43rd JAAM E001-4(Light edition)
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43回JAAMでの発表スライド改訂版。これを更に修正するなどして（略
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43rd JAAM E001-4(Light edition)
- 1. The property of patients with altered mental status in emergency department Advanced Emergency & Critical Care Center, SMGH Norifumi Matsuda, Makoto Matsuura, Kazuki Suganuma, Kenya Iwakura, Mitsuru Nakatani, Kazuhiro Shiga, KenichiYano, Seiichi Asai,Tatsuya Hayakawa
- 2. Introduction • The cause of altered mental status (AMS) often remains unclear in emergency department (ED). • Increase in reluctance to perform invasive tests like lumbar puncture for the elderly with AMS. • This study aims to reveal the etiology of AMS in ED.
- 3. Material & Method • Subjects: patients who presented to the ED with AMS; – ED patients who arrived by ambulance or helicopter – ED patients who walked-in to the ED, and were admitted • Duration of Study: April 2013 to March 2015 • Age groups: detailed analysis was performed onAbove; – Patients over the age of 65 – Adult patients under the age of 65 • Statistical analysis: Microsoft Excel 2011 & R(3.1.2 )
- 4. Result 1: Background of Patients Age Distribution of Patients Summary of the chief complaint ＜65 n=535 ≧65 n=1074 n=907 n=773 Altered mental status Excited state Other
- 5. 0 5 10 15 20 25 30 35 Psychiatric disorder Intoxication CNS disease Metabolic & Endocrine disease Trauma 0 5 10 15 20 25 30 35 CNS disease Metabolic & Endocrine disease Respiratory system disease Cardiovascular system disease Dehydration Result 2: Categorizing the causes of AMS ≧65 （n=1074） (%) ＜65（n=535） (%) Cerebral stroke Hypoglycemia & diabetic coma Hypoglycemia & diabetic coma Cerebral stroke
- 6. Result 3: Diagnostic steps Hypoglycemia, Electrolyte imbalance, CO2 narcosis etc… (n=177) ABG analysis Imaging & ECG Stroke, Intracranial SOL, Aortic disease etc... (n=453) Blood test Hepatic coma, Uremia etc... (n=46) Acute heart failure, pneumonia, UTI, MOF etc... (n=268) Combination of ED-investigations ED-patients with AMS (n=1609) Routine tests were negative (n=665) Undiagnosed ED-patients (n=121) Psychiatric disorder, Intoxication etc… (n=544)
- 7. Discussion • Hypoglycemia and cerebral stroke must be diagnosed quickly for a positive health outcome. • Psychiatric evaluation is an important and effective for diagnosis and care in patients under the age of 65. • Medical interview and serial ED-investigations are enough to diagnose over 90% patients withAMS. • Observation with fluid therapy can be appropriate for some patients of any age, but only with undiagnosed AMS.
- 8. Conclusion • Sufficient evaluation can be performed using current diagnostic tools in the ED and medical consultation including psychiatric evaluation. • Lumbar puncture procedure to determine undiagnosedAMS may not always be necessary.
Notas del editor
- Altered mental status in the population is diverse, and the cause often remains unclear in emergency department. This is even more difficult to determine in elderly patients with AMS, where there is seemingly increasing reluctance to perform invasive tests such as lumbar puncture. Some strategies have already been proposed to diagnose AMS. However, variations in the etiology of disease requires these strategies to be much more sophisticated. This study aims to reveal a property of patients with altered mental status in ED.
- The subjects of this research were patients who presented with AMS that arrived to the emergency department by ambulance or helicopter, and walk-in patients who were admitted from April 2013 to March 2015. All patients were screened. However, detailed analysis was performed only on patients over the age of 16. The adult patients were divided into two groups: those under the age of 65, and those over the age of 65.
- The total number of subjects in this study was 1680. The 71 patients under 16 age were eliminated from the dataset for the detailed analysis. Of the 1609 patients analyzed in detail, 535 patients comprised the under 65 age group, and 1074 patients comprised the over 65 age group. It was noted that the under 65 age group contained more agitated patients, who were subsequently diagnosed with a psychiatric disorder.
- The etiology of presenting diseases varied depending on the age group. The most common five categories of each group are presented here. In the over 65 age group, CNS disease was the most common, with a large proportion of cerebral stroke. This was followed by metabolic & endocrine disease, with a large proportion of these patients diagnosed with hypoglycemia and diabetic coma. The less prevalent cause of AMS in this age group were respiratory and cardiovascular diseases. Dehydration made up 7%, it was the most prevalent of exogenous diseases in the elderly. Psychiatric disorder was most prevalent in patients under 65 years old, followed by intoxication and CNS disease. Almost all trauma patients with altered mental status also presented with a head injury.
- Diagnostic steps were common in both age groups. Arterial blood gas analysis revealed 124 patients with hypoglycemia and 16 patients with diabetic coma. It was also diagnostic for a respiratory failure and an electrolyte imbalance. Neuroimaging identified 419 patients, with approximately 30% requiring a brain MRI due to no significant signs after undergoing a head CT. Where routine diagnostic testing was performed, 665 patients remained undiagnosed. Of these patients, detailed medical interviews and physical examinations brought sufficient information to diagnose 544 patients with psychiatric disorders, intoxications, syncope and so on. Of the 121 patients who remained undiagnosed in the emergency department, 84% saw an improvement in presenting symptoms and physical condition with fluid therapy. These patients were ultimately diagnosed with dehydration. Interestingly, it was noted that of these 121 undiagnosed patients, lumbar puncture was diagnostic only for 7 patients with encephalopathy and CNS infection.
- The urgent diseases such as cerebral stroke and hypoglycemia must be diagnosed quickly to ensure a positive health outcome. The diagnosis of psychiatric disease and intoxication was prevalent in the under 65 age group. Therefore, a psychiatric evaluation is important. This study has determined that a medical interview and serial investigations currently available in the emergency department are enough to diagnose over 90% of patients. In addition, observation with fluid therapy can be appropriate for some patients, but only if they have undiagnosed altered mental status without any other abnormalities.
- This study has found that medical consultation combined with the current diagnostic tools available in the ED could provide sufficient evaluation of diagnosis. Lumbar puncture is diagnostic only for a minor property of AMS patients, therefore it may not always be necessary.