Altered Mental Status Hs and Ts

[SoCuteMD]

My sis is studying for her EMT re-cert and I want to give her this list. Anyone remember it. So far we have:
hypotension
hypo-/hyperglycemia
thiamine deficiency

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[Hard24Get]

My sis is studying for her EMT re-cert and I want to give her this list. Anyone remember it. So far we have:
hypotension
hypo-/hyperglycemia
thiamine deficiency

never heard of this mnemonic, sounds useful. I know there is:

hyper/hyponatremia
hypercalcemia
hyper/hypothyroidism
hypoxia/hyperpnea
hepatic encephalopathy
hypertension
thromboembolism
toxicology

can't think of how to turn infectious etiology into a h or t...

 

[deleted109597]

never heard of this mnemonic, sounds useful. I know there is:

hyper/hyponatremia
hypercalcemia
hyper/hypothyroidism
hypoxia/hyperpnea
hepatic encephalopathy
hypertension
thromboembolism
toxicology

can't think of how to turn infectious etiology into a h or t...

There are five causes of Altered MS.
Structural=tumors, bleeds, etc
Vital signs=tachy, HTN, hypotension
Toxicology=which includes infectious
Metabolic=hypo/hyper whatevers
Psych=trash can to fall into if you can't find the other 4

 

[Pose]

You may be looking for:

AEIOU TIPS

Alcohol
Epilepsy
Insulin
Overdose
Uremia
Trauma
Infection
Psychiatric
Stroke

 

[Pose]

In fact, you probably are NOT looking for that.

H's:
hyper/hyponatremia
hyper/hypoglycemia
hypercalcemia
hyper/hypothyroidism
hypoxia/hyperpnea

 

[BKN]

My sis is studying for her EMT re-cert and I want to give her this list. Anyone remember it. So far we have:
hypotension
hypo-/hyperglycemia
thiamine deficiency

Hs and Ts is for differential of pulseless electrical activity.

AEIOU and TIPS is for AMS and coma, but is of limited usefulness since essentially all diseases in advanced stages cause AMS. Each letter in the mnemonic stands for about 5-50 things.

 

[Annette]

What about hypo/hyperthermia?

 

[BKN]

What about hypo/hyperthermia?

From a coma lecture that I give:

Coma mnemonic for the brain impaired Doc

w A for alcoholism

w E for encephalopathy

w I for insulin

w O for opiates

w U for uremia

w T for trauma and environmental disturbance

w I for infection

w P for psychiatric

w S for syncope

Alcoholics have many reasons to be impaired

w Head trauma, hypothermia

w Infections: pneumonia, meningitis, sepsis

w Withdrawal: delerium tremens, post-ictal

w Metabolic: alcoholic ketoacidosis, lactic acidosis

w Brain atrophy, Wernicke’s, Korsakoff’s, lead encephalopathy

w Toxic alcohols: methanol, isopropyl, ethylene glycol

w Liver failure, hypoxia

E for encephalopathy

w Post-ictal

w Hypertensive Encephalopathy

w Intracerebral mass

w CVA - vasocclusive

n thrombosis

n embolism

n venous infarct

w CVA- hemorrhagic

n Intracerebral hemorrhage

n Subarachnoid hemorrhage

I for insulin

w Too little

n Diabetic Ketoacidosis

n Hyperosmolar Non-ketotic Coma



w Too much

n Hypoglycemia

O for opiates

w Essentially any chemical including water



w sedatives

w anticholinergics

w hallucinogens

w sympathomimetics

U for uremia

w Hyper and hypo Na, hyper and hypo Ca, hyper and hypo Mg, hypophosphatemia

w Hyper and hypo T4, Hyper and hypo adrenal, panhypopituitarism

w Liver, renal, and exocrine pancreas failure,

w HYPERCARBIA

w HYPOXIA, HYPOXIA, HYPOXIA

T for trauma and environmental disturbance

w Epidural, Subdural, Subarachnoid and intracerebral hemorrhage

w Concussion and contusion

w Hypo and hyperthermia

I for infection

w Meningitis

w Sepsis

w Brain abscess

w Encephalitis

w The weirdos: cerebral syphillis, malaria, tuberculosis, cystocercosis, nagleria, cryptococcosis, toxoplasmosis, etc

P for psychiatric

w Voluntary psychogeniuc unresponsiveness

w Involuntary psychogenic unresponsiveness

w Catatonia

S is for syncope

w Arrhythmias

w Infarction

w Hypovolemia

w Hemorrhage

w Vasodepressor syncope

Causes of Stupor or Coma in 500 patients

w Diffuse dysfunction 76%



w Supratentorial lesions 20%



w Subtentorial lesions 12%



w Psychiatric 8%

Things that aren’t coma

w Dementia

w Acute Confusional State (Delerium)

w Persistent Vegetative State

w Akinetic Mutism

w Locked in syndrome

w Psychogenic Unresponsiveness

Brain death

 

[SoCuteMD]

Hs and Ts is for differential of pulseless electrical activity.

You are right. Clearly my brain is still hibernating from summer...

 

[DropkickMurphy]

I was actually taught the H and T's for AMS in addition to AEIOU-TIPS

H- hypotension, hyper/hypoglycemia, [H+] (hydrogen ions- i.e. acidosis), hemorrhage (intracranial), hyper/hyponatremia, hypercarbia.....
T- tablets/toxins, trauma (head), thyroid, temperature (including fever).....

 

[beyond all hope]

I've been trying to work on a teaching module for AMS which includes a good framework for thinking about AMS. I've always used AEIOUTIPPS but I find it hard to remember all of the aspects. Somewhat similar to IbnSina's. The reason I like this one is it also comes with a framework for workup:

Intracranial: tumors, bleeds -> HCT
Infection: PNA, UTI, Meningitis -> CXR/UA/LP
Metabolic: lytes, adrenals/thyroid, liver/kidney, glucose, oxygen/CO2 -> accucheck, chem 8, ABG
Toxic/withdrawl: EtoH/tox screen
Shock: MI, etc. : EKG, VS

please let me know if you have anything to add to above.

 

[BKN]

I've been trying to work on a teaching module for AMS which includes a good framework for thinking about AMS. I've always used AEIOUTIPPS but I find it hard to remember all of the aspects. Somewhat similar to IbnSina's. The reason I like this one is it also comes with a framework for workup:

Intracranial: tumors, bleeds -> HCT
Infection: PNA, UTI, Meningitis -> CXR/UA/LP
Metabolic: lytes, adrenals/thyroid, liver/kidney, glucose, oxygen/CO2 -> accucheck, chem 8, ABG
Toxic/withdrawl: EtoH/tox screen
Shock: MI, etc. : EKG, VS

please let me know if you have anything to add to above.

I start with an extremely confusing case that led to potential disaster when I was young and foolish. I then spend less than 5 minutes on the mnemonic and possible diagnoses. I spend about an hour on Plum and Posner's classification and how to classify in 3 minutes using their basic exam:

Classification:
1. Diffuse (metabolic) lesions
2. Supratentorial mass lesions causing herniation
3. Subtentorial mass or destructive lesions
4. Psychogenic unresponsiveness

Exam:
1. pupillary size, shape and reactivity
2. respiratory pattern
3. motor response and tone
4. oculocaloric responses

Then I spend about 10 minutes on intial stabilization and additonal diagnostic measures. I don't spend any time on reading imaging, that's another lecture.

Then I go back to the original case and how we got out of the hole. It's better to be lucky than good.

 

[beyond all hope]

Huge fan of the P&P criteria myself (as a grad student I even wrote a poem about Posner's theories of cognitive assimiliation. Yes, I'm a dorkatron).

That being said, supratentorial lesions usually cause focal motor/sensory deficits, and subtentorials usually cause balance issues and CN deficits. Rarely will either cause AMS unless they involve increased IC pressure +/- herniation. Almost all will either be CVAs or show up on noncon HCT. In my limited experience the common causes of AMS in the ED are the toxic/metabolic delirium (deliria? delirums?), have a nonfocal exam, and these are often the most difficult to evaluate.

I agree with everything you said regarding AMS/Coma in the ED, I just think that AEIOUTIPPS is too much to remember. I find myself unable to remember which letter means what (is E electrolytes or EtOH? Is I infection or insulin?)

I try to tailor my discussions to practical ED evaluations of common problems.
I guess I'm assuming that as med students they will have been exposed to the Plum and Posner classification. Am I assuming too much?

 

[BKN]

Huge fan of the P&P criteria myself (as a grad student I even wrote a poem about Posner's theories of cognitive assimiliation. Yes, I'm a dorkatron).

That being said, supratentorial lesions usually cause focal motor/sensory deficits, and subtentorials usually cause balance issues and CN deficits. Rarely will either cause AMS unless they involve increased IC pressure +/- herniation. Almost all will either be CVAs or show up on noncon HCT.

may not show up if in the brainstem

In my limited experience the common causes of AMS in the ED are the toxic/metabolic delirium (deliria? delirums?), have a nonfocal exam, and these are often the most difficult to evaluate.

I would say yes, yes and no. The diffuse lesions are less emergent and you have time to think. The masses (with coma) are dying now.

P&P give a series of 500 cases- after hypoglycemia and narcotic od removed. 76% diffuse dysfunction, 20% supratentorial mass, 12% subtentorial mass or destructive lesion, 1% psychogenic unresponsiveness. My experience similar.

I try to tailor my discussions to practical ED evaluations of common problems.
I guess I'm assuming that as med students they will have been exposed to the Plum and Posner classification. Am I assuming too much?

Sounds good. But you are assuming too much. When I give this talk to my residents, P&P are a mystery. See, I'm poetic too.