of trauma. Pupil size,

symmetry, and reactivity should be assessed. Pinpoint pupils

are a sign of opiate overdose or pontine hemorrhage. An

asymmetrically dilated "blown" pupil is a sign of uncal herniation. Fundi should be assessed for the presence of papilledema or subhyaloid hemorrhage associated with SAH.

Neck stiffness indicates meningeal irritation caused by either

SAH or infection. Cardiovascular exam should assess for

dysrhythmias (atrial fibrillation), murmurs (endocarditis),

or rubs (pericarditis). Lung exam should assess for symmetric breath sounds, respiratory rate, wheezes, rhonchi, and

rales. Abdominal exam should assess for masses and organomegaly (alcoholic liver disease, splenic sequestration in

sickle cell disease). Skin exam should assess for color, turgor

(dehydration), rashes (petechiae, purpura suggesting thrombotic thrombocytopenic purpura or meningococcemia),

and infection (cellulitis, fasciitis). If the neurologic examination cannot be completed because of the patient's mental

status, document what you are able to do and how the

patient appears. Mental status assessment should include

AVPU (alert, responds to voice, responds to pain, unresponsive). If the patient responds to voice, the appropriateness

and coherence of the response should be documented. The

cranial nerves, motor, deep tendon reflexes (including

Babinski or plantar reflex), cerebellar, and sensory examinations should be included if possible.

DIAGNOSTIC STUDIES

.... Laboratory

Multiple laboratory tests are obtained in an attempt to gain

more information, although a cause can usually be

ascertained from a thorough history and physical

examination. Initial laboratory tests should include complete blood count (leukocytosis, anemia, and

thrombocytopenia); chemistry (electrolyte abnormalities,

acidosis, and renal failure); urine (pregnancy test,

toxicology screen, infection); coagulation and liver studies

(liver failure, coagulopathy); blood cultures (if infection

suspected); arterial blood gas (hypoxia, hypercarbia, acidosis, and lactate); alcohol level; and serum t oxicology screen.

.... Imaging

Head computed tomography ( CT) scans should be performed to assess for mass lesion, hydrocephalus, and

intracerebral or subarachnoid bleed. Include a chest x-ray if

hypoxia, abnormal respirations, or evidence of pulmonary

infection is present. Electrocardiogram should be performed on all patients, looking for ischemia, QT or QRS

prolongation, or changes consistent with electrolyte

abnormalities.

PROCEDURES

A lumbar puncture may be indicated when considering a

central nervous system infection or bleeding after a

negative head CT scan.

MEDICAL DECISION MAKING

A systematic approach to the altered mental status patient

and the recognition oftreatable causes (mnemonicAEIOUTIPS) will provide optimal management (Figure 79-1 and

Table 79- 1). History, physical examination, and initial

laboratory and imaging tests will often reveal the cause of

mental status change.

TREATMENT

ED patients withAMS should be treated for any life-threatening

abnormalities while ongoing patient assessment continues.

Hypoglycemia, a common cause of AMS, should be treated

with intravenous (N) dextrose: adults: 1 amp DSO (50% glucose solution), pediatrics: 2-4 mL/kg D25 (25% glucose solution). Hypoxic patients should receive oxygen therapy

(administer 100% 02, mechanical ventilation as needed) while

searching for a potential cause (pneumonia, congestive heart

failure, pneumothorax, pulmonary embolism). Patients with

Table 79-1. AEIOU TIPS differential diag nosis

of patients with AMS.

A-Alcohol

E-Epilepsy, Electrolytes, Encephalopathy (HTN and hepatic)

1-lnsulin (hypo- and hyperglycemia), Intussusception (peds)

0-Qpiates, Overdose

U-Uremia

T-Trauma, Temperature (hypo- and hyperthermia)

1-lnfection, Intracerebral hemorrhage

P-Psychiatric, Poison

S-Shock

CHAPTER 79

ABCs

Bedside glucose

naloxone/th iamine

IV /0/monitor

History

Improvement with

naloxone or glucose, treat t-- ll>f underlying hypog lycemia

or opiate overdose

From patient, paramedics,

friends, family

Physical exam

· Abnorma l vita l signs (fever,

hypotension)

• Foca l neurologic finding

• Hypoxia, abnormal respirations

Head CT, lab studies,

CXR, ECG, LP 1-----l�

Etiology determined

Admit and treat

Etiology undetermined

Admit for further testing

Figure 79-1. Altered mental status diag nostic algorithm. ABCs, airway, breathing, and

circu lation; CT, computed tomography; CXR, chest x-ray; ECG, electroca rd iogram; GCS, Glasgow

coma scale; LP, lumbar puncture.

suspected opiate overdose (history or pupillary examination)

should be treated presumptively: adults: naloxone 2-4 mg N

given in 0.2- to 0.4-mg increments to avoid precipitating opiate withdrawal in chronic abusers. In a nonemergent setting,

administer naloxone 2-4 mg in a nebulizer with 3 mL of saline.

Pediatric patients should receive naloxone 0.01-0.1 mglkg N.

Actively seizing patients should receive N benwdiazepines:

diazepam 0.1-0.2 mglkg N (or 0.5 mg!kg per rectum) or

lorazepam 0.1 mg!kg N. Patients with suspected meningitis or

sepsis should receive N fluid resuscitation and broadspectrum antibiotic coverage. If hypertensive encephalopathy

is a suspected cause for AMS, the mean arterial pressure should

be reduced by 25% in 30 minutes with N antihypertensive

medications.

DISPOSITION

..... Admission

Most patients with AMS who are not immediately treatable

require admission to the hospital for further work-up, therapies, and observation. The level of admission (observation

unit, floor, telemetry, intensive care unit) should be guided

by the patient's vital signs, reassessments in mental status,

abnormalities identified, and comorbid illnesses.

ALTERED MENTAL STATUS

..... Discharge

Patients with hypoglycemia caused by insulin, who are able

to eat and remain normoglycemic after a period of obser ­

vation, may be safely discharged. If on long-acting oral

hypoglycemics, patients require admission for observation.

For patients with narcotic overdose, discharge is appropriate if the patient improves with naloxone and remains

stable after the duration of action of naloxone has elapsed

(ie, 1-4 hours).

SUGGESTED READING

Huff JS. Altered mental status and coma. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 201 1, pp. 1135-1 1 42.

Lehman RK, Mink J. Altered mental status. Clin Pediatr Emerg

Med. 2008;9:68-75.

William K, Brady WJ, HuffJS, et al. Altered mental status: Evaluation

and etiology in the ED. Am ! Emerg Med. 2002;20:613-617.

Headache

joseph M. Weber, MD

Key Points

• Consider emergent causes of headache first.

• Have a low threshold to perform a computed

tomography (CT) scan on patients with a possible

emergent cause for their headache.

INTRODUCTION

Headache is the presenting complaint in 3-5% of all visits

to the emergency department (ED). Headaches are classically divided into primary headache syndromes (migraine,

tension, cluster) and secondary causes, which can range

from benign (sinusitis) to emergent (subarachnoid hemorrhage [SAH], meningitis, tumor with increased intracranial pressure [ICP]). In clinical practice, the emergency

physician attempts to classify a patient's headache as emergent or benign. The majority of headaches in patients

presenting to the ED have a benign etiology; however,

5-10% of patients have a serious or potentially life-threatening cause for their headache (Table 80- 1).

Brain tissue is insensate. In benign headache syndromes, pain originates from blood vessels, venous

Table 80-1 . Headache classification by incidence.

Type of Headache

Tension

Unknown cause

Migraine

Serious secondary cause

Life· threatening

Incidence (%)