Altered Mental Status

Mnemonic: “HE STOPS AEIOU TIPS“

ETIOLOGIES

• Hypertensive/Hepatic encephalopathy
• Electrolyte derangement (Na⁺, Ca²⁺)

• Stroke
• Trauma (intracranial hemorrhage)
• Opiates
• Psychiatric (Conversion Disorder vs Psychosis)
• Seizure

• Acidemia
• Endocrinopathies (hypoglycemia, hypo/hyperthyroidism, adrenal insufficiency, Cushing’s syndrome)
• Intoxication/wIthdrawal
• HypOxemia/CO₂ retention
• Uremia

• Temperature (hyper/hypothermia) or Thiamine deficiency (Wernicke-Korsakoff Syndrome)
• Infection (especially meningitis/encephalitis or UTI in the elderly)
• Porphyria
• Sepsis

WORKUP

• History and Physical (looking for symptomatology/course/last known well, substance use, history of liver disease/seizures/psychiatric disorders, signs of infection, difficulty breathing)
• Labs/Imaging
  • CBC (to look for infection)
  • CMP (to look for electrolyte derangements, liver disease, renal injury, acidosis)
  • UDS (to look for substance use) + EtOH level
  • ABG (to look for acid/base derangements, hypercarbia, hypoxemia)
  • EKG and Troponin level (to evaluate for ACS)
  • TSH to evaluate for hypo-/hyperthyroidism
  • Consider CT of the brain to evaluate for brain bleed based on history and physical exam
  • Consider MRI of the brain to evaluate for structural etiologies
  • Consider lactic acid, blood cultures, chest x-ray, urinalysis with microscopy and urine cultures to evaluate for sepsis and infections
  • Consider an EEG to evaluate for sublinical seizures
  • Consider B12/folate levels
  • Consider treating empirically for Wernicke Encephalopathy with high-dose IV Thiamine (Empiric treatment: 500 mg q8hours for 2 days, then 200-300 mg daily for 5 days)