Cause Of Altered Mental Status Research Articles

The diagnostic yield of a 2-h versus a 30-min electroencephalogram for patients with altered mental status in neurological intensive care unit

BackgroundThe continuous electroencephalogram (cEEG) monitoring is recommended for critical ill patients with altered mental status, The cEEG detects seizure activity and nonconvulsive status epilepticus (NCSE) more efficiently than routine electroencephalogram (rEEG). Yet, cEEG is not widely available in many neurological intensive care units (NICU) in limited resource countries. Ideal study duration, and whether cEEG is useful and cost-effective in terms of patient outcome compared to (rEEG), is still questions under research. The main objective in our study was the relative diagnostic yield of the 2 h, prolonged EEG recording, compared to the 30-min rEEG recording in the NICU.ResultsThere was no significant diagnostic yield for the 2-h electroencephalogram (EEG) over the 30-min EEG for patient with altered mental status in the NICU. Being with altered mental state in an NICU carries a poor outcome, we found that death occurred in 68.9% of patients. Acute ischemic stroke is the most common cause of altered mental status in NICU by about 53.3% of patients. Less than half of the patients (42.2%) were receiving anti-seizure medications (ASM).ConclusionsAs long as the cEEG is not available in the NICU, the 30-min EEG has a good diagnostic yield and it is almost equivalent to the prolonged 2-h EEG, and if the EEG is recommended for a longer duration, we recommend a long-term EEG more than 2 h.

Impact of altered mental status on antibiotic prescribing and outcomes in hospitalized patients presenting with pyuria

BackgroundPyuria is nonspecific and may result in over-treatment of asymptomatic bacteriuria (ASB). The Infectious Diseases Society of America recommends against antibiotic treatment of ASB for most patients including those presenting with altered mental status (AMS). Close observation is recommended over treatment to avoid missing alternative causes of AMS and overuse of antibiotics resulting in adverse events and resistance. ObjectivesThe purpose of this study was to evaluate patient outcomes associated with antibiotic treatment of pyuria in patients presenting with AMS at hospital admission without specific urinary tract infection (UTI) symptoms. The primary objective was to compare 30-day readmission rates of patients with pyuria and AMS treated with antibiotics (AMS+Tx) versus those who were not treated (AMS-NoTx). Secondary outcomes included identifying risk factors for antibiotic treatment, comparing alternative diagnoses for AMS, and comparing safety outcomes. MethodsThis retrospective cohort study evaluated adult patients with AMS and pyuria (10 WBC/hpf) admitted between February 1, 2020 and October 1, 2021, in a 350-bed community teaching hospital. Patients with documented urinary symptoms were excluded. Additional exclusion criteria included admission to critical care, history of renal transplant, urological surgery, coinfections, pregnancy, and neutropenia. ResultsTwo-hundred patients were included (AMS+Tx, n = 162; AMS-NoTx, n=38). There was no difference in 30-day hospital readmission rate for AMS between groups (AMS+Tx 16.7% vs AMS-NoTx 23.7%, P = 0.311). An alternative diagnosis of AMS occurred more frequently when antibiotics were withheld (AMS+Tx 66% vs. AMS-NoTx 86.8%, P = 0.012). Urinalyses showing bacteria (odds ratio 2.52; 95% CI, 1.11-5.731) and positive urine culture (OR 3.36; 95% CI, 1.46-7.711) were associated with antibiotic prescribing. ConclusionsInappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria; however, treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI. Patients who were monitored off antibiotics had higher rates of alternative AMS diagnosis.

Alcohol Withdrawal with Delirium Tremens.

Emergency medicine (EM) residents (1st year and 2nd year levels), 4th year medical students and advanced practice providers. Alcohol use has played a major role in causing significant morbidity and mortality for patients. In 2016, it was the 7th leading risk factor for deaths and disability-adjusted life years globally.1 Among heavy alcohol users admitted for hospital management, the incidence of alcohol withdrawal syndrome is estimated to be 1.9 to 6.7%.1 Alcohol withdrawal (AW) in the ED has been associated with increased use of critical care resources, and frequent ED visits for alcohol-related presentations have been associated with mortality rates that are about 1-4% when withdrawal progresses to delirium tremens (DTs).1 Patients with alcohol withdrawal can present in many different ways to the ED including anxiety, tachycardia, delirium tremens (DTs), seizures and severe autonomic dysfunction leading to severe sickness and death.2 Therefore, it is extremely important for an EM physician to recognize the signs of AW in patients and to manage the critically ill patients. In addition, Clinical Institute Withdrawal Assessment (CIWA) of alcohol was developed to assess severity of alcohol withdrawal in 1989.3 EM physicians should utilize CIWA to help determine the severity of AW. By the end of the session, learner will be able to 1) discuss the causes of altered mental status, 2) utilize CIWA scoring system to quantify AW severity, 3) formulate appropriate treatment plan for AW by treating with benzodiazepine and escalating treatment appropriately, 4) treat electrolyte abnormalities by giving appropriate medications for hypokalemia and hypomagnesemia, and 5) discuss clinical progression and timing to AW. This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. The session was run during first year EM resident intern orientation, and it was run during two consecutive years. There was a total of 32 EM residents who participated. There was a total of 16 residents who actively managed the patient while the other 16 were observers. Each session had four learners and was run twice in two separate rooms. There was one simulation instructor running the session and one simulation technician who acted as a nurse. After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right the amount of complexity (based on their Gestalt), (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. The responses were collected using a Likert scale of 1 to 5 with 1 being "Strongly disagree" and 5 being "Strongly agree." There was a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge and in patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. The median response for questions 1, 3 and 5 is 5. The median response for questions 2 and 4 was 4. The range of responses for questions 1, 2, 3 and 5 was 4-5 while the range for question 4 was 3-5. This high-fidelity simulation was a cost-effective and realistic way of educating learners on how to manage AW with DTs. Learners are forced to start with a broad differential for the patient who presents with AMS. As they recognize the cause of mental status, the patient quickly decompensates into developing severe agitation and autonomic dysfunction requiring learners to manage the patient and establish an airway. Learners found the case to be beneficial in learning the management of AW. Alcohol withdrawal, delirium tremens, agitation, altered mental status.

Hepatic Encephalopathy following Transjugular Intrahepatic Portosystemic Shunt Placement.

Hepatic encephalopathy (HE) is a complex condition that arises as a complication of chronic liver disease and portosystemic shunting. Its pathophysiology involves several factors, including impaired ammonia metabolism, portosystemic shunting, sarcopenia, and systemic inflammation. The symptoms of HE can vary significantly, with manifestations ranging from subclinical signs to a comatose state. The West Haven classification system is most commonly used to grade the severity of HE. There is a broad differential for the presenting symptomatology of HE and other causes of altered mental status must be excluded during the workup. HE is a well-known complication of transjugular intrahepatic portosystemic shunt (TIPS) placement. Even though newer stent designs help reduce the risk of HE with smaller diameter shunts, it is essential that patients are counseled regarding this potential risk prior to the procedure. Once a diagnosis of HE has been confirmed, the mainstay of therapy is lactulose and rifaximin. In cases where a patient has received a TIPS placement and continues to experience refractory HE despite medical therapy, it may be necessary to consider shunt reduction or closure.

Assessment of altered mental status in the Emergency Department using quantitative pupillometry: a prospective cohort study (P7-4.006)

<h3>Objective:</h3> To assess whether quantitative pupillometry (QP) can distinguish between Emergency Department (ED) patients presenting with altered mental status (AMS) of primary neurologic versus non-neurologic etiology. <h3>Background:</h3> The rapid assessment of patients with AMS in the ED remains a major clinical challenge. Pupillary examination can aid in clinical decision making, yet is limited by interrater reliability. QP offers automated measurement of pupillary characteristics and may support the standardization of patient assessment. However, few studies have investigated the role of QP to aid in ED-based assessment of patients with neurologic presentations. <h3>Design/Methods:</h3> Between December 2021 and October 2022, 218 patients presenting with AMS were screened in two large, urban EDs. QP data were collected using an FDA-approved pupillometer (NeurOptics, Irvine, CA) and included pupil diameter, percentage constriction, latency/velocity of constriction, and dilation velocity. Final diagnoses were obtained from discharge summaries. Patients with intoxication or multiple causes of AMS were excluded. AMS was grouped as primary neurologic (ischemic stroke, intracranial hemorrhage, or seizure) or non-neurologic (infectious, metabolic, or psychiatric) in etiology. QP data were also collected from 56 nonaltered control patients. <h3>Results:</h3> 73 patients were included (29 and 44 patients with primary or non-neurologic AMS, respectively). Mean age was 64 years (SD 19.7) and 59.7% were female. A single-factor ANOVA test revealed statistically significant differences between the two AMS cohorts and controls; patients of either AMS category had lower percent constriction, constriction velocity, and dilation velocity than controls (p&lt;0.05). However, when a two-tailed T test was performed comparing primary versus non-neurologic AMS etiology, pupillary characteristics were indistinguishable (p=NS). <h3>Conclusions:</h3> QP use was feasible in the ED setting. While QP returned significantly different pupillary values in AMS patients versus controls, QP could not differentiate between broad categories of AMS. Further investigation with more specific patient cohorts is required further assess QP use in the ED. <b>Disclosure:</b> Miss Alexis has nothing to disclose. Mr. Fernandez-Penny has nothing to disclose. Benjamin Abella has nothing to disclose.

Vitamin D Toxicity Presenting as Altered Mental Status in Elderly Patients.

Background and objective Around 25-30% of elderly patients present toemergency departments (ED) with altered mental status (AMS), with hypercalcemia being one of the metabolic causes. Elderly patients, due to their multiple vulnerability factors and relative homeostenosis, are susceptible to alterations in mental state at even milder grades of hypercalcemia. There is a trend of overzealous prescription of higher doses of vitamin D in elderly patients for various ailments, which often exceeds the requirements of the patients.In this study, we aimed to establish vitamin D toxicity (VDT) as an underlying cause of AMS in elderly patients presenting to the hospital. Methods This was a descriptive case study conducted at a tertiary care university hospital in North India, from January 2015 to March 2020 for a total duration of five years. Elderly patients (aged ≥60 years) who were admitted with VDT as a cause for underlying hypercalcemia were included. The evaluation included patient history regarding the dosage of vitamin D received, route of administration, and biochemical parameters, such as serum calcium, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D [25(OH)D], and albumin. All other potential causes for hypercalcemia and AMS were ruled out concurrently. Results A total of 19 patients were enrolled in the study, with a mean age of 72.3 years (range: 62-86 years). All patients had received injectable vitamin D formulation. The meanserum calcium among the patients was 12.52 ± 1.12 mg/dL (range: 11.2-15.7 mg/dL), whereas the mean 25(OH)D was 196.34 ± 70.44 ng/mL (range: 107-356 ng/mL). The mean cumulative vitamin D supplement intake was 2.594 ± 0.841 million IU (range: 1.2 million-4.2 million IU). While six patients had mild hypercalcemia, 12 had moderate, and one person had severe hypercalcemia, with altered sensorium (85%) being the most commoncomplaint for presenting to ED, followed by generalized weakness (15%). Conclusion VDT can manifest with AMS as an initial presenting complaint. The geriatric population, due to various underlying vulnerability factors, is more susceptible than their younger counterparts. We strongly recommend thatin elderly patients, higher doses of vitamin D should be prescribed only after checking their serum levels, and frequent monitoring of vitamin D should be performed.

Altered Mental Status and Its Causes: Commonest Dilemma of Residents and Emergency Physicians

Objective: To assess the frequency of the various medical conditions in patients presenting with altered mental status (AMS) in the Emergency Department of Pakistan Naval Ship (PNS) Shifa Hospital.&#x0D; Study Design: Prospective longitudinal study.&#x0D; Place and Duration of Study: Emergency Department, Pak Naval Ship Shifa Hospital, Karachi Pakistan from Feb-Jul 2021.&#x0D; Methodology: Adult patients who have presented with altered mental status (Glasgow coma scale score less than 15) or who have the diagnosis "AMS" written in their notes were included in the study. Patients were observed in the wards until a definitive diagnosis could be made.&#x0D; Results: Sixty patients presented with AMS at the Emergency Department of PNS Shifa, during the study period. The causes of AMS were sepsis (20, 33.33%), CVA (12, 20%), metabolic (hepatic/uremic) encephalopathy (8, 13.33%), diabetic complications (7, 11.66%), seizures (5, 8.33%), drug intoxication (4, 6.66%) and respiratory failure due to lung pathology (4,6.66%). The overall mortality rate was 20%.&#x0D; Conclusion: Sepsis is the most frequently encountered cause of altered mental state in emergency department patients,followed by CVA, metabolic encephalopathy, and diabetic complications.

176 Point-of-Care Electroencephalography Enables Rapid Evaluation and Management of Non-convulsive Seizures in the Emergency Department

Non-convulsive seizures (NCSs) are increasingly recognized as a cause of altered mental status in the emergency department (ED). NCSs are primarily diagnosed using electroencephalography (EEG), however this tool is often unavailable in most academic and community hospital EDs. The resultant uncertainty in diagnosing NCSs clinically is significant and leads to delayed and often inappropriate treatment with anti-seizure medications (ASMs), unnecessary intubation, and increased morbidity. Point-of-care electroencephalography (pocEEG) could fill this critical gap in the ED, as it has for inpatient and intensive care unit (ICU) settings.

NBOMe Toxicity and Fatalities: A Review of the Literature

In the decade since the introduction of the novel synthetic hallucinogen NBOMe into the consumer market, this drug has become an increasingly prevalent, yet poorly understood cause of altered mental status (AMS) resulting in hospitalization. In this literature review, we conducted a PubMed query for mentions of NBOMe ingestion since Suzuki et al.’s publication of their 2015 review. Among English language publications published between October 2014 and June 8, 2021, were sixteen case reports and six case series detailing a total of 42 cases of NBOMe toxicity. Notably, 26 (62%) patients experienced tachycardia, 22 (52%) had hypertension, 34 (81%) experienced hallucinations. Nine of 42 cases ended in fatality, including six cases of apparent direct NBOMe toxicity, one death by suicide, and two cases of fatalities from trauma after “excited delirium.” At least seven individuals believed that they had purchased and consumed LSD. This updated review of the literature underlines the high prevalence of fatality associated with NBOMe ingestion, as well as the need for increased knowledge among law enforcement and emergency medical providers of the toxidrome of NBOMe when responding to cases of AMS.

Frequency of major causes of coma patients presented to emergency room of tertiary care hospitals with impaired conscious level, in Qassim region of Saudi Arabia.

Background: Disorders of consciousness including coma can be caused by a wide variety of etiologies affecting the central nervous system. Severity of coma may vary according to the causes of coma and patient’s characteristics. Objective: To determine frequency of major causes of coma patients presented to Emergency Department (ED) of tertiary care hospitals in Qassim region of Saudi Arabia. Methods: This retrospective audit study consisting of cases of coma, presented with impaired conscious level of any age and either gender admitted through ED of tertiary care hospitals in X region of Saudi Arabia over past 2 years. Patients with transient impairment of conscious level, pregnant women, referred cases of multiple organ failure and no clear etiological diagnosis on discharge were excluded from the study. After ethical approval, the data of the patients were collected retrospectively from the medical records on structured Proforma (Annexure-1). Results: Out of 422 patients of coma, 96 (22.7%) were observed with severely reduced GCS (≤8 score). About 2/3rd of patients had non-traumatic causes of coma (NTC) out of this cerebral infarction (16.4%) and metabolic brain dysfunction (15.6%) were the major causes in age group &gt;50 years. The most frequent single cause of altered mental status was traumatic brain injury (TBI) in 31% of cases with age group less the 40 years most affected 68%. Regarding the localization of coma, we observed; Diffuse brain dysfunction in 40% (n=169), Supra tentorial location in 44.8% (N=189) and infra tentorial localization in 15.2% (n=64) of cases, however the severe coma causes in older patients (&gt;60 years) were infratentorial stroke, CNS infection, brain metastasis and brain anoxia (p&lt;0.001). Conclusions: The leading cause of coma in our study in the age group less than 40 years was TBI about 68% of cases, but highly significant association of severe coma was found with older patients (&gt;60 years), infratentorial stroke, CNS infection, brain metastasis and brain anoxia.

Covid-19 Associated Subdural Hematoma: A Case Report Intracranial Hemorrhage in the Setting of Covid-19

Coronavirus disease 2019 (COVID-19) is a pandemic that began in December 2019 as a result of the global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We frequently associate COVID-19 with symptoms of fever, shortness of breath, and pneumonia; however, we are slowly uncovering the fact that systems other than the respiratory are being affected. We present a 60-year-old female who presented with altered mental status and was found to have COVID-19 induced subdural hematoma. Although intracranial hemorrhages are extremely rare in the setting of COVID-19, it is known that the affinity of SARS-CoV-2 to the angiotensin-converting enzyme 2 receptors, in addition to the cytokine storm, predisposes infected individuals to intracranial hemorrhages. Thus, it is crucial to consider intracranial hemorrhage as a possible cause of altered mental status in patients infected with COVID-19 and weigh the potential risk versus benefits of utilizing anticoagulants when managing the thrombotic complications of this virus.

A clinical decision rule predicting outcomes of emergency department patients with altered mental status.

Study objectiveApproximately 5% of emergency department patients present with altered mental status (AMS). AMS is diagnostically challenging because of the wide range of causes and is associated with high mortality. We sought to develop a clinical decision rule predicting admission risk among emergency department (ED) patients with AMS.MethodsUsing retrospective chart review of ED encounters for AMS over a 2‐month period, we recorded causes of AMS and numerous clinical variables. Encounters were split into those admitted to the hospital (“cases”) and those discharged from the ED (“controls”). Using the first month's data, variables correlated with hospital admission were identified and narrowed using univariate and multivariate statistics, including recursive partitioning. These variables were then organized into a clinical decision rule and validated on the second month's data. The decision rule results were also compared to 1‐year mortality.ResultsWe identified 351 encounters for AMS over a 2‐month period. Significant contributors to AMS included intoxication and chronic disorder decompensation. ED data predicting hospital admission included vital sign abnormalities, select lab studies, and psychiatric/intoxicant history. The decision rule sorted patients into low, moderate, or high risk of admission (11.1%, 44.3%, and 89.1% admitted, respectively) and was predictive of 1‐year mortality (low‐risk group 1.8%, high‐risk group 34.3%).ConclusionsWe catalogued common causes for AMS among patients presenting to the ED, and our data‐driven decision tool triaged these patients for risk of admission with good predictive accuracy. These methods for creating clinical decision rules might be further studied and improved to optimize ED patient care.

Altered mental status in COVID-19.

BackgroundAltered mental status (AMS) is a common neurological manifestation of COVID-19 infection in hospitalized patients. The principal causes of AMS have yet to be determined. We aimed to identify the common causes of AMS in patients with COVID-19 presenting to the emergency department with AMS on arrival.MethodsWe conducted a retrospective observational study of patients presenting with AMS to three New York hospitals, from March 1 to April 16, 2020. Underlying causes of AMS on arrival to the emergency department (ED) were categorized as (1) neurological causes (stroke, seizure, encephalitis); (2) metabolic encephalopathy; (3) indeterminant. Multivariable analysis was used to assess independent predictors.ResultsOverall, 166 patients presented to the ED with AMS. Metabolic encephalopathy was diagnosed as the cause in 154 (92.8%), with 118 (71.1%) categorized as multifactorial ME and 36 (21.7%) with single-cause ME. Hypoxia 103 (62.0%) and renal failure 75 (45.2%) were the most common underlying mechanisms. Neurological causes of AMS occurred in a total 20 patients (12%) and as the sole factor in 5 (3.0%); 10 (6.0%) cases were seizure related and 10 (6.0%) were cerebrovascular events. Of the 7 patients with indeterminant causes, only 1 was suspicious for encephalitis (0.6%). Age, pre-existing dementia and cerebrovascular disease, and impaired renal function were independent predictors of AMS.ConclusionIn patients with COVID-19, AMS on presentation to the ED is most frequently caused by metabolic encephalopathy (delirium). Seizures and cerebrovascular events contribute to a lesser degree; encephalitis appears rare.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00415-021-10623-5.

Moyamoya as a Cause of Altered Mental Status in the Emergency Department: A Case Report

IntroductionThis case reviews a patient with moyamoya disease, a rare cause of altered mental status. It highlights the importance of maintaining clinical suspicion for uncommon causes of common presentations.Case ReportA 64-year-old male presented with seizures and persistent altered mental status. Computed tomography demonstrated findings consistent with bilateral ischemia. Cerebral angiography was performed with no thrombus identified but moyamoya disease present.ConclusionAlthough rare, moyamoya should be considered as a potential cause of patients presenting with altered mental status. The case presented also highlights the importance of avoiding common diagnostic biases.

Changes in Diagnosis of Poisoning in Patients in the Emergency Room Using Systematic Toxicological Analysis with the National Forensic Service.

BackgroundIt is difficult to diagnose patients with poisoning and determine the causative agent in the emergency room. Usually, the diagnosis of such patients is based on their medical history and physical examination findings. We aimed to confirm clinical diagnoses using systematic toxicological analysis (STA) and investigate changes in the diagnosis of poisoning.MethodsThe Intoxication Analysis Service was launched in June 2017 at our hospital with the National Forensic Service to diagnose intoxication and identify toxic substances by conducting STA. Data were collected and compared between two time periods: before and after the initiation of the project, i.e., from June 2014 to May 2017 and from June 2017 to May 2020.ResultsA total of 492 and 588 patients were enrolled before and after the service, respectively. Among the 588 after-service patients, 446 underwent STA. Among the 492 before-service patients, 69.9% were diagnosed clinically, whereas the causative agent could not be identified in 35 patients. After starting the service, a diagnosis was confirmed in 84.4% of patients by performing a hospital-available toxicological analysis or STA. Among patients diagnosed with poisoning by toxins identified based on history taking, only 83.6% matched the STA results, whereas 8.4% did not report any toxin, including known substances. The substance that the emergency physician suspected after a physical examination was accurate in 49.3% of cases, and 12% of cases were not actually poisoned. In 13.4% of patients who visited the emergency room owing to poisoning of unknown cause, poisoning could be excluded after STA. Poisoning was determined to be the cause of altered mental status in 31.5% of patients for whom the cause could not be determined in the emergency room.ConclusionA diagnosis may change depending on the STA results of intoxicated patients. Therefore, appropriate STA can increase the accuracy of diagnosis and help in making treatment decisions.

1090. HHV-6 Encephalitis following Chimeric Antigen Receptor T-cell Therapy: Report of 2 Cases

BackgroundHuman herpesvirus 6 (HHV-6) is the most common cause of infectious encephalitis following hematopoietic stem cell transplant. Chimeric antigen receptor T-cell (CAR-T) therapy is a novel cancer-directed immunotherapy; chemotherapy conditioning for CAR-T results in prolonged, severe immunosuppression. HHV-6 encephalitis has not been reported in patients after CAR-T therapy.MethodsWe report 2 cases of HHV-6 encephalitis after CAR-T therapy.Results Case 1: A 69 year old man underwent CAR-T therapy after fludarabine/cyclophosphamide (Flu/Cy) conditioning for relapsed diffuse large B cell lymphoma (DLBCL). His course was complicated by cytokine release syndrome (CRS) requiring tocilizumab and neurotoxicity requiring high dose dexamethasone. On day 29 he was febrile to 39.3℃, confused, and had difficulty speaking. Mental status (MS) worsened, so LP and MRI of the brain were performed. HHV-6 CSF PCR was positive, and ganciclovir (GCV) was started. He improved gradually over 10 days. At follow up, he reported mild short term memory difficulty but no focal deficits. Case 2: A 57 year old man underwent CAR-T therapy after Flu/Cy conditioning for refractory DLBCL. His course was complicated by CRS requiring tocilizumab. On day 6, he had difficulty concentrating, slowed thinking, stuttering and repetitive speech. MS continued to worsen, and dexamethasone and siltuximab were given for CAR-T neurotoxicity. After 1 week he was following commands. By week 3 he remained intermittently confused and agitated, so MRI and LP were performed. HHV-6 PCR was positive in the CSF. He was started on GCV and improved gradually over the next 2 weeks but remained dysarthric with slowed speech. On day 55, HHV-6 remained detectable in CSF but not quantifiable and GCV was discontinued despite persistent cognitive deficits.Table 1: Demographics and clinical characteristics of 2 patients with HHV-6 encephalitis following CAR-T therapy ConclusionDiagnosing HHV-6 encephalitis can be challenging after CAR-T therapy because altered MS is often attributed to CAR-T associated neurotoxicity. It is important to maintain a high index of suspicion for infectious causes of altered MS after CAR-T therapy, including HHV-6 encephalitis, especially in patients treated with further immunosuppression for CRS and CAR-T related neurotoxicity.Disclosures All Authors: No reported disclosures

Rapid Detection of Significant Traumatic Brain Injury Requiring Emergency Intervention.

Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, "baby's butt," "Mickey Mouse ears," absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.

Blast Crisis.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of blast crisis. Chronic myeloid leukemia (CML) makes up 15% of diagnosed adult leukemias with the median age of diagnosis being 67 years old. Chronic myeloid leukemia consists of three phases: chronic, accelerated, and blast phases. Most patients are initially diagnosed while in the chronic phase.1 Of those diagnosed in the chronic phase and being treated with a tyrosine kinase inhibitor (TKI), about 1% -1.5% of CML patients per year will subsequently transform into an advanced phase or blast crisis.2 While rare, blast crisis is considered an oncologic emergency, with increased mortality occurring primarily from subsequent infections or bleeding. Therefore, emergency physicians must be familiar with its clinical presentation and subsequent management. By the end of this simulation, the participant will be able to: 1) create a thorough differential for the undifferentiated febrile, altered patient, 2) identify the signs and symptoms of blast crisis, 3) describe proper resuscitation of a patient in blast crisis, and 4) describe the indications, steps, and contraindications of performing a lumbar puncture. This session was conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis, differential diagnosis, and management of blast crisis. Debriefing methods may be left to the discretion of participants, but the authors have used advocacy-inquiry techniques. This scenario may also be run as an oral boards case. Our simulation center's feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form, with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received all 6 or 7 scores (consistently effective/very good or extremely effective/outstanding). During the debriefing session, feedback from the residents was largely positive. They appreciated reviewing the broad differential of altered mental status and oncologic emergencies. While many groups anchored on the diagnosis of encephalitis, they also expressed that after this experience, blast crisis would be added to their differential for patients with CML. This is a cost-effective method for reviewing blast crisis. Learners were able to identify more common causes of altered mental status in their differentials, but without further prompting, they were unable to ultimately come up with the diagnosis of blast crisis. Our main take-away is to continue reviewing oncologic emergencies as a part of our residency curriculum. Medical simulation, chronic myeloid leukemia, blast crisis, leukostasis, emergency medicine, oncologic emergencies, hematologic emergencies.

A STROKE OF BAD LUCK: NEW-ONSET MANIA IN ELDERLY PATIENT FOLLOWING UNDETECTED STROKE, A CASE REPORT

A STROKE OF BAD LUCK: NEW-ONSET MANIA IN ELDERLY PATIENT FOLLOWING UNDETECTED STROKE, A CASE REPORT

Altered mental status in the emergency department, a retrospective analysis

Background: Altered mental status (AMS) is a common presentation of patients to the emergency department (ED), posing a significant challenge for the physician to accurately diagnose and begin appropriate management. The etiology of AMS spans a wide variety of clinical syndromes and is not consistent in all countries and regions. Materials and Methods: This was a retrospective analysis of 407 patients presenting to the ED with AMS in the months of January 2013 to April 2013. The details of the presentation, investigations, final diagnosis, and management were extracted from charts in the hospital electronic database. Results: AMS constituted 2.8% of patients registered at the ED during the study period. Of the 407 patients, 254 (62.3%) were male, and 153 (37.5%) were female. Mean age was 52.34 ± 17.84 years. Majority (n = 287; 70.4%) of the patients were in the age group between 18-64 years. Etiological factors were neurological (n = 151; 37.1%), metabolic/endocrine (n = 75; 18.4%), infections (n = 55; 13.5%) system/organ dysfunction (n = 49; 12%), toxicological (n = 39; 9.6%), miscellaneous (n = 19; 4.7%), oncological (n = 12; 2.9%), and psychiatric (n = 7; 1.7%). About 17.9% had mild AMS, 47.4% had moderate AMS, and 34.6% had severe AMS. Majority (65.1%) presented to ED within 24 h of onset of AMS. Total mortality rate was 11.5% (n = 47). Conclusions: This study has conveyed the frequency of various etiologies of AMS and its stratification in regards to age and severity. Neurological conditions remain the most common cause of AMS. Data reveal a large fraction of patients presenting beyond 24 h of onset of AMS. Public education concerning the establishment of support systems for the vulnerable population can lead to faster presentation to the ED and subsequent management.