What's the next step in managing a patient with altered mental status and recent COVID-19 exposure?

Management of Altered Mental Status in a Patient with Recent COVID-19 Exposure

The next step in managing a patient with altered mental status and recent COVID-19 exposure should be prompt assessment for COVID-19 infection, evaluation of oxygenation status, and implementation of appropriate respiratory support if needed. 1

Initial Assessment and Management

• Perform immediate evaluation of respiratory status, including oxygen saturation measurement, as hypoxemia is a common cause of altered mental status in COVID-19 patients 1
• Conduct COVID-19 testing to confirm infection status in the context of recent exposure 1
• Assess fluid status to identify potential hypovolemia or dehydration, which can contribute to altered mental status and increase risk of acute kidney injury 1
• Monitor vital signs including temperature, as fever may indicate active infection and contribute to mental status changes 2

Respiratory Support

• If oxygen saturation is below 93% despite standard oxygen therapy, consider high-flow nasal oxygen (HFNO) with initial settings of 30-40 L/min and FiO2 50-60% 1
• For patients with worsening respiratory distress despite HFNO (FiO2 >70%, gas flow >50 L/min for 1 hour), consider escalation to non-invasive ventilation (NIV) or invasive mechanical ventilation 1
• Avoid NIV in patients with hemodynamic instability, multiple organ failure, or abnormal mental status as these are contraindications 1
• If acute respiratory distress syndrome (ARDS) develops, implement protective lung ventilation strategies with lower tidal volumes and appropriate PEEP 1

Neurological and Psychiatric Evaluation

• Establish a prompt identification and assessment mechanism for adverse mental states, as more than 60% of COVID-19 patients may experience anxiety and depression 1
• Evaluate for potential neurological manifestations of COVID-19, which can present as altered mental status 3
• Consider brain imaging only to rule out other causes of altered mental status, as routine use is not supported by current evidence 1
• Provide basic mental health and psychosocial support while addressing immediate medical needs 1

Additional Considerations

• Evaluate for acute kidney injury, which is common in COVID-19 patients and associated with increased mortality 1
• Maintain optimal fluid status (euvolemia) to reduce the risk of acute kidney injury 1
• Consider individualized risk assessment for thrombotic events, as COVID-19 is associated with increased coagulopathy 1
• For patients with myalgia or neuropathic symptoms, NSAIDs may be considered as first-line treatment with careful monitoring for adverse effects 4

Pharmacological Management

• If pharmacological intervention is needed for severe anxiety, select medications with short half-lives and low risk of drug-drug interactions at the lowest possible dose and shortest duration 1
• Avoid hydroxychloroquine as it provides no benefit and may worsen prognosis 4, 2
• Consider dexamethasone for patients with severe COVID-19 requiring oxygen support 2
• Evaluate the need for anticoagulation based on individual risk factors for thrombotic events 1

Common Pitfalls to Avoid

• Do not delay respiratory support in patients with hypoxemia, as this can rapidly worsen altered mental status and overall prognosis 1
• Avoid aggressive exercise or physical activity programs in patients recovering from COVID-19, as this may worsen symptoms in 75% of long COVID patients 4
• Do not neglect mental health assessment and support, as psychological sequelae are common and can contribute to altered mental status 1
• Avoid using medications with high risk of drug-drug interactions or those that may suppress respiratory drive in patients with potential respiratory compromise 1