Metabolic encephalopathy diagnosis and management
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Overview of the diagnosis and management of metabolic encephalopathy for third year medical students in the Personalized Education Program portion of the third year curriculum at SIU Medicine
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Metabolic encephalopathy diagnosis and management
- 2. Robert Robinson, MD, FACP No Disclosures
- 5. 77 YEAR OLD LOST IN PARKING LOT • Wandering • Does not know how he got there • Cannot find car • Oriented to person • Knows address • Brought to ED by EMS for evaluation
- 6. 77 YEAR OLD LOST IN PARKING LOT Diagnosis History Exam Tests
- 7. DEFINITION- DSM-V Metabolic Encephalopathy Acute Onset Attention Awareness Cognition Not neurocognitive disorder Evidence of a medical cause
- 8. 77 YEAR OLD LOST IN PARKING LOT Diagnosis History Exam Tests
- 9. 77 YEAR OLD LOST IN PARKING LOT • CT Head • CBC • BMP • UA • Urine toxicology • Blood alcohol level • Chest X-ray • EKG • Cardiac enzymes
- 10. 77 YEAR OLD LOST IN PARKING LOT • CT Head • CBC • BMP • UA • Urine toxicology • Blood alcohol level • Chest X-ray • EKG • Cardiac enzymes • Discuss patient with primary care provider
- 11. DEFINITION- DSM-V Metabolic Encephalopathy Acute Onset Attention Awareness Cognition Not neurocognitive disorder Evidence of a medical cause
- 12. 77 YEAR OLD LOST IN PARKING LOT • Not metabolic encephalopathy • Progression of dementia
- 14. 62 YEAR OLD 2 DAYS POSTOP • Confused • Tolerated pain meds on POD #1 • No significant PMHx • SHx – Family denies alcohol/drugs • Exam • Confused, inattentive • Febrile • Tachycardia • Hypertensive • Tremor • Diaphoretic
- 15. PREVALENCE IN HOSPITALS Metabolic Encephalopathy 30% J Am Geriatr Soc. 1992;40(8):829. , J Gen Intern Med. 1998;13(4):234.
- 16. CAM (CONFUSION ASSESSMENT METHOD) Features Acute onset and fluctuating course Inattention Disorganized Thinking OR Altered level of consciousness • Most common assessment tool • Superior to MMSE • Sensitivity 94-100% • Specificity 90-95% J Am Geriatr Soc. 2008;56(5):823.
- 17. RISK FACTORS Dementia Stroke Parkinson’s Disease Sensory impairment Critical illness Sleep deprivation
- 19. COLLISION OF FACTORS Chronic Conditions Acute Illness Environment Medications Metabolic Encephalopathy
- 20. 62 YEAR OLD 2 DAYS POSTOP • Confused • Tolerated pain meds on POD #1 • No significant PMHx • SHx – History of alcohol abuse • Exam • Confused, inattentive • Febrile • Tachycardia • Hypertensive • Tremor • Diaphoretic
- 22. MEDICATIONS AS A CAUSE Medications 30% CNS Drugs. 1996; 5:103.
- 24. PRESCRIPTION DRUGS • Take a thorough drug history • Call pharmacies • Review medication administration record (MAR) • Pay close attention to drug changes • Consider drug withdrawal
- 25. COMMON PRECIPITATING DRUGS • Narcotics • Benzodiazepines • Muscle relaxers • Antipsychotics • Antidepressants • Antibiotics
- 26. CONSIDER CHECKING LEVELS • Anti-seizure medications • Digoxin • Theophylline • Lithium
- 28. OVER THE COUNTER DRUGS • Take a thorough drug history • Antihistamines (including H2 blockers) • Alternative medicines • Analgesics • Sleep aids
- 30. RECREATIONAL DRUGS • Take a thorough drug history • Alcohol (consider withdrawal...) • Stimulants • Sedatives • Narcotics • “Designer drugs” - MDMA, MDPV
- 31. MDMA – ECSTASY, MOLLY • Delirium, agitation • Hyponatremia • Hyperthermia • Liver injury • Rhabdomyolysis • Serotonin syndrome (with SSRI, MAOI) 3,4-methylenedioxymethamphetamine
- 32. MDPV – BATH SALTS • Delirium, agitation • Hypertension • Tachycardia • Seizures • Psychosis Methylenedioxypyrovalerone
- 33. SYNTHETIC CANNABIS – SPICE, K2 • Delirium • Psychosis • Hypertension • Myocardial infarction • Stroke • Seizures
- 34. 62 YEAR OLD 2 DAYS POSTOP • Metabolic Encephalopathy • Drug history • Narcotics for pain control (New) • Possible chronic alcohol use
- 36. LABORATORY EVALUATION • For most patients • CBC • BMP • TSH • UA + Culture • Consider • ABG • Toxicology screening • Drug levels • CMP • B12 • Folate • RPR
- 37. IMAGING STUDIES • Tailor studies based on history/exam • Chest x-ray • CT of brain • MRI of brain
- 38. CT WITHOUT NEUROLOGICAL FINDINGS Posive CT Findings 4% 96% Acta Neurol Scand. 2008;118(4):245.
- 39. OTHER STUDIES • Tailor studies based on history/exam • Lumbar puncture • EEG
- 40. NON-CONVULSIVE STATUS EPILEPTICUS 0% 10% 20% 30% 40% Privitera 1994 Claassen 2004 Epilepsy Res. 1994;18(2):155., Neurology. 2004;62(10):1743.
- 41. 62 YEAR OLD 2 DAYS POSTOP • Metabolic Encephalopathy • Drug history • Narcotics for pain control (New) • Possible chronic alcohol use • Labs unremarkable
- 43. 67 YEAR OLD IN ICU • Admitted for septic shock and UTI • On vent • Reducing sedation • Agitated • Combative
- 45. DEFINITION- DSM-V Metabolic Encephalopathy Acute Onset Attention Awareness Cognition Not neurocognitive disorder Evidence of a medical cause
- 46. How to assess ICU patients
- 47. CAM-ICU Features Acute onset and fluctuating course Inattention Disorganized Thinking OR Altered level of consciousness
- 48. CAM-ICU – ONSET AND COURSE Is there evidence of an acute change in mental status from the patient’s baseline? OR Has the patient had any fluctuation in mental status in the past 24 hours as evidenced by fluctuation on a sedation/level of consciousness scale (i.e., RASS/SAS), GCS, or previous delirium assessment?
- 49. CAM-ICU – INATTENTION Say to the patient, “I am going to read you a series of 10 letters. Whenever you hear the letter ‘A,’ indicate by squeezing my hand.” Read letters from the following letter list in a normal tone 3 seconds apart. S A V E A H A A R T or C A S A B L A N C A or A B A D B A D A A Y Errors are counted when patient fails to squeeze on the letter “A” and when the patient squeezes on any letter other than “A.” Two or more errors qualifies for inattention.
- 50. CAM-ICU – DISORGANIZED THINKING Ask the following Yes/No questions Will a stone float on water? Are there fish in the sea? Does one pound weigh more than two pounds? Can you use a hammer to pound a nail? Say to patient: “Hold up this many fingers” (Hold 2 fingers in front of patient) “Now do the same thing with the other hand” More than one error qualifies for disorganized thinking
- 51. CAM – ALTERED LEVEL OF CONSCIOUSNESS Present if the RASS score is anything other than alert and calm (zero)
- 53. 67 YEAR OLD IN ICU • Admitted for septic shock and UTI • On vent • Reducing sedation • Agitated • Combative
- 54. Treatment
- 56. PHYSICAL RESTRAINTS • 3x more likely to have persistent delirium • Increased risk for • Falls • Pressure ulcers • Increased agitation Arch Intern Med. 2007;167(13):1406.
- 57. BENZODIAZEPINES • Commonly used in treatment of delirium • No clear evidence of benefit Cochrane Database Syst Rev. 2009;
- 59. NEUROLEPTIC MEDICATIONS • Haloperidol • Haloperidol + Quetiapine • Risperidone • Olanzapine • Quetiapine Cochrane Database Syst Rev. 2007 Crit Care Med. 2010;38(2):419 J Hosp Med. 2013 Apr;8(4):215-20
- 60. HALOPERIDOL + QUETIAPINE Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study *. Devlin, John; Roberts, Russel; Fong, Jeffrey; Skrobik, Yoanna; Riker, Richard; Hill, Nicholas; Robbins, Tracey; Garpestad, Erik Critical Care Medicine. 38(2):419-427, February 2010. DOI: 10.1097/CCM.0b013e3181b9e302
- 61. HALOPERIDOL VS. QUETIAPINE Maneeton B, Maneeton N, Srisurapanont M, Chittawatanarat K. Quetiapine versus haloperidol in the treatment of delirium: a double-blind, randomized, controlled trial. Drug Des Devel Ther. 2013 Jul 24;7:657-67.
- 62. HALOPERIDOL VS. NEWER NEUROLEPTICS Hyung-Jun Yoon, Kyoung-Min Park, Won-Jung Choi, Soo-Hee Choi, Jin-Young Park, Jae-Jin Kim and Jeong-Ho Seok Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium BMC Psychiatry 2013, 13:240
- 63. FREQUENCY OF ADES 80% Adverse Drug Event 20% BMC Psychiatry 2013, 13:240
- 64. Prevention
- 66. RISK FACTORS FOR DELIRIUM • Dementia • Stroke • Parkinson’s Disease • Sensory impairment • Critical illness • Sleep deprivation
- 67. MODIFYING RISK FACTORS • Orientation • Sleep • Mobilization • Glasses • Hearing aids Cochrane Database Syst Rev. 2014;1:CD009537 Promising data from small studies
- 68. AVOIDING PRECIPITATING FACTORS • High risk drugs • Withdrawal syndromes • Metabolic disturbances • Manage Pain
- 69. Prophylaxis
- 70. RISPERIDONE 0% 10% 20% 30% 40% Hakim 2012 Prakanrattana 2007 Risperidone Placebo Anaesth Intensive Care. 2007 Oct;35(5):714-9., Anesthesiology. 2012 May;116(5):987-97.
- 71. OLANZAPINE 0% 10% 20% 30% 40% 50% Larsen 2010 Olanzapine Placebo Psychosomatics. 2010 Sep-Oct;51(5):409-18.
- 72. MELATONIN 0% 10% 20% 30% 40% Sultan 2010 Al-Aama 2011 Melatonin Placebo Saudi J Anaesth. 2010 Sep;4(3):169-73., Int J Geriatr Psychiatry. 2011 Jul;26(7):687-94
- 73. RAMELTEON 0% 10% 20% 30% 40% Hatta 2014 Ramelteon Placebo JAMA Psychiatry. 2014 Apr;71(4):397-403.
- 75. MALE FOUND UNRESPONSIVE • Brought to ED by police • Unknown identity • No history • Disheveled • Smells strongly of alcohol • Snoring • No signs of trauma • Vitals stable
- 78. COLLISION OF FACTORS Chronic Conditions Acute Illness Environment Medications Metabolic Encephalopathy
- 79. MALE FOUND UNRESPONSIVE • Brought to ED by police • Unknown identity • No history • Disheveled • Smells strongly of alcohol • Snoring • No signs of trauma • Vitals stable • Alcohol Intoxication
- 80. MALE FOUND UNRESPONSIVE • Brought to ED by police • Unknown identity • No history • Disheveled • Smells strongly of alcohol • Snoring • No signs of trauma • Vitals stable • Alcohol Intoxication • Thiamine deficiency
- 81. MALE FOUND UNRESPONSIVE • Brought to ED by police • Unknown identity • No history • Disheveled • Smells strongly of alcohol • Snoring • No signs of trauma • Vitals stable • Alcohol Intoxication • Thiamine deficiency • Aspiration pneumonia
- 82. MALE FOUND UNRESPONSIVE • Brought to ED by police • Unknown identity • No history • Disheveled • Smells strongly of alcohol • Snoring • No signs of trauma • Vitals stable • Alcohol Intoxication • Thiamine deficiency • Aspiration pneumonia • Subdural hematoma