Acute Management of Older Adult Found Down with Altered Mental Status:
An Unfolding Case Study

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Margarita Castillo is a thin, frail 73-year-old Filipina female who presents with a history of multiple ground level falls in the previous week. This morning, her friend Mr. Flores, who lives down the street, became concerned when Mrs. Castillo’s newspaper was still on her front porch at 10 a.m. He went to check on her and found her on the floor and confused. He called 911 and she was taken to the emergency department (ED) in a cervical collar.



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What are your initial steps to assess and manage Mrs. Castillo’s care?

Type your answer in the box below.


Please drag the bottom right corner to expand the box.



Photo courtesy of UW Medicine




The initial assessment (and management) of the trauma patient should follow Advanced Trauma Life Support (ATLS) guidelines1 for primary (the ABCDEs) and secondary surveys. In addition, the providers should determine if the patient has any advance directives that should guide treatment.

Clinical Pearl...

Though this might not seem initially like “trauma,” this patient has most likely had a fall and needs to be cared for as any other trauma patient.

1Advanced trauma life support (ATLS®): the ninth edition. ATLS Subcommittee et al. J Trauma AcuteCare Surg. (2013).


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On arrival to the ED, Mrs. Castillo’s blood pressure (BP) is 92/48 mmHg, heart rate (HR) is 104 beats/minute (bpm), respiratory rate (R) is 8 breaths/min (bpm), and temperature (T) is 97.0°F. Pulse oximetry is 90% on supplemental oxygen at 2L/min via nasal cannula. She has shallow breaths with noted grimacing. An intravenous (IV) line was started by EMS and normal saline (NS) is currently running at 75 mL/hour. A Foley catheter is placed for accurate measurement of output.

On the neurological examination, her Glasgow Coma Score (GCS) is 15, and she is tangential in her speech, speaking in both English and Tagalog and is demonstrating word finding difficulty.


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Based on the information you have thus far, identify Mrs. Castillo’s problems and potential problems in order of priority.

Type your answer in the box below.






  1. Altered mental status
  2. Respiratory insufficiency/hypoxemia
  3. Hypotension
  4. Tachycardia
  5. Pain
  6. New onset multiple falls
  7. s/p fall; possible spine injury → spine precautions
  8. s/p fall; possible head injury → neurological monitoring
  9. Unclear advance directive/durable power of attorney
  10. Unclear family support
  11. Capacity for continued independent living

Clinical Pearl...

Correlation between SpO2 and ABG


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What are the possible differential diagnoses for altered mental status (AMS) in this patient?

Type your answer in the box below.






  • Electrolyte imbalance
  • Hypoxemia/hypercapnia
  • Infection
  • Head trauma
  • Cardiovascular event – ischemia or arrhythmia
  • Hypotension and hemodynamic instability/shock
  • Neurologic event – stroke, intracranial hemorrhage, seizure
  • Thyroid disorder
  • Delirium
  • Toxin or medication effect
  • Uremia
  • Alcohol intoxication or withdrawal
  • Hepatic encephalopathy

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What are the possible differential diagnoses associated with respiratory insufficiency in this patient?

Type your answer in the box below.




  • Hypoventilation due to pain or medications
  • Atelectasis from shallow breathing
  • Aspiration
  • Underlying emphysema or asthma
  • Pneumonia
  • Congestive heart failure/pulmonary edema
  • Pulmonary emboli
  • Pneumothorax

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What types of information would be important for you to gather from her friend, Mr. Flores, at this point?

Type your answer in the box below.




  • Past medical history
  • Prior fall history
  • Medications
  • Allergies
  • Social history
  • Family contact information
  • Advance directives

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Listen to the conversation between Mr. Flores and the provider while she gathers information about Mrs. Castillo.






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The members of the interprofessional team go to work. Find out what their priorities are at this time.



Pharmacist




Social Worker



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Advanced Practice Provider or Physician

The Advanced Practice Provider’s (APP’s) or Physician’s priority is to complete the physical examination of the patient.

What tests would be a priority at this point in order to better differentiate the cause of Mrs. Castillo’s problems?

Please check your answers below:

    Labs:

  • ABG
  • Basic metabolic panel
  • Blood alcohol level
  • Blood culture x 2
  • CBC w/differential
  • CBC without differential
  • CK/Troponin
  • Coagulation panel
  • Ferritin
  • Hemoglobin A1c
  • Lactate
  • Liver function tests
  • Thyroid function tests
  • U/A
  • Urine toxicology screen
  • VDRL
  • Vitamin D level
  • Type and screen

    • Diagnostic Studies:

  • Portable chest x-ray (CXR)
  • Head CT
  • Spine CT
  • Bilateral knee xray
  • EKG

Green answers are correct.
Red answers are not correct.





Clinical Pearl...



A non-contrast head CT should be ordered given Mrs. Castillo’s age, history of fall, current symptoms and history of daily aspirin use. At this point, contrast CT is not appropriate as we have not ruled out hemorrhage as a cause of her AMS.


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Initial Test Results

  • ABG → pH 7.21, pCO2 64 mmHg, pO2 58 mmHg, HCO3 23 mEq/L, O2 Sat 89%
  • Lactate: 2 mmol/L
  • Finger stick glucose: 302 mg/dL
  • CXR: preliminary reading 4th and 5th rib fractures on left, old left-sided rib fractures (to be confirmed by radiologist)
  • EKG: Sinus tachycardia – see picture to right

Based on these initial findings, what are the priority actions now?

Type your answer in the box below.






  • Rapid sequence intubation by ED team
  • Notify respiratory therapy of patient intubation
  • Order post-intubation CXR
  • Communicate the need for an ICU bed to charge nurse/bed control

Clinical Pearl...

Acidemia vs Acidosis

Click to enlarge picture.


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Post-intubation Test Results

    You reassess Mrs. Castillo 15 minutes post-intubation and find:
  • ABG → pH 7.32; pCO2 49 mmHg; pO2 350 mmHg; HCO3 22 mEq/L; O2 Sat 100%
  • Current VS: BP 102/54; HR 108 beats/min; Temp 97.1F
  • Vent settings: AC 16; FiO2 1.0; TV 450; PEEP 5
  • GCS is Eye 3/Verbal 1T/Motor 6
  • Urine production 40 mL/hour.
  • She is guarding her L side.






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Click on the pictures below to see the test results.



Blood test



Urinalysis



Radiology reports


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Based on the exam findings post-intubation and diagnostic test results available, what are the next steps in your management of Mrs. Castillo?

Type your answer in the box below.






  • Clear spine, remove collar and get patient off backboard
  • Bolus with 1L normal saline over 1 hour
  • Order urine/serum osmolality, Na+; urine specific gravity (sg)
  • Seek consults from pharmacist, neurosurgery team, and social worker
  • Transition care to Critical Care Team
Clinical Pearl...

Glucose level

Although Mrs. Castillo’s glucose level is high, it is not harmful in the short term. There is a concern about how she would respond to treatment at this point, and we want to avoid hypoglycemia. The risks of treatment outweigh the benefits at this point. Her elevated glucose level should be addressed later in her care.


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Interprofessional Consults

Click on the boxes below to find out more.

Pharmacist

Neurosurgeon

Social Worker


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Preparation for Transfer to ICU

Here is Mrs. Castillo’s problem list from when she first arrived in the ED:

  1. Altered mental status
  2. Respiratory insufficiency/hypoxemia
  3. Hypotension
  4. Tachycardia
  5. Pain
  6. New onset multiple falls
  7. s/p fall; possible spine injury → spine precautions
  8. s/p fall; possible head injury → neurological monitoring
  9. Unclear advance directive/durable power of attorney
  10. Unclear family support
  11. Capacity for continued independent living


Photo courtesy of UW Medicine


Refine the problem list based on current information as you prepare to pass off responsibility of care to the ICU team.

Type your answer in the box below.






  1. Subdural hematoma, non-operable
  2. Hyponatremia, unknown etiology
  3. Altered mental status
  4. Unknown if patient has advance directive/durable power of attorney
  5. Type 2 diabetes, hyperglycemia
  6. Hypotensive, history of hypertension (current status: addressing with fluid resuscitation)
  7. Respiratory failure requiring mechanical ventilation (current status: stable)
  8. Chronic kidney disease, stage 3A
  9. Rib fractures; new and old
  10. Pain
  11. Fall risk
  12. Possible elder abuse and/or neglect
  13. Currently unable to each family
  14. Unclear capacity for continued independent living; discharge disposition


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Handoff of Care

Handoff of Care to the ICU






Clinical Pearl...

There should be standardization in the handoff communication. Using SBAR (Situation, Background, Assessment, Recommendation) is one of the possible methods.


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Pharmacist

The pharmacist’s priority is to review her medication and available medical history.




  • Aspirin EC 81 mg daily
  • Simvastatin 20 mg at bedtime
  • Propranolol LA 120 mg daily
  • Ropinirole 3 mg before bedtime
  • Tylenol PM - suggested dose 2 tabs qhs prn. Contains APAP 500 mg and diphenhydramine 25 mg per tablet – confirm dose
  • Metformin 1000 mg twice daily
  • Alendronate 70 mg every week on Tuesday
  • Calcium carbonate with vitamin D 500 mg/400 IU – confirm dose
  • Enalapril 5 mg twice daily




  • Most recent visit to the patient’s primary care provider 16 months ago.
  • Diagnoses were osteoporosis, hyperlipidemia, type 2 diabetes, hypertension, and restless leg syndrome.
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Social Worker




    The social worker:
  • Talks directly with Mrs. Castillo to gather as much information as possible given her mental status.
  • Attempts to reach Mrs. Castillo’s children, but they are unreachable at this time. Social worker will continue to attempt to reach them until successful.
  • Gathers information from Mr. Flores including:
    • Family dynamics she should be aware of to provide the best care to Mrs. Castillo.
    • Information he may know about Mrs. Castillo’s durable power of attorney and if she has an advance directive or POLST. There is no information in the EHR. Mr. Flores doesn’t know if the patient has an advance directive, but he “wants everything done.”
  • Relay all pertinent information to medical team as they collaborate on Mrs. Castillo’s plan of care.

Clinical Pearl...

The social worker must balance respect for Mr. Flores and his desire to be included in the plan of care with Mrs. Castillo’s privacy. Mr. Flores, while a friend of Mrs. Castillo, is not legal next of kin. He must be treated considerately, but the social worker must also maintain Mrs. Castillo’s privacy and focus on locating legal next of kin.

Close



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Blood Tests

Blood Alcohol Level: 0
INR: 1.0 (normal)
PTT: 35 seconds

CBC:
Hgb 9.9 g/dL
Hct 38%
Platelets 152,000/mm3
WBC 12,000 cells/mcL
Neutrophils 70% - Hi
Lymphocytes 23%
Monocytes 6%
Eosinophils 1%
Basophils 0.2%

BMP:
BUN 27 mg/dL
CO2 22 mmol/L
Creatinine 0.95 mg/dL
BUN/Creatinine Ratio: 28 - Hi
Glucose 310 mg/dL - Hi
Sodium 112 mEq/L - Lo
Chloride 85 mEq/L
Potassium 4.3 mmol/L
GFR calculated: 57.7 mL/min/1.73 m2 - Lo
Troponin: 0.01 ng/mL negative
CK: 50 U/L


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Urinalysis

U/A- wnl, except for + protein
Urine Toxicology Screen-negative

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Radiology




Multiple left-sided rib fractures. Most of these appear to be chronic and healed; however, there are acute-subacute appearing fractures of the anterolateral aspect of the left 4th and 5th ribs. Ununited chronic fracture of the lateral aspect of the left 6th rib.



Spine CT: No fractures.





Head CT: 3mm right acute on chronic holohemispheric subdural hematoma without shift. No noted skull fractures.

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Pharmacy Consult

The rationale for this consult is to obtain pain medication recommendations.

What should be ordered for this patient?

  • Fentanyl 25 mcg IV
  • Morphine sulfate 1mg IV
  • Meperidine 25 mg IM
  • Midazolam 0.5 mg IV

Green answer is the best choice.





Clinical Pearl...

Listen to the pharmacist’s rationale for drug choice




Photo courtesy of UW Medicine.

Close



Social Worker Consult

The rationale for obtaining this consult is the presence of multiple rib fractures; need for assessment of possible elder abuse and locating legal next of kin (LNOK).


Social worker reports that she has attempted to contact patient’s daughter, but has not been able to reach her. Social worker will continue to reach out to daughter and locate other family members. Once family has been reached, social worker will conduct safety assessment for Mrs. Castillo, including assessing for possible elder abuse or neglect due to rib fractures.

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Neurosurgery Consult

The rationale for obtaining this consult is for surgical evaluation of the patient’s subdural hematoma.

Neurosurgery finds that the SDH is non-operable and recommends the transfusion of a 6-pack of platelets.


Clinical Pearl...

Aspirin therapy, such as Mrs. Castillo was receiving, disrupts platelet function by inhibiting COX-1 for the life of the platelet (~7-10 days). Presently, platelet transfusion for patients receiving antiplatelet agents, such as aspirin, is controversial and requires further study. A summary of work in this area is provided in the link below.