UMEM Educational Pearls

Title: reflux and ACS misdiagnosis

Category: Cardiology

Keywords: reflux, esophagitis, misdiagnosis, myocardial infarction (PubMed Search)

Posted: 7/20/2008 by Amal Mattu, MD (Updated: 11/26/2024)
Click here to contact Amal Mattu, MD

 The most common misdiagnosis in cases of missed acute MI is reflux esophagitis. Various studies have demonstrated the following factors that lead to this misdiagnosis:
1. 20% of patients with acute MI describe their pain using the words "indigestion" or "burning."
2. Almost 50% of patients with acute MI report an increase in belching during their ischemic symptoms.
3. 15% of patients get some relief of their ischemic pain with antacids and 7% of patients get complete relief of their ischemic pain with antacids.
4. 8% of patients report that their ischemic pain began while eating.

Before you ever write "Reflux esophagitis" or "GERD" on the chart of a patient you are about to send home, think twice about the possibility of acute cardiac ischemia.
 



Title: Febrile Seizures

Category: Pediatrics

Keywords: pediatric fever, pediatric seizure (PubMed Search)

Posted: 7/18/2008 by Don Van Wie, DO (Updated: 11/26/2024)
Click here to contact Don Van Wie, DO

PEDIATRIC FEVER + SEIZURE = FEVER

When a child has a fever and a seizure, do the age appropriate workup for a fever and you won't go wrong!!!

  • Routine laboratory studies usually are not indicated unless they are performed as part of a search for the source of a    fever.
  • Electrolytes assessments are rarely helpful in the evaluation of febrile seizures.
  • Patients with febrile seizures have an incidence of bacteremia similar to patients with fever alone.


  • Title: Salicylate Serum Concentrations - Be Wary

    Category: Toxicology

    Keywords: Salicylate, aspirin, metabolic acidosisM (PubMed Search)

    Posted: 7/17/2008 by Fermin Barrueto (Updated: 11/26/2024)
    Click here to contact Fermin Barrueto

    •  Therapeutic concentration considered 10-20 mg/dL
    •  Some hospitals report in "mg/L" thus a level of 110 mg/L is therapeutic
    •  Symptoms of Toxicity usually > 40 mg/dL
    •  Consider Hemodialysis in any patient with a serum concentration >100 mg/dL

    First Line Therapy:  Urine Alkalinization (pH >7.5) by administrating NaHCO3

    Other Indications for Hemodialysis in Salicylate Poisoned Patient:

    1. Renal Failure
    2. CHF
    3. Acute Lung Injury
    4. Persistent CNS disturbances
    5. Refractory metabolic acidosis or electrolyte abnormality
    6. Hepatic insufficiency with coagulopathy


    Title: Sciatic Nerve Injury

    Category: Neurology

    Keywords: sciatica, sciatic nerve, foot drop (PubMed Search)

    Posted: 7/16/2008 by Aisha Liferidge, MD (Updated: 11/26/2024)
    Click here to contact Aisha Liferidge, MD

    • The Sciatic Nerve is commonly injured during intramuscular buttocks injections as well as hip fracture dislocations and posterior dislocations.  In such instances, always confirm and document preserved sciatic nerve function.
    • Sciatic nerve injury often results in foot drop due to decreased function of the hamstring, calf, and anterolateral lower leg muscles.
    • Sciatic nerve injury may also cause loss cutaneous sensation over the calf , as well as the sole and lateral portions of the foot.


    Title: Noninvasive Ventilation Pearls

    Category: Critical Care

    Keywords: noninvasive ventilation (PubMed Search)

    Posted: 7/15/2008 by Mike Winters, MBA, MD (Updated: 11/26/2024)
    Click here to contact Mike Winters, MBA, MD

     Noninvasive Ventilation Pearls

    • Multiple studies support the use of noninvasive positive pressure ventilation (NPPV) in acute exacerbations of COPD, acute cardiogenic pulmonary edema, and immunocompromised patients (organ transplant) with hypoxic respiratory failure.
    • The timing of NPPV initiation is important.  NPPV should be started as soon as possible, as delays increase the likelihood of intubation
    • The best predictor of success is a favorable response to NPPV within the first 1 to 2 hours
      • reduction in respiratory rate
      • improvement in pH
      • improved oxygenation
      • reduction in PaCO2
    • Also crucial to NPPV success is a well fitting interface (mask)
    • Although patients report greater comfort with nasal masks, they also permit more air leakage through the mouth and have been associated with a higher rate of initial intolerance in the acute setting.
    • For acute applications of NPPV in the ED, a full face mask is preferred 

    Show References



    Title: Ruling Out Pulmonary Embolism During Pregnancy

    Category: Vascular

    Keywords: Pulmonary Embolism, Pregnancy (PubMed Search)

    Posted: 7/14/2008 by Rob Rogers, MD (Updated: 11/26/2024)
    Click here to contact Rob Rogers, MD

    Evaluating for Pulmonary Embolism During Pregnancy

    Highest risk of PE is within the first week postpartum

    Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:

    • Pulmonary CTA-this strategy is safe and accepted. Plenty of data to support you if you choose this strategy. Some evidence recently that shielding the baby may actually increase scatter radiation to the fetus. Check with your Radiologist. 
    • V/Q scan-also an acceptable strategy. Probably more radiation to the fetus. If you choose this test, remember that many experts recommend you insert a foley to drain the bladder (reduces radiation exposure to the fetus). 
    • Negative PERC (Pulmonary Embolism Rule Out Criteria) + Negative, trimester adjusted d-dimer level. Adjusted trimester cutoffs for d-dimer in pregnancy are: 1st 750 ng/dL, 2nd 1000 ng/dL, and 3rd 1250 ng/dL. So, figure out what trimester your patient is and if they are PERC - and the d-dimer falls below the cutoff,  you are done. Remember to adjust the pulse to 105 bpm if using the PERC rule for rule out as heart rate goes up in pregnancy.
    • Start with lower extremity US, if DVT +, you are done

    **For explanation of PERC rule, see earlier pearl.

    Show References



    Title: ECG changes in myopericarditis

    Category: Cardiology

    Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)

    Posted: 7/13/2008 by Amal Mattu, MD (Updated: 11/26/2024)
    Click here to contact Amal Mattu, MD

    The pericardium is electrically silent, and so true acute pericarditis should not be associated with ECG changes. STE actually implies concurrent involvement of the myocardium; i.e. myopericarditis. The greater the degree of myocardium involved, the more ECG changes will develop, including STE, AV blocks, and dysrhythmias. Additionally, myocardial involvement is implied by elevated troponin levels, the magnitude of which is related to the amount of myocardial involvement.

    [Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol 2008;127:17-26.]



    Title: Scaphoid Fracture

    Category: Orthopedics

    Keywords: scaphoid, fracture (PubMed Search)

    Posted: 7/13/2008 by Michael Bond, MD (Updated: 11/26/2024)
    Click here to contact Michael Bond, MD

    SCAPHOID FRACTURE:

    • One of the most frequently missed fractures in the ED
    • Most common carpal fracture.
    • 10-20% fractures are “occult”
    • Significant long-term complications:
      • Non-union
      • Avascular necrosis
    • Complications more common due to the fact the blood supply comes form from the distal end of the bone.
    • The more distal the fracture, the greater risk of complications
    • MR remains the best test for occult fx.


    Title: Intussusception

    Category: Pediatrics

    Keywords: Intussusception (PubMed Search)

    Posted: 7/12/2008 by Don Van Wie, DO (Updated: 11/26/2024)
    Click here to contact Don Van Wie, DO

     

          Intussusception
    •  Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment.
    • 90 % occur at the terminal ileum (ie, ileocolic).
    • Male-to-female ratio is approximately 3:1.
    • Usually seen between 5-9 months of age and 66% of all cases are in the first year of life.
    • The classic triad of colicky abdominal pain, vomiting, and red currant jelly stools occurs in only 21% of cases
    • Currant jelly stools are observed in only 50% of cases.
    • Most patients (75%) without obviously bloody stools have stools that test positive for occult blood.
    • If intussusception is strongly suspected, perform a contrast or air  enema without delay.
    • Mortality with treatment is 1-3%.
    • If untreated, this condition is uniformly fatal in 2-5 days.


    Title: Metformin Toxicity - An Emergency Department Diagnosis

    Category: Toxicology

    Keywords: lactic acidosis, metformin, renal failure (PubMed Search)

    Posted: 7/10/2008 by Fermin Barrueto (Updated: 11/26/2024)
    Click here to contact Fermin Barrueto

     

     

    • Metformin is the most commonly prescribed oral diabetic mediction in US
    • Relative contraindication is in renally impaired patients, they are susceptible to the lactic acidosis
    • Lethal adverse effect is the increase production of lactate
    • ED patient with an anion gap metabolic acidosis, check for metformin and check the lactate
    • The lactic acidosis is often severe (>10 mmol/L) and carries a high mortality rate that has been estimated at >40%
    • Correction of pH and emergent hemodialysis are essential

    Show References



    Title: Reasons to Call your Neurointerventionalist

    Category: Neurology

    Keywords: neurointerventionalist, vascular dissection, ischemic stroke, subarachnoid hemorrhage (PubMed Search)

    Posted: 7/9/2008 by Aisha Liferidge, MD (Updated: 11/26/2024)
    Click here to contact Aisha Liferidge, MD

    Top Reasons to call your Neurointerventionalist:

    1. Vascular "blowouts" (i.e carotid tumor or trauma). 
    2. Symptomatic dissections within 6 hours of onset (i.e. carotid or vertebral).
    3. Ischemc Stroke with visible clot on CT angiogram outside of 3-hour IV tPA window.
    4. Ischemic Stroke with visible clot on CT angiogram outside of 3-hour IV tPA window or with contraindication for tPA (i.e may be MERCI Device candidate).
    5. Subarachnoid hemorrhage of aneurysmal origin.


    Title: Redefining Hypotension

    Category: Critical Care

    Keywords: hypotension, trauma, elderly (PubMed Search)

    Posted: 7/7/2008 by Mike Winters, MBA, MD (Updated: 11/26/2024)
    Click here to contact Mike Winters, MBA, MD

    Hypotension begins at 110 mmHg?

    • Many of us use the historical SBP cut-off point of 90 mmHg or less to identify hypotension and shock
    • Importantly, there is no data to support this arbitrary value
    • Particularly in older patients, hypotension, hypoperfusion, and increased mortality may begin sooner than previously realized
    • In this study of over 80,000 patients from the National Trauma Data Bank, a SBP < 110 mmHg was found to be more clinically relevant for identifying hypotension and hypoperfusion
    • Take Home Point: strongly consider raising your threshold for identifying hypotension and initiating resuscitation, especially in the older trauma patient.

    Show References



    Title: Etomidate and adrenal suppression

    Category: Critical Care Literature Update

    Keywords: etomidate, adrenal insufficiency (PubMed Search)

    Posted: 7/7/2008 by Mike Winters, MBA, MD (Updated: 11/26/2024)
    Click here to contact Mike Winters, MBA, MD

    Recent Articles from the Critical Care Literature

    Duration of adrenal insufficiency following a single dose of etomidate in critically ill patients

    Vinclair M, Broux C, Faure P, Brun J, Genty C, et al. Intensive Care Med 2008;34:714-9.
                Etomidate has become a favored first-line induction agent for intubation in the emergency department.  Given its excellent hemodynamic tolerance, etomidate is especially useful in hemodynamically unstable patients. A known side effect of etomidate is adrenal suppression, due to inhibition of 11β-hydroxylase, the enzyme that converts 11β-deoxycortisol into cortisol. As a result, recent literature has raised concerns that etomidate may worsen patient outcomes in those with relative adrenal insufficiency, namely those with septic shock.
                The current study is a prospective, observational study conducted in France from October 2005 to January 2006. The purpose of the study was to assess the duration of adrenal suppression following a single dose of etomidate, given either in the field or in the emergency department for RSI. Importantly, patients with septic shock, or those with preexisting adrenal insufficiency, were excluded from this study. To diagnose adrenal insufficiency, the investigators measured total cortisol and 11β-deoxycortisol following a high-dose cosyntropin stimulation test (250 mcg). Values were obtained at 12, 24, 48, and 72 hours following etomidate administration. An accumulation of 11β-deoxycortisol with a lack of cortisol rise was used to establish etomidate-related adrenal insufficiency.
                A total of 40 patients were included in this study. The majority of patients required intubation as a result of either trauma or subarachnoid hemorrhage. At hour 12, 80% of patients fulfilled the investigators definition of etomidate-related adrenal insufficiency, whereas by hour 48, only 9% met criteria. In addition, at hour 24, patients with etomidate-related adrenal suppression required larger doses of norepinephrine that those without adrenal inhibition. From their data, the authors conclude that a significant proportion of patients without septic shock have adrenal suppression for at least 12 hours following a single dose of etomidate. This effect, however, appeared reversible in that most patients recovered adrenal function by hour 48. Finally, the authors recommend that systemic steroid supplementation be considered during the first 48 hours in hemodynamically unstable patients who have received etomidate for intubation.
                There are a number of limitations with this study. The most important limitation is, perhaps, the authors’ definition of etomidate-related adrenal insufficiency. Diagnosing adrenal insufficiency in critically ill patients remains controversial. The cosyntropin test (high- or low-dose) has many recognized limitations. In addition, measurement of 11β-deoxycortisol is difficult because reference values for critically ill patients are rare. The authors also chose to measure total serum cortisol, rather than the more biologically active free serum cortisol. Lastly, data for all 40 patients at 72 hours was not complete.
                Take Home Points: This small, observational study found a high incidence of adrenal suppression for at least the first 12 hours in unstable patients receiving etomidate for intubation. Importantly, this study excluded patients with sepsis or septic shock. Given the limited number of patients and the difficulty in defining adrenal insufficiency in the critically ill, this study provides some interesting results and is hypothesis-generating at best. Their recommendation for systemic steroid supplementation during the first 48 hours following etomidate administration in unstable patients cannot be supported by this study.


    Title: Ruling Out Pulmonary Embolism in Cancer Patients

    Category: Vascular

    Keywords: Pulmonary Embolism, Cancer (PubMed Search)

    Posted: 7/7/2008 by Rob Rogers, MD (Updated: 11/26/2024)
    Click here to contact Rob Rogers, MD

    Ruling Out PE in Cancer Patients: Use D-Dimer??

    Most of us are aware of the data that suports using a highly-sensitive d-dimer combined with low-moderate risk score to r/o PE. Sounds simple enough. What about using d-dimer in a cancer patient to rule it out? Well, this is being studied more and more.

    Most of us would be a little uneasy about using a d-dimer as a stand-alone test to r/o PE in a cancer patient. After all, they have cancer, aren't they high risk?

    The following study showed that the there was a VERY high negative predictive value and a VERY high sensitivity of a negative d-dimer in this group of cancer patients.


    Abstract
    PURPOSE: To prospectively evaluate (a) the diagnostic performance of D-dimer assay for pulmonary embolism (PE) in an oncologic population by using computed tomographic (CT) pulmonary angiography as the reference standard, (b) the association between PE location and assay sensitivity, and (c) the association between assay results and clinical factors that raise suspicion of PE. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was obtained. Five hundred thirty-one consecutive patients were clinically suspected of having PE; 201 were enrolled (72 men, 129 women; median age, 61 years) and underwent CT pulmonary angiography and D-dimer assay. Relevant clinical history, symptoms, and signs were recorded. CT images were interpreted, and the location of emboli was recorded. The negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity, and diagnostic likelihood ratios of the D-dimer assay results were calculated. RESULTS: Forty-three patients (21%) had pulmonary emboli at CT. D-Dimer results were positive in 171 patents (85%). The NPV and sensitivity were 97% and 98%, respectively. The specificity and PPV were 18% and 25%, respectively. No association was shown between clinical history, symptoms, or signs and NPV, PPV, sensitivity, or specificity or between location of PE and sensitivity.
    CONCLUSION: D-Dimer results have high NPV and sensitivity for PE in oncologic patients and, if negative, can be used to exclude PE in this population. Combining the assay with clinical symptoms and signs did not substantially change NPV, PPV, sensitivity, or specificity.

    Whether this is ready from prime time or not remains to be determined, but it is interesting that we might be able to do this in the future to r/o PE in cancer patients.
     

    Show References



    Title: Myopericarditis

    Category: Cardiology

    Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)

    Posted: 7/7/2008 by Amal Mattu, MD (Updated: 11/26/2024)
    Click here to contact Amal Mattu, MD

    Both acute pericarditis and myopericarditis are intensely inflammatory. As a result, CRP testing is extremely sensitive for these conditions and is excellent for evaluating their presence or absence.

    Show References



    Title: Joint Fluid Analysis

    Category: Orthopedics

    Keywords: Arthrocentesis, Joint, Fluid, Septic (PubMed Search)

    Posted: 7/6/2008 by Michael Bond, MD (Updated: 11/26/2024)
    Click here to contact Michael Bond, MD

    Joint Fluid Analysis:

    This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain.  For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.

     

    Synovial Fluid Interpretation
    Diagnosis Appearance WBC PMNs Glucose % of
    Blood Level
    Crystals
     Normal  Clear  <200  <25  95 - 100  None
     Degenerative
    Joint Disease
     Clear  <4000  <25  95 - 100  None
     Traumatic
    Arthritis
     Straw colored  <4000  <25  95 - 100  None
     Acute Gout  Turbid  2000 - 50,000  >75  80 - 100  Negative birefringence
     PseudoGout  Turbid 2000 - 50,000  >75  80 - 100  Positive birefringence  
     Septic Arthritis  Purulent / turbid  5000 - > 50,000  >75  < 50  None
     Rheumatoid
    Arthritis
     Turbid  2000 - 50,000  50-75  ~75  None

     To view a gout crystal click this link.

    To view a pseudogout crystal. Click this link

    Pearls: 

    • A WBC Count >50,000 is septic arthritis until cultures are negative. 
    • Due to the wide range of WBC for septic arthritis have a high index of suspicion and do not discount the diagnosis because the WBC count is only 10,000.

    Show References



    Title: recombinant Factor VIIa for ICH

    Category: Critical Care Literature Update

    Keywords: intracerebral hemorrhage, recombinant factor VIIa (PubMed Search)

    Posted: 7/6/2008 by Mike Winters, MBA, MD (Updated: 11/26/2024)
    Click here to contact Mike Winters, MBA, MD

     

    Recent Articles from the Critical Care Literature

    Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage.

    Mayer SA, Brun NC, Begtrup MSc, Broderick J, Davis S, et al. NEJM 2008;358:2127-37.
                Intracerebral hemorrhage (ICH) accounts for approximately 10% to 15% of all strokes, yet has the highest morbidity and mortality, with up to 40% of patients dying within 30 days. Aside from age, size, location, intraventricular extension, and GCS, hematoma expansion is an independent determinant of morbidity and mortality. Hematoma expansion is reported to occur in up to 70% of patients within the first several hours of the ICH. Recent research has focused on therapies to limit hematoma expansion. One such therapy is recombinant human activated Factor VII (rFVIIa). Excitement regarding this expensive drug came from a single phase 2 trial (Mayer SA, et al. NEJM 2005:352:777-85.) that demonstrated rFVIIa significantly reduced hematoma expansion and improved patient mortality.
                The FAST trial (Factor Seven for Acute Hemorrhagic Stroke), was a manufacture sponsored, phase 3 trial performed by the same investigators to confirm the findings of their previous phase 2 study. The FAST trial was a multi-center, randomized, double-blind, placebo-controlled trial conducted at 122 sites in 22 countries. Patients had to be at least 18 years of age with a spontaneous ICH documented by CT within 3 hours of symptom onset. Important exclusion criteria included GCS < 5 at presentation, secondary ICH (trauma, AVM), current anticoagulant therapy, thrombocytopenia, DIC, previous disability from CVA, or a thromboembolic event < 30 days prior to symptom onset. The primary end-point was disability or death defined by a modified Rankin score of 5 or 6 at day 90. The modified Rankin score evaluates global disability and handicap and ranges from 0 to 6. A score of 5 indicates a patient who is bed-bound and incontinent, whereas a score of 6 indicates death.
                Of 8,886 patients screened, 821 underwent randomization and received placebo, 20 mcg/kg of rFVIIa, or 80 mcg/kg of rFVIIa. Treatment had to start within 1 hour of the baseline CT and no more than 4 hours after the onset of symptoms. Patients then underwent a repeat CT at 24 hours and 72 hours to evaluate for hematoma expansion. Of note, the majority of the patients in this study were Caucasian males, older than 65 year of age who had deep gray matter ICHs. 
                As reported by the trial investigators, rFVIIa did reduce hematoma expansion at 24 hours compared to placebo. In the placebo arm, 26% of patients had hematoma growth, whereas only 11% of patients who received 80 mcg/kg of rFVIIa had hematoma expansion. In addition, the investigators report that the reduction in hematoma growth was even greater in those treated in less than 2 hours from onset of symptoms. However, when you look at the data for 72 hours, there was no significant difference in total hematoma volume or edema volume. More importantly, mortality at 90 days did not differ between placebo and the treatment groups. In fact, a higher percentage of patients who received 80 mcg/kg of rFVIIa had a worse outcome than compared with placebo. Furthermore, there was an absolute increase of 5% in the frequency of arterial thromboembolic serious events (MI, ischemia CVA) in the group receiving 80 mcg/kg of rFVIIa.
                Take Home Point: This phase 3 trial failed to demonstrate improved 90 day mortality in patients with spontaneous ICH who received rFVIIa. Although hematoma expansion was reduced at 24 hours in the rFVIIa groups, total lesion volume and edema volume at 72 hours remained unchanged. Although rFVIIa has been used in a variety of clinical settings, the results of this study indicate that it does improve mortality in patients with spontaneous ICH. Given the expense of the drug and lack of benefit, this should not be a drug we are using in the ED to treat patients with spontaneous ICH.


    Title: Cardiac Involvement in Kawasaki Disease

    Category: Pediatrics

    Keywords: Kawasaki Disease; Cardiac; Coronary Aneurysm (PubMed Search)

    Posted: 7/4/2008 by Don Van Wie, DO (Updated: 11/26/2024)
    Click here to contact Don Van Wie, DO

    Cardiac Involvement in Kawasaki Disease

    • 50% can have Myocarditis (tachycardia, decreased ventricular function, arrhythmias, CHF, shock)
    • 30% can have Pericarditis In untreated patients;
    • 20 – 25% will have Coronary Artery Aneurysm during second and third week of illness Coronary Artery Aneurysms have risk of rupture, thrombosis, or stenosis
    • Myocardial Infarction is leading cause of Death due to thrombosis, rupture, or stenosis of a coronary aneurysm
    • Treatment with IVIG in the Acute Phase (within 10 days of onset of fever) reduces the risk of coronary artery dilation and aneurysms from 20-25% to < 5 % for coronary dilation and <1 % for giant coronary aneurysm. BUT NOT TO ZERO.

     

    So the Pearl is if you have a pediatric patient with a complaint of Chest Pain, ask if there was any history of Kawasaki Disease and get an EKG ASAP if the answer is yes!

    Show References



    Title: Trends in Drug Abuse

    Category: Toxicology

    Keywords: drugs of abuse, heroin (PubMed Search)

    Posted: 7/3/2008 by Ellen Lemkin, MD, PharmD (Updated: 11/26/2024)
    Click here to contact Ellen Lemkin, MD, PharmD

     ADOLESCENT DRUG ABUSE

    • "Pharming" is prescription drug abuse
    • Teens will take medications from their home medicine cabinets, mix them in bags together indiscriminately and make "trail mix" to pass around parties
    • "Cheese" is a combination of heroin with cough and cold preparations. The heroin concentration in cheese is typically between 2-8% compared to 30% found in black tar heroin, and is considered "starter heroin"

    Show References



    Title: Differentiating Delirium from Dementia

    Category: Neurology

    Keywords: delirium, dementia, CAM, MMSE (PubMed Search)

    Posted: 7/2/2008 by Aisha Liferidge, MD (Updated: 11/26/2024)
    Click here to contact Aisha Liferidge, MD

    • The Confusion Assessment Method (CAM) and Mini-Mental State Exam (MMSE)  can be used in combination to effectively differentiate delirium from dementia, respectively.
    • CAM relies on observations by family members, caregivers, and clinicians to assess the following four symptoms:
      1. acute confusional onset
      2. inattention
      3. disorganized thinking
      4. ltered level of consciousness
    •  

    • Using CAM, the diagnosis of delirium requires the presence of both the first and second features, plus one of the two other features.
    • CAM is 95-100% sensitive and 95% specific for diagnosing delirium in the elderly.
    • MMSE is not a diagnostic tool but identifies cognitive impairment suggestive of delirium by assessing orientation, short-term memory, calculation ability, and language (score 18-26 = mild dementia).
    • A positive CAM and an MMSE score of > 25 is predictive of delirium.
    •