Toxic Metabolic Encephalopathy

Terms in this set (41)

Inability to carry out a coherent plan of thought or action (GLOBAL/diffuse disturbance of cortical function: speed of processing, clarity, coherence)

T/F: Encephalopathy is potentially reversible.

Toxic metabolic:

List of causes for alteration in mental status

Acute encephalopathy (Acute confusional state; Altered mental status)

Delirium is characterized by:

Fluctuations of alertness and attention; Decreased concentration and coherent thought/skilled movements; Disorientation, memory, language, irritability and agitation, restlessness, apathy, hallucinations; Nocturnal exacerbations common

What mental status exam tests would you do in an encephalopathic patient?

Level of alterness, orientation, and attention

The hallmark of encephalopathy is:

Impaired ATTENTION (early finding in delirium, late finding in dementia)

Symptoms of encephalopathy include:

Hallucinations, delusions, agitation or lethargy; Irritation to light touch; Withdraw limbs unequally; Asterixis, myoclonus, tremor, sometimes hyperreflexia (acute liver malfunction)/hyporeflexia (thyroid derrangement)

T/F: Dementia is a major risk factor for delirium.

T/F: Delirium is a risk factor for developing dementia later on.

TRUE. NOT causative, just a marker that something's already going on in the brain

T/F: Ecephalopathy is often multifactorial

Why does encephalopathy occur?

Metabolic homeostasis

Normal CNS function depends on homeostatic mechanisms, including:

Regulating circulating electrolytes, blood sugar, O2, hormones; Renal and hepatic mechanisms for detoxifying toxic products of metabolism such as ammonia

T/F: Small changes in metabolic parameters can produce clinical symptoms.

FALSE. Need WIDE variations to change neuronal and glial dysfunction

Because the brain is location-based, global disruption of metabolic homeostasis can result in:

Behavior change, poor coordination, ataxia, confusion, seizures, stupor and coma; May be a lag in recovery of CNS symptoms after the metabolic problem is corrected

Encephalopathy causes include:

VIITTAMIN: Vascular, Inlammatory, Infectious, Traumatic, Toxins, Autoimmune, Metabolic, Idopathic/Genetic; Neoplastic

A major vascular cause of encephalopathy is:

Hypertensive encephalopathy

Two major inflammatory/infectious causes of encephalopathy include:

Urinary tract infection in elderly; Infection of the CNS (encephalitis)

Metabolic: endocrine disorders that cause encephalopathy include:

Hypo/hyperglycemia; Hypo/Hyperthyroidism

The most likely electrolytes to cause metabolic encephalopathy include:

SODIUM (low and high) and CALCIUM (high)

Major nutritional deficiencies that can cause metabolic encephalopathy are:

Respiratory metabolic enceaphalopathy can be caused by:

High CO2, hypoxia

Organ failure that can cause metabolic encephalopathy include:

Uremia (kidney disease); Hyerammonia (liver disease)

Prescription meds that can cause toxic encephalopathy include:

Overdose; Antibiotics (ciprofloxacin); and anticholinergic drugs and sedating drugs (diphenhydramine--benadril, lorazapam) in elderly

T/F: Alcohol intoxication or withdrawal can cause toxic encephalopathy.

Alcohol intoxication can cause __ in the nervous system

Euphoria, ataxia, confusion, coma, death

Alcohol withdrawal can cause __ in the nervous system

Delirium tremens (Tremor, hallucinations, confusion, autonomic features); Seizures within 48 hours

Wernicke's encephalopathy

Triad: Opthalmoparesis (nystagmus), gait ataxia and confusion; Responds to thiamine replacement (GIVE THIAMINE before glucose; thiamine is a cofactor for metabolism of carbs/sugars);

Causes of Wernicke's encephalopathy include:

Alcohol is the most common cause, but also seen from cachexia from cancer, starvation from bariatric surgery for obesity, and anorexia

Wernicke-Korsakoff Syndrome

Prolonged thiamine deficiency; Chronic necrosis of diencephalon (thalamus and hypothalamus), mammilary bodies, periventricular regions of brainstem, anterior cerebellum; Anterograde amnesia with confabulation

How do you test for encephalopathy?

Vital signs and labs; Brain imaging can be normal but EEG shows encephalopathy

EEG can be useful for testing encephalopathy because:

1. Differentiate neuro vs. psych; 2. Rule out subclinical seizures or "non-convulsive status epilepticus" (encephalopathy mimic)

Mimics of Encephalopathy include:

Dementia with Lewy Bodies; REM sleep behavior disorder (act out dreams) and parasomnias (sleepwalking); Wernicke's aphasia; Psychosis, mania, depression; Nonconvulsive status epilepticus (last two: differentiate with EEG)

Nonconvulsive status epilepticus

Nonstop seizure state; Produces a mental state similar to encephalopathy; Can be differentiated with an EEG

Exacerbating factors of encephalopathy include:

Elderly and cognitively impaired are more vulnerable ("sensitive brain")

Things to pay attention to for treatment of encephalopathy include:

Orientation--sleep/wake cycle, etc; Complicated med and psych problems and multiple meds; Anesthesia for surgeries (avoid with history of delirium?); Alcohol or benzo withdrawal

Clinical impact of delirium includes:

Fall prevention

Older patients with delirium die __ years earlier than normal.

How to treat encephalopathy:

IDENTIFY CAUSE! Thiamine with glucose; Narcan/Naloxone for opiate overdose; Hydration, electrolytes; Antipsychotics used off-label (controversial); Brain function "lags behind" labs

Approach to diagnosis for altered mental status:

1. Identify the problem (history, exam); 2. Are there focal neuro findings? (If so--needs CT scan; If no--need MRI); 3. If not do toxic-metabolic workup

Toxic metabolic workup includes:

ABC's (vital signs, BP, Fever); Complete blood count; Basic metabolic profile (electrolytes, kidney function, glucose); Tox screen; Liver function tests

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