Acute Somnolence (Rapid Response Calls)

foreign medicine and today I'm discussing how to respond to another potential urgent page a rapid response call this time for somnolence imagine you're an intern sitting back listening to a case in Morning Report when suddenly this message comes across your pager Dave from unit M7 calling regarding patient Lou she's very sleepy unable to keep her eyes open and is confused she was fined one hour ago vital stable bedside ebal requested ASAP as you hurry out of the room you might start thinking about all the possible things that could be going on with Miss Lou but unfortunately you recall that the diagnostic framework or diagnostic schema for altered mental status is absurdly large far too large to comprehensively consider at the bedside during an acute event luckily however before we even get to her room we can dramatically reduce the number of diagnoses we need to be considered because of three things first not all causes of altered mental status typically lead to somnolence some predominantly lead to agitation instead which from the message seems like it's not the case here second whatever this was must have developed very suddenly and third this is presumably something that tends to strike hospitalized people so with all that in mind we can actually now down the list of possibilities pretty significantly first are the metabolic causes these include medications of which common culprits are opiates and benzodiazepines but also Gabapentin muscle relaxants and antihistamines hypo and hyperglycemia while hyperglycemia takes some time to develop patients can flip from relatively asymptomatic to symptomatic more quickly hypercapnia that is an elevated blood carbon dioxide level can lead to somalence and uncommon but classic scenario in which this happens is when a patient with COPD is placed on excessive oxygen which normalizes their O2 sat and makes the patient superficially seem better briefly only for the CO2 to rise via multiple mechanisms stimulant withdrawal leads to sedation here in California methamphetamines is by far the biggest culprit here but in other places of the world it might be cocaine and last is surreptitious opiate abuse occurring in the hospital under primary neurologic etiologies we have an ischemic stroke and intracranial hemorrhage but also a post-ictal state following a seizure and while relatively rare we should also keep in mind non-convulsive status epilepticus and last are two diagnoses I would place in an other category shock and or sepsis and hypoactive delirium both of which would warrant a separate differential diagnosis of Their Own so going back to Ms Liu who you are running to go see you're now in her room and find her as the nurse reported sleepy confused and minimally arousable it's time for a highly focused history and physical exam due to the patient's mental status the history can only consist of things obtained from the chart review does she have cardiovascular risk factors which would suggest either a stroke or hemorrhage has she been recently started on any new medications or received a higher dose or has she recently developed acute kidney injury which could reduce the clearance of a medication she's been on up for a while recent head trauma suggests the possibility of an intracranial bleed dementia is a huge risk factor for hypoactive delirium if she currently has an active infection she could be developing sepsis and infection is also a delirium risk factor a history of drug abuse suggests either intoxication with an opiate or benzo or a withdrawal from a stimulant if she has a history of COPD she's at risk of hypercapnia particularly if she's on a new oxygen therapy and in a patient with diabetes you need to worry about derangements of glucose the physical exam for an acutely somnolent patient is typically focused on vitals and the neural exam the combination of hypotension and tachycardia of course suggests sepsis and shock while focal neural findings are most suggestive of an ischemic stroke though other diagnoses can do this as well and the new occurrence of urinary and in particular fecal incontinence suggests the patient has experienced an unwitnessed seizure what kind of Diagnostics are appropriate for a patient with acute somnolence everyone should get a finger stick glucose because it's so quick and inexpensive and because hypoglycemia is both extremely dangerous and extremely easy to treat most patients should receive a venous blood gas to rule out hypercapnia once again it's quick and easy and relatively easy to address if drug abuse is considered a possibility send off a urine talk screen though if the abuse was extremely reason as in the patient just used some drugs in the hospital the relevant compounds may not yet be detectable in the urine if shock receptus is a possibility a full panel of labs is indicated however they usually won't shed much light on any of the other possible diagnoses under consideration in the rare situation in which non-convulsive status epilepticus is suspected get an EEG and last is the big question does this patient require emergent neural Imaging while you might think that in order to be safe any patient with an acute change in mental status needs their brain imaged these scans are expensive and an unstable patient is also at risk of further deterioration during the non-trivial time there'll be sub-optimally monitored going to and from Radiology and in the case of CT scans they actually come with a non-trivial exposure to radiation while every situation is different and there will be exceptions typical indications for emergent neural Imaging include new focal neural findings recent head trauma or an unwitnessed fall the use of anticoagulation and a suspected seizure regarding whether that emergent scan should be a non-contrast head CT or an MRI depends on their relative accessibility at your institution and how suspicious you are of an acute ischemic stroke which is better evaluated by the much longer and much more expensive MRI there's not much empiric treatment to consider for the somalent patient if they are hypotensive or there are other signs of shock switch framing of the case altogether from somnolence to shock and treat accordingly with fluids and repressors if the patient is minimally arousable and either a low respiratory rate or hypoxemic administer Narcan on the other hand if the patient is just a little sleepy but arousable and there is no respiratory compromise I would think twice about giving Narcan the abrupt reversal of opiates in a patient with severe pain or with opiate dependence can be an extremely unpleasant experience irrespective of whether or not you give Narcan the patient needs to be very closely monitored afterwards in those who receive Narcan this is because narcan's duration of action is shorter than most opiates and patients may need to receive subsequent doses while the opiate is still being metabolized and or eliminated from the body and then those in who uh might have opiate overdose or opiate toxicity and who you chose not to give Narcan the need for unusually close monitoring is because you may be catching the opiate toxicity while it's still early and actively getting worse if Narcan is ineffective for respiratory depression and or the patient is not protecting their Airway in the event of opiate toxicity intubation should be very strongly considered I'll end with common pitfalls of responding to acute somnolence in the hospital not immediately checking the glucose an over-reliance on other lab tests which are usually not helpful with the situation not ordering a head CT when indicated or ordering it when it's not while the former error is certainly much more dangerous that doesn't mean that there is no harm from the latter not considering decreased medication clearance as the culprit in patients experiencing acute kidney injury or decreased clearance due to Med interactions delaying calling a stroke code in the presence of new focal neural findings and finally not redosing Narcan after it wears off before the causative opiate is cleared that's it for this video on approach to somalence in the hospital if you found it helpful please check out the rest of the series on a number of acute problems that can develop in hospitalized patients on the internal medicine wards [Music]

Channel: Strong Medicine

Views: 8,747

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Id: cc9lOf9kk9M

Length: 9min 22sec (562 seconds)

Published: Tue Jan 17 2023

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